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The modification of smoking behavior: A search for effective variables
Behav. Res. B Therapy,
1970, Vol. 8. pp. 133 to 146.
PergsmonPress.
Printed in England
THE MODIFICATION OF SMOKING BEHAVIOR : A SEARCH FOR EFFECTIVE VARIABLES* DOUGLAS A. BERNSTEIN University of Illinois, Urbana, Illinois, U.S..% (Received 8 September
i969)
Summary-A smoking withdrawal clinic procedure employing social pressure was compared to an attention placebo condition and other control conditions designed to subtract “non-active” variance due to such factors as mere contact with an experimenter and individual etfort, with and without the expectation of future help. Both Social Pressure and Placebo Ss responded to treatment with significant reduction in smoking, but did not differ. Subjects asked to quit smoking on their own, displayed significant gains only if future aid was not expected, and the behavior of subjects who were unaware of their participation in an experiment remained essentially unchanged. Data on suggestibility, internal vs. external control of reinforcement, extroversion and emotionality were collected in Experiment 3, but failed to correlate significantly (nithin treatment conditions) with success in quitting smoking. SINCE about
1962, the volume of research aimed at the modification of cigarette smoking behavior has expanded dramatically (e .g. National Clearinghouse for Smoking and Health, 1967a, 1967b, 1968~1, 1968b). An extensive review of iiterature in this area (Bernstein, 1969) shows, however, that the increase in quantity of investigative effort has not yet been matched by corresponding improvemenf in quality of the research designs and methods employed to generate the data. The current state of affairs in smoking research closely paraileIs that which has existed more generally in other areas of behavior modification research. As Paul (1966, p. 2) points out, the difficulties stem from “formidable methodoIogica1 and control problems. . . and from a lack of a feasible model for outcome research.” A tentative outcome model appropriate for smoking research has been presented elsewhere (Bernstein, 1969) in conjunction with a series of recommendations for upgrading smoking research methodology. The present paper reports a series of three experiments aimed at exploring that model and following some of those recommendations within the context of attempts to answer specific questions about the effective components of any smoking modification technique.
The currently available body of smoking modification research results (see Bernstein, 1969) allows at least two firm conclusions. First, nearly any procedure aimed at smoking reduction or abstinence in which subjects (Ss) are “treated” in some way (as opposed to being exposed to anti-smoking literature, for example) will result in behavior change in the desired direction for most Ss who remain in treatment. This is clear from the pattern of separateIy reported results of a variety of treatments (e.g. cfinics, drugs, “behavior therapy,”
l Research presented in this manuscript was supported doctoral Research Fellowship 5-Fl-hlH-32, 578-02.
133
by United States Public Health Service Pre-
134
DOUGLAS
A. BERMTEIN
hypnosis and the like) and from a few compara!ive studies (e.g. Koenig and ?ifasterj, 196j; C&x, 1966; Keutzer, 1968). Second, the period during vvhich most treatments are effecti\-e usually correspond to the duration of the esP;:riment or clinic in which they are dispensed. That is, post-treatment relapse is to be expecrcd as a ruie. In light of these strong trends, the obvious research qtiejtions to ask !nvol:-d specification of the presumably common effective c .:riable(s) which produce the behavior change noted in smoking modification research projects. That is, wrhich elements of treatmznt procedures are vital and which are not? The research to be reported below focused upon analogues to “smoking withdrawal clinics” since they are common and popular. Hopefully, hoviever, the data Cl1 have relevance to other modification procedures as well.
STUDY
1
in the first preliminary experiment, the following relatively simple hypothesis was tested: A group clinic-type treatment will be more efl‘ective in terms of smoking behavior change than either an “attention-placebo” condition (Paul, 196G) or no treatment. Accordingly, 16 male volunteer University of Illinois undergraduates (mean age: 20; mean smoking rate/day: 25) were assigned, mainly in the basis of class schedule, to either Social Pressure (SPR), Group Placebo (GPL), ~ndividuai Piacebo (IPL) or no treatment. The IPL condition was included to assess the role of group contact and interaction, Pre-assessments Ss were recruited through advertisement in the student newspaper and none were paid for participation. Prior to assignment to condition, each S was seen individually by the principal investigator (who conducted ali procedures and treatments in Study I and Study II) in a structured interview during which data regarding S’s smoking (and quitting) history, reasons for wishing to quit, class schedule and the like were collected. Any S who smoked fewer than ZOcigarettes per day or had been smoking for less than one year at the time of the interview was excluded from &he project. At the conclusion of the interview, eligible Ss were given a small, ruled notebook and asked to keep an accurate record of smoking behavior for seven ful! days.* The resulting data (in terms of average daily consumption) constituted each S’s basetine smoking level. All Ss in all studies except those in no-contact control groups continued to record smoking behavior throughout the treatment period.
All treatments consisted of eight 20-25 min sessions over a two-week period. At each meeting, each S reported any smoking behavior which had occurred since the previous meeting. Social pressure (SPR). In this condition, the social character of the smoking habit, in terms of onset, maintenance and discontinuation, was stressed. It was explained that since smoking is initiated and maintained by social pressure, such pressure can also be employed, through the group, to eliminate the behavior. Thus, each S made a commitment to quit smoking, not onfy to himself, but to ail group members. The meetings consisted of group * All data reported in this paper are based upon self-report and are thus open to some suspicion. important
problem has been discussed elsewhere (Bernstein,
1969).
This
THE ~IODTFIC.~TIOS
OF S\IOKING
BEK4VIOR:
.4 SEARCH
FOR EFFECTIVE
V.%RRI.+BLES
135
discussion of problems encountered in trying to quit smoking, physical and non-physical consequences of quitting, attitudes toiiard smoking and occasional question-and-answer scments xvith the experimenter (E). Grorf!~ phcebu (GPL). This condition was designed to assess the extent of behavior change attributable to such non-specific effects as contact with E, expectation of change, and suggestion. The Ss were told that the main factor responsible for failure to quit smoking is the &zomfort accompanying the attempt and that such discomfort, often characterized as “withdrakval symptoms,” is best thought of as physical and psychological stress. It was explained that an extremely effecti\-e “treatment” had been developed which is designed to produce “stress tolerance” and thus eliminate the discomfort involved in quitting smoking. The actual procedure consisted of a group version of Paul’s (1966) attentionplacebo condition and required Ss to perform a relatively simple and very boring auditory discrimination task after ingesting a j-gram lactose capsule, Ztldi~*idualplncebo (IPL). This condition was identical to GPL except for the fact that Ss were “treated” at individual rather than group sessions. ?V’Otreattnent control. The .Ss assigned to this condition were told that, due to excessive demands upon experimenter and laboratory time, a two week delay prior to treatment would be necessary. No information about the nature of the treatment and no instruction regarding their smoking behavior during the waiting period kvere given. Following the delay, these Ss were then run in the IPL condition. Post-assessments After treatment was completed, the smokin, * behavior of SPR, GPL and IPL Ss was assessed through I2 weekly telephone calls. Control Ss were followed up in the same way for 10 weeks following their delayed treatment. The research assistant making these calls had no previous contact aith the Ss and was blind with respect to the condition to which each Shad been assigned. The calls were brief and involved no more conversation than was necessary to obtain data on smoking behavior within 24 hr of the contact.
24 2 22
A SPR (N:3)
D
A IPL(N 20
;
I8
;
IO
31
0 CONYROl_(N:4f OGPL(N:3)
z* 2
6
z4 g2 0
Baseline
I
2 3 4 5 6 7 8 DAYS OF TREATMENT
9
10 II
3
IO 17 24 31 30 45 52 59 66 73 BO 87
bays
stNcE
FIG. 1. Treatment and follow-up data: Study
TREATMENT I.
136
to
DO L’GLASA. BERXSTEIX
One S in each of the three experimental completion of the final session.*
conditions
dropped
out of the project prior
Data for the 13 remaining Ss is present:d in Fig. I. Al1 treated Ss reduced their smoking behavior dramatically after the first session and maintained their gains throughout the two weeks of treatment contact. Control Ss shobved no decrease in smoking at the end of that same period.? A total of eight of the nine treated Ss were considered “successes” in that they reduced smoking to below 25 per cent of baseline. Thus, the experimental groups’ performance were nearly identical. By the 12th iveek of follow-up contacts, however, the similarity disappeared. At that point, GPL and IPL Ss tvere smoking at about 50 per cent of baseline white SPR Ss Lvere at about the 25 per cent level. The performance of controi Ss durin g their deIayed treatment was simiiar to that of other treated Ss and their post-treatment data closely resembles that of other placebo Ss in that smoking increased toward about the 50 per cent level.
STUDY
II
The second experiment was designed to assess the stability of the phenomena noted in Study I, namely placebo vs. non-placebo comparabiIity during treatment, as well as to obtain, through unique contro1 conditions, a better idea of the relative importance of several variables which were suspected of operating to produce behavior change. Since it was hypothesized that increasing the intensity of post-treatment contact might retard relapse, the role of follow-up contact frequency was also assessed in this study. After an interview and a week of baseline recording, 32 male University of Illinois undergraduate volunteers {mean age: 21; mean smoking rate/day: 25) were assigned to one of five conditions: GPL, SPR, Effort Control (EfC), Expectation Control (Exe) or Contact Control (CC). The IPL condition was dropped since it was found to be comparable to GPL in terms of producing smoking reduction kvhile being much more expensive (in terms of time) to run. The EfC condition was included to control for the effects of Ss’ oun, unaided attempts to quit smoking. A truly effective treatment should be shown superior to such efforts as we11 as to placebo. Thus, EfC was identical to the No Treatment Control condition in Study I with the exception that the Ss were told at an initiai session to try to quit on their own during the waiting period. In addition, they were contacted by telephone seven times during the two-week delay and asked about their smokin g behavior during the previous in terms of frequency, to 24 hrs. These calls, in addition to the first meetin g, corresponded the meetings attended by SPR and GPL Ss. The ExC condition these abiiity to quit smoking upon one% own resolve
in EfC Ss. Thus,
was designed to control for the expectation of future help present Ss were told that the most important variable correlated with the is determination and that no special treatment can really improve to stop. Treatment was neither promised nor offered. As was the
* Complete data on “drop-outs” in all studies reported here are available upon request from the author. t Data indicating the number of cigarettes smoked during treatment and follow-up by each S in all studies reported here is available upon request from the author.
THE MODIFICATIO?;
OF SMOK1NG
BEHAVIOR:
A SEARCH
FOR EFFECTIVE V.ARLULES
137
case with EfC Ss, no instructions were given regarding quitting procedures and further contact was limited to seven tefephone calls, the content of which was identical to those received by EfC Ss. Contact Control Ss were treated as in Study 1. Four GPL 5s and one SPR S dropped out of the experiment, the Iatter before attending any treatment sessions. Following the tlvo ueek treatment period, the remaining 11 GPL and SPR Ss were randomly assigned to either high (H) or low (L) frequency follow-up groups. The former were telephoned three times each week for just over five weeks (follow-up was terminated due to the end of the semester), while L Ss were contacted once each week for the same period. Subjects in the ExC group were assigned to the H condition, as were the EfC SS, following their delayed treatment. AI1 CC Ss were assigned to the L condition.
line
FIG. 2.
DAYS OF TREATMENS
Daily group means during treatment period:
Study II.
As is made clear by Fig. 2, the GPL and SPR Ss again showed an immediate change in in smoking behavior after the first session. The two curves do not, however, exhibit the striking similarity found in study T. Although this is due primarily to the performance of one GPL S which elevates the GPL curve, there was a general tendency for SPR SS to do somewhat better than Ss in GPL. While the smoking behavior of the CC Ss remained essentially unchanged (an observation which would have been predicted by a look at population quit rates, see Bernstein, 1969), that of the EfC and ExC groups (especially the latter) shows immediate changes. The superior performance of ExC relative to EfC seems to confirm the intuitive notion that Ss who expect outside help following an unaided attempt at quitting wiil not do as well as S who cannot expect such hefp. At1 SPR Ss were successful in reducing smoking behavior below 25 per cent of baseline and three of four GPL Ss did so. Of the eight EfC Ss, only one was successful on his own while two of four ExC Ss ended the iirst two weeks below 25 per cent of baseline. Two EfC Ss refused treatment after their delay period through neither reduced smoking significantly while waiting. The remaining six EfC Ss were run in either GPL or SPR and all were successful in reducing their smoking during both delayed treatments.
138
DOUGLAS
A. BERNSTEIN
36 t 0 32 i
16 k :I2 $8 $4 r 0
0 3 5 7 1012 1417 19 21 24262831333538 DAYS SINCE
TREATMENT
FIG. 3. Follow-up
data:
Study Il.
Follow-up assessments (see Fig. 3), indicated that, while frequency of contact was not an effective variable (at least the frequencies employed) in maintaining treatment period gains, the post-treatment relationship between SPR and GPL curves found in Study I again obtained here. The differences were even more clear cut in this case, however, with SPR Ss smoking at about 15 per cent of their pretreatment rate (only one relapsed) as compared to the two of three successful GPL Ss who had essentially returned to their old rate. Follow-up data on EfC Ss who received delayed GPL or SPR treatment show no comparable difference in relapse rate (one in each group relapsed). STUDY The final experiment represents a replication important differences should be noted.
III and expansion
of Study II, though several
Subjects A total of 23 male and 25 female Northwestern University undergraduate volunteers served as Ss. Females were included due to a lack of sufficient numbers of male volunteers. Pre-assessments As a supplement to the information collected at the standard screening interview, all Ss were administered the Pittsburgh Social Extroversion-Introversion and Emotionality Scales (which contain the MMPI L scale) (Bendig, 1962), the Rotter Internal-External Control Scale (I-E) (Rotter, Seeman and Liverant, 1962), and the Barber Suggestibility Scale (BBS). The principal investigator conducted all interviews but had no further contact with the Ss. Experimenters Two male first-year graduate students in psychology were paid to act as experimenters and were trained by the principal investigator. Neither E was informed of the results of Studies I and II. Each E conducted one group of six Ss in each of the four conditions of the experiment.
THE MODIFICATION
OF SMOKING BEHAVIOR:
A SEARCH FOR EFFECTIVE VARIABLES
139
Procedure
A total of 12 Ss were assigned Because of the paucity of acceptable
to each
of four
SPR, GPL, was dropped.
groups:
Ss, the CC condition
EfC and ExC.
Post-assessments
At the conclusion of the second treatment week, follow-up calls began on either a high frequency (HF) or a low frequency (LF) basis. Attempts were made to contact Ss randomly assigned to HF three times each week while LF Ss received a call once a month. Since the follow-up variable was not effective in Study II, this increase in the contact intensity difference between HF and LF was aimed at increasing the probability of picking up some effect of frequency (even if it only meant greater relapse at very low frequency). In an attempt to minimize expectancy effects (Rosenthal, 1966) which might influence the data generated in this experiment, the following procedures were adopted: (a) no data, collected by either E, were available for inspection by the principal investigator until all Ss (including those receiving delayed treatment) were in the follow-up stage, (b) neither E was informed that the GPL procedure was a placebo condition, and (c) the research assistant making the follow-up calls turned in her data in written form for examination by the principal investigator. In order to assess Es’ expectancies about the study, each was asked to provide, prior to contacting any Ss, but after training, a written results he expected to be generated by the research design.
statement
detailing
the
RESULTS A total of seven Ss dropped out of the study prior to completion and, thus, the bulk of the data reported in this section is based upon the performance of the remaining 39 Ss. Pre-assessments
One way analyses of variance were performed for each of the six pre-assessment scales. There were no significant main effects for any of these analyses, indicating that the treatment groups did not differ in terms of the personality measures employed. A repeated measures analysis of variance was performed on the smoking data reported over the seven days of the baseline period and showed no differences between groups in terms of level of pretreatment period smoking, no significant change in smoking level during the baseline period and no significant interaction between treatment groups and time. In addition, there was no significant difference between males and females in terms of the number of cigarettes smoked over the baseline period (t= l-62, df=37).* Since it seemed at least indirectly relevant to the issue of accuracy of self-report data, each S’s estimate of his average daily consumption (as reported at the screening interview) was correlated with his mean daily consumption data collected during the baseline week. The product-moment coefficient was +O-69 (p> O-0005) and the mean of the actual performance data was less than that of the estimates.
* Summary tables and raw data relevant to all analyses reported in this paper, as well as data for Ss receiving delayed treatment are available from the author upon request.
DOCGLAS
110
.A. BERNSTEIN
Treatment
Treatment group means for each day of the treatment period are plotted in Fig, 4. The difference bft\veen mean baseline performance and mean first treatment day performance for SPR, GPL and E\C groups \\;is significant (f=9.05, dJ-= 33. p
24 t k 0 227
,kl
EfC
iN
II)
SPR
!N
9)
91
IO)
0’Bose-’ llne
! I
I
2
’
3
DAYS
i
4* OF
I
I
/
4
I
I
6
7
a
9
to
II
TREATMENT
FIG. 3. Daily group means during treatment period:
Study III
More detailed assessment of the treatment main effect was accomplished by a Duncan Multiple Range Test, corrected for unequal IV (Edwards, 1963; Kramer, 1956), performed on the mean total number of cigarettes smoked per day over the entire treatment period for the four treatment groups. The results indicated that the EfC and ExC groups each differed significantly (p-cO.01,r/f=31) from each other and (in opposite directions) from the SPR and GPL groups, kvhich did not themselves differ significantly. The main effect of Days was si_cnificant (~-CO-OOS),as \vas its linear component (p< 0.005), attesting to the overall increase in smoking over the treatment period which, at first glance, looks to be due in large measure to the performance of thz EfC Ss. (The performance of those Ss at the end of treatment was not significantly different from their baseline rates: t= 145, df= 10). However, mean performance scores for the other three groups combined also showed a significant increase from first to last day of treatment (t=2*70, df=27,p
THE MODIFICATION
OF S!.lOKISG
0’
FIG. 5. Group
I
SPR
BEHAVIOR:
1
A SEARCH FOR EFFECTIVE VARLkBLES
I
GPL EfC CONDITION
141
I
EXC
treatment period means plotted by experimenter: Study III.
As was the case during baseline, there was no significant difference performance of males and females during treatment (t=0.51, 4’=37).
between the overall
Since to many researchers interested in the modification of smoking behavior, presentation of data in terms of absolute levels of smoking is unsatisfactory, a supplementary analysis of the treatment period data was performed in which S’s reduction was assessed in The treatment variable was again found to be terms of percentage of his own baseline. significant. Behavior change over treatment was also examined in relation to the personality data collected prior to the experimental manipulation. This involved correlation, within each treatment group, of scores on five of the six personality scales (BSS performance, Rotter I-E, Extroversion, Emotionality and L Scale) with mean daily consumption during the last two days of treatment. The BSS subjective involvement score was not included in the analysis since it is so dependent upon the BSS performance score (the correlation between the two for the present sample was +0.89, p
30 28
Although LF Ss smolied more during that follow-up period tlmn did HF Ss, it seems clear that this is the result of the initial difference present at the onst’t of rht: follow-up period. This replicated the finding of Study II which indicated that follow-up contact
THE MODlFICATION
OF S?tOKING
BEHAVIOR:
X SEARCH
FOR EFFECTIVE
VhRIABLES
143
frequency was not an effective variable in terms of maintenance of behavior change. It is of some interest to note, incidentally, that the marked increase in smoking at 24 days after treatment corresponded exactly to the beginning of a week of final examinations.
28 26
il8g 165 14 6 IZg IOii
80 SPR IN 6,6.6,6.4) 0 GPL (N 8.5.5,6,7) a ExC (N: 9,6,5,7.6)
Z6 ‘;14 2-
I
FIG. 7. Follow-up
I
I
3
24
period data sent changing
I
87 59 DAYS SINCE TREATMENT
I
115
plotted by treatment condition. (Figures in parentheses N per data point over the follow-up period.)
repre-
As can be seen in Fig. 7, where follow-up performance is plotted by treatment condition, earlier findings indicating superiority of SPR over GPL in terms of reduction maintenance were not replicated. The impressive posttreatment performance of ExC, Ss apparent in Fig. 3, also failed to replicate. DISCUSSION Perhaps the most significant replicated finding was that involving the treatment period performance of the SPR and GPL groups. As had been the case in both earlier studies, there was no difference in Study III between the groups in terms of their response to treatment. Thus, treatment data for the SPR and GPL groups in these studies support the hypothesis that the sufficient conditions for initial smoking behavior change in volunteer groups are met by the non-specific factors found in the GPL condition employed, namely participation in an experiment, expectation of change, suggestion, contact with an experimenter or leader and the like (e.g. Keutzer, 1968; Mees, 1966). They also fall into line with the growing body of data which indicates that some treatment is better than none, but that the specific nature of that treatment is not crucial (e.g. Keutzer, 1968; Koenig and Masters, 1965; Mees, 1966; Ober, 1966). Of equal significance was replication in the treatment period of Study III of the ExC effect in the second pilot study. If this effect is a general one (a total of only 14 Ss have been run in the ExC condition to date), it is clear that validation of any treatment requires demonstration of its superiority relative to both attention placebo “treatments” arzd individual effort (without expectation of help).
DOtiGLAS
111
A. BERNSTEIN
The magnitude of the reduction in smoking by SPR and GPL groups, both in terms of initial change and maintenance of change, was not as great in the final study as had been found earlier. In both Studies I and II, the means for SPR and GPL dropped immediately to nearly 0 and. in most cases, remained below 2.00 throughout treatment. In Study III neither mean dropped below 3.00 initially and, as was noted earlier, there was a general tendency to increase smoking significantly during the treatment period. It is as though the erfects found in the earlier studies are present but have been diluted, and since the treatment techniques themselves vvere changed in the third esperiment only in the direction of increased potency (e.g. luxurious reclining chairs and high quality earphones were employed in the GPL condition, and both SPR and GPL were run in a nearly soundproof laboratory), it seems reasonable to seek an explanation for this “washing-out” of effects in terms of (a) decreased ‘motivation” on the part of Northwestern Ss and (b) reduced competence of the esperirnenters involved in Study III. Lack of interest in the project at Northwestern was evidenced by the fact that three weeks of sustained advertising was required to recruit 48 acceptable Ss, and even that was accomplished only by opening the experiment to females. At Illinois, an adequate number of Ss was obtained through a single announcement. The graduate student experimenters, though trained for a month prior to Study III, were not as knowledgeable about smoking and its modification as the principal investigator (who had conducted Studies I and II). It is highly probable that their relativte lack of information and confidence had an impact upon their Ss (Rosenthal, 1966). The question of vvhy, when other effects were being diluted by these factors, the ExC effect was apparently unaffected during the treatment period, must remain unanswered at this point. Perhaps a single ExC contact with a less than fully competent E is insufhcient to dilute the effect of ExC instructions. Methodological
considerations
Several methodological isssues relating to smoking modification research in general deserve consideration here. One of these, relating to the acceptability of self-report measures in such research, had been discussed elsewhere (Bernstein, 1969) and will be mentioned again only briefly in order to relate certain aspects of the present results to it. No efforts were made to assess the accuracy of the self-report data obtained in the experiments reported here since no reasonable technique for doing so reliably and nonreactively has yet been developed. However, the significant (p <0.0005) correlation of + 0.69 obtained between baseline estimates and baseline recording reports was encouraging, especially when it was noted that, on the average, Ss’ estimates tended to exceed their subsequent reports. This finding contradicts that of Hoinville and Biggs (1966) and Todd and Laws (1959), which described the opposite relationship between unrecorded estimates and behavior. The discrepancy might be explained in terms of the effect of baseline recording. It can be argued that the baseline recording procedures themselves are reacti1.e measures and thus, by drawing S’s attention to his smokin g, or whatever, reduce the amount of smoking If this were the case in the present study,‘and it occurring during the baseline period. cannot be ruled out as impossible, the effect was immediate and constant since the analysis of variance on the baseline data for all Ss revealed no significant effect of time on baseline performance. Still, it was not possible in the present series of studies to determine precisely the degree to which Ss’ reports of smoking behavior reflected actual frequencies. This problem, though
THE SlODIFICATION
common alchouglt
OF S?.fOI;ING
to all smoking modj~cation its solution is a prerequisite
BEHAVIOR:
A SEARCH
FOR EFFECTIVE VARIABLES
research, has not received serious attention for truly adequate research in the area.
I45
to date,
Another issue involving method is at least as crucial as that of data accuracy and concerns assurance that the data, however accurate, will, in fact, be collectable. In the present research, the factor mainly responsible for the difficulty encountered in attempting interpretation, or even description of experimental effects was that of incomplete contact with Ss, both during and after treatment. While absences during treatment do not usually result in irrevocable data loss, they can, if frequent enough, compromise the reasonableness of including the Ss involved in their assigned groups for purposes of analysis. After treatment has been concluded, gaps in contact are obviously more serious. An exce&nt technique for reducing the probability of treatment period attribution has been employed by Mees (1966) but did not come to the present author’s attention until after Study III was underway. Mees (1966) and Keutzer (1968) required each 5” to place a $20 deposit which was returned at the conclusion of treatment. Modification of the refund contingency such that one or more absences from treatment sessions would result in forfeit of the deposit might be extremely effective in keeping attendence at near 100 per cent throughout the treatment period. The problems of maintaining post-treatment contact are somewhat more difficult. One solution might be to arrange to pay Ss for phonin g or mailing their follow-up data at specified intervals. It would have to be made clear to the Ss, of course, that payment will be made regardless of the nature of the report, thus placing the emphasis on accuracy rather than “goodness” in the data. If one’s interest in follow-up data is primarily in terms of smoking (in any amount) vs. non-smoking, an alternative procedure might be developed where paid research assistants observe .Ss in public places where smoking is permitted and record the presence or absence of smoking behavior. The observations could be made at several sites and at varying times of the day, week and semester (if college Ss are used) such that the probability of a systematic bias (resulting in an excessive number of false negatives) would be reduced. Systematic observation of Ss in specially contrived, though non-reactive waiting areas where “pull” or temptation to smoke can be varied experimentally might also provide valuable, though incomplete data. These suggestions are meant only to indicate the direction in which more reliable followup contact procedures might evolve. The range of alternatives which are testable is limited onIy by the bounds of the experimenter’s ingenuity. The point is that the lack of more sophisticated techniques makes the need for more imaginative use and development of presently available tools a necessity if the status of research on the modification of smoking behavior is to be elevated.
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53, 199-209. BERNSTEIN D. A. (in press) The modification of smoking behavior: an evaluative review. Psychol. Bull. BROWN J. A. C. (1963) The nature and treatment of smoking, Med. Wd Land. 98, 187-192.
146
DOUGLAS .A. BERSSTEIN
EDWARDS A. L. (1960)
Experinrmfal
Design in Psychological
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Holt. Rinehart &
\\‘inston,
Sew
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ht. (1965)
pubi. KM. %ii5,69b697. HOINVILLEG. W. and Brass
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with special reference to cessation,
,-t,lr. 1.
II. 1%‘.(1966) Establishing smoking habits in retrospect, S!afi~. 16, 1313. KEUTZER CAR~LIN (1968) Behavior modification of smoking: the experimentsI investigation of diverse techniques, Behov. Ref. & Therapy 6, 137-157. KOENIG K. P. and MASTERS J. (1965) Experimental treatment of habitual smoking, B&v. Rrs. & ?%erap,~ 3,235-X3. MEES H. L. (1966) Placebo effects in aversive control: a preliminary report. Paper presented at the joint meeting of the Washington State-Oregon Psychological Association, Ocean Shores, W’ashington. National Clearinghouse for Smoking and Health. (1967) Bibiiogrophy on Smoking md Heulth. Arlington, Virginia: United States Public Health Service. (a) National Ciearinghouse. for Smoking and Health. (1967) Direclury o$On-going Rrsenrch in Snrokir~~untl ffeairh. Arlington, Virginia: United States Public Health Service. (b) National Clearinghouse for Smoking and Health. (1965) &)ibliugrupity or( Smokirrg and Hm!fh. Arlington, Virginia: United States Public Health Service. (a) National Clearinghouse for Smoking and Health. (1965) Director,? of On-going Research in Stnokitr,~ anti Heulrh. Arlington, Virginia: United States Public Health Service. (b) OBEK D. C. (1966) The modification of smoking behavior. Unpublished doctoral dissertation, University of Illinois. PAUL G. L. (1966) Insighf vs. Desensiri:atior~ irr Psychotherapy. Stanford University Press, Stanford. ROSENTHALR. (1966) Experitnenter Eficts in Behavioral Research. Appleton-Century-Crofts, New York. BOnER J. B. (1966) Generaiized expectancies for internal versus external control of reinforcement, P.rychcti. &fonogr. 80 (Whole No. 609). Ron-RR J. B., SEEMANM. and LIVERANTS. (1962) Internal versus external control of reinforcement: a major variable in behavior theory. In Decisions, Vatttes and Groups jed. N. F. W:\SHBURNE)Vol. 2, pp. 473-5 16. Pergamon Press, London. TODD G. F. and LAWSJ. T. (1959) The reliability of statementsabout smoking habits, Tobacco iWzm~j2cturers Standing Committee Research Paper, Great Britain. (2nd edition).
1970, Vol. 8. pp. 133 to 146.
PergsmonPress.
Printed in England
THE MODIFICATION OF SMOKING BEHAVIOR : A SEARCH FOR EFFECTIVE VARIABLES* DOUGLAS A. BERNSTEIN University of Illinois, Urbana, Illinois, U.S..% (Received 8 September
i969)
Summary-A smoking withdrawal clinic procedure employing social pressure was compared to an attention placebo condition and other control conditions designed to subtract “non-active” variance due to such factors as mere contact with an experimenter and individual etfort, with and without the expectation of future help. Both Social Pressure and Placebo Ss responded to treatment with significant reduction in smoking, but did not differ. Subjects asked to quit smoking on their own, displayed significant gains only if future aid was not expected, and the behavior of subjects who were unaware of their participation in an experiment remained essentially unchanged. Data on suggestibility, internal vs. external control of reinforcement, extroversion and emotionality were collected in Experiment 3, but failed to correlate significantly (nithin treatment conditions) with success in quitting smoking. SINCE about
1962, the volume of research aimed at the modification of cigarette smoking behavior has expanded dramatically (e .g. National Clearinghouse for Smoking and Health, 1967a, 1967b, 1968~1, 1968b). An extensive review of iiterature in this area (Bernstein, 1969) shows, however, that the increase in quantity of investigative effort has not yet been matched by corresponding improvemenf in quality of the research designs and methods employed to generate the data. The current state of affairs in smoking research closely paraileIs that which has existed more generally in other areas of behavior modification research. As Paul (1966, p. 2) points out, the difficulties stem from “formidable methodoIogica1 and control problems. . . and from a lack of a feasible model for outcome research.” A tentative outcome model appropriate for smoking research has been presented elsewhere (Bernstein, 1969) in conjunction with a series of recommendations for upgrading smoking research methodology. The present paper reports a series of three experiments aimed at exploring that model and following some of those recommendations within the context of attempts to answer specific questions about the effective components of any smoking modification technique.
The currently available body of smoking modification research results (see Bernstein, 1969) allows at least two firm conclusions. First, nearly any procedure aimed at smoking reduction or abstinence in which subjects (Ss) are “treated” in some way (as opposed to being exposed to anti-smoking literature, for example) will result in behavior change in the desired direction for most Ss who remain in treatment. This is clear from the pattern of separateIy reported results of a variety of treatments (e.g. cfinics, drugs, “behavior therapy,”
l Research presented in this manuscript was supported doctoral Research Fellowship 5-Fl-hlH-32, 578-02.
133
by United States Public Health Service Pre-
134
DOUGLAS
A. BERMTEIN
hypnosis and the like) and from a few compara!ive studies (e.g. Koenig and ?ifasterj, 196j; C&x, 1966; Keutzer, 1968). Second, the period during vvhich most treatments are effecti\-e usually correspond to the duration of the esP;:riment or clinic in which they are dispensed. That is, post-treatment relapse is to be expecrcd as a ruie. In light of these strong trends, the obvious research qtiejtions to ask !nvol:-d specification of the presumably common effective c .:riable(s) which produce the behavior change noted in smoking modification research projects. That is, wrhich elements of treatmznt procedures are vital and which are not? The research to be reported below focused upon analogues to “smoking withdrawal clinics” since they are common and popular. Hopefully, hoviever, the data Cl1 have relevance to other modification procedures as well.
STUDY
1
in the first preliminary experiment, the following relatively simple hypothesis was tested: A group clinic-type treatment will be more efl‘ective in terms of smoking behavior change than either an “attention-placebo” condition (Paul, 196G) or no treatment. Accordingly, 16 male volunteer University of Illinois undergraduates (mean age: 20; mean smoking rate/day: 25) were assigned, mainly in the basis of class schedule, to either Social Pressure (SPR), Group Placebo (GPL), ~ndividuai Piacebo (IPL) or no treatment. The IPL condition was included to assess the role of group contact and interaction, Pre-assessments Ss were recruited through advertisement in the student newspaper and none were paid for participation. Prior to assignment to condition, each S was seen individually by the principal investigator (who conducted ali procedures and treatments in Study I and Study II) in a structured interview during which data regarding S’s smoking (and quitting) history, reasons for wishing to quit, class schedule and the like were collected. Any S who smoked fewer than ZOcigarettes per day or had been smoking for less than one year at the time of the interview was excluded from &he project. At the conclusion of the interview, eligible Ss were given a small, ruled notebook and asked to keep an accurate record of smoking behavior for seven ful! days.* The resulting data (in terms of average daily consumption) constituted each S’s basetine smoking level. All Ss in all studies except those in no-contact control groups continued to record smoking behavior throughout the treatment period.
All treatments consisted of eight 20-25 min sessions over a two-week period. At each meeting, each S reported any smoking behavior which had occurred since the previous meeting. Social pressure (SPR). In this condition, the social character of the smoking habit, in terms of onset, maintenance and discontinuation, was stressed. It was explained that since smoking is initiated and maintained by social pressure, such pressure can also be employed, through the group, to eliminate the behavior. Thus, each S made a commitment to quit smoking, not onfy to himself, but to ail group members. The meetings consisted of group * All data reported in this paper are based upon self-report and are thus open to some suspicion. important
problem has been discussed elsewhere (Bernstein,
1969).
This
THE ~IODTFIC.~TIOS
OF S\IOKING
BEK4VIOR:
.4 SEARCH
FOR EFFECTIVE
V.%RRI.+BLES
135
discussion of problems encountered in trying to quit smoking, physical and non-physical consequences of quitting, attitudes toiiard smoking and occasional question-and-answer scments xvith the experimenter (E). Grorf!~ phcebu (GPL). This condition was designed to assess the extent of behavior change attributable to such non-specific effects as contact with E, expectation of change, and suggestion. The Ss were told that the main factor responsible for failure to quit smoking is the &zomfort accompanying the attempt and that such discomfort, often characterized as “withdrakval symptoms,” is best thought of as physical and psychological stress. It was explained that an extremely effecti\-e “treatment” had been developed which is designed to produce “stress tolerance” and thus eliminate the discomfort involved in quitting smoking. The actual procedure consisted of a group version of Paul’s (1966) attentionplacebo condition and required Ss to perform a relatively simple and very boring auditory discrimination task after ingesting a j-gram lactose capsule, Ztldi~*idualplncebo (IPL). This condition was identical to GPL except for the fact that Ss were “treated” at individual rather than group sessions. ?V’Otreattnent control. The .Ss assigned to this condition were told that, due to excessive demands upon experimenter and laboratory time, a two week delay prior to treatment would be necessary. No information about the nature of the treatment and no instruction regarding their smoking behavior during the waiting period kvere given. Following the delay, these Ss were then run in the IPL condition. Post-assessments After treatment was completed, the smokin, * behavior of SPR, GPL and IPL Ss was assessed through I2 weekly telephone calls. Control Ss were followed up in the same way for 10 weeks following their delayed treatment. The research assistant making these calls had no previous contact aith the Ss and was blind with respect to the condition to which each Shad been assigned. The calls were brief and involved no more conversation than was necessary to obtain data on smoking behavior within 24 hr of the contact.
24 2 22
A SPR (N:3)
D
A IPL(N 20
;
I8
;
IO
31
0 CONYROl_(N:4f OGPL(N:3)
z* 2
6
z4 g2 0
Baseline
I
2 3 4 5 6 7 8 DAYS OF TREATMENT
9
10 II
3
IO 17 24 31 30 45 52 59 66 73 BO 87
bays
stNcE
FIG. 1. Treatment and follow-up data: Study
TREATMENT I.
136
to
DO L’GLASA. BERXSTEIX
One S in each of the three experimental completion of the final session.*
conditions
dropped
out of the project prior
Data for the 13 remaining Ss is present:d in Fig. I. Al1 treated Ss reduced their smoking behavior dramatically after the first session and maintained their gains throughout the two weeks of treatment contact. Control Ss shobved no decrease in smoking at the end of that same period.? A total of eight of the nine treated Ss were considered “successes” in that they reduced smoking to below 25 per cent of baseline. Thus, the experimental groups’ performance were nearly identical. By the 12th iveek of follow-up contacts, however, the similarity disappeared. At that point, GPL and IPL Ss tvere smoking at about 50 per cent of baseline white SPR Ss Lvere at about the 25 per cent level. The performance of controi Ss durin g their deIayed treatment was simiiar to that of other treated Ss and their post-treatment data closely resembles that of other placebo Ss in that smoking increased toward about the 50 per cent level.
STUDY
II
The second experiment was designed to assess the stability of the phenomena noted in Study I, namely placebo vs. non-placebo comparabiIity during treatment, as well as to obtain, through unique contro1 conditions, a better idea of the relative importance of several variables which were suspected of operating to produce behavior change. Since it was hypothesized that increasing the intensity of post-treatment contact might retard relapse, the role of follow-up contact frequency was also assessed in this study. After an interview and a week of baseline recording, 32 male University of Illinois undergraduate volunteers {mean age: 21; mean smoking rate/day: 25) were assigned to one of five conditions: GPL, SPR, Effort Control (EfC), Expectation Control (Exe) or Contact Control (CC). The IPL condition was dropped since it was found to be comparable to GPL in terms of producing smoking reduction kvhile being much more expensive (in terms of time) to run. The EfC condition was included to control for the effects of Ss’ oun, unaided attempts to quit smoking. A truly effective treatment should be shown superior to such efforts as we11 as to placebo. Thus, EfC was identical to the No Treatment Control condition in Study I with the exception that the Ss were told at an initiai session to try to quit on their own during the waiting period. In addition, they were contacted by telephone seven times during the two-week delay and asked about their smokin g behavior during the previous in terms of frequency, to 24 hrs. These calls, in addition to the first meetin g, corresponded the meetings attended by SPR and GPL Ss. The ExC condition these abiiity to quit smoking upon one% own resolve
in EfC Ss. Thus,
was designed to control for the expectation of future help present Ss were told that the most important variable correlated with the is determination and that no special treatment can really improve to stop. Treatment was neither promised nor offered. As was the
* Complete data on “drop-outs” in all studies reported here are available upon request from the author. t Data indicating the number of cigarettes smoked during treatment and follow-up by each S in all studies reported here is available upon request from the author.
THE MODIFICATIO?;
OF SMOK1NG
BEHAVIOR:
A SEARCH
FOR EFFECTIVE V.ARLULES
137
case with EfC Ss, no instructions were given regarding quitting procedures and further contact was limited to seven tefephone calls, the content of which was identical to those received by EfC Ss. Contact Control Ss were treated as in Study 1. Four GPL 5s and one SPR S dropped out of the experiment, the Iatter before attending any treatment sessions. Following the tlvo ueek treatment period, the remaining 11 GPL and SPR Ss were randomly assigned to either high (H) or low (L) frequency follow-up groups. The former were telephoned three times each week for just over five weeks (follow-up was terminated due to the end of the semester), while L Ss were contacted once each week for the same period. Subjects in the ExC group were assigned to the H condition, as were the EfC SS, following their delayed treatment. AI1 CC Ss were assigned to the L condition.
line
FIG. 2.
DAYS OF TREATMENS
Daily group means during treatment period:
Study II.
As is made clear by Fig. 2, the GPL and SPR Ss again showed an immediate change in in smoking behavior after the first session. The two curves do not, however, exhibit the striking similarity found in study T. Although this is due primarily to the performance of one GPL S which elevates the GPL curve, there was a general tendency for SPR SS to do somewhat better than Ss in GPL. While the smoking behavior of the CC Ss remained essentially unchanged (an observation which would have been predicted by a look at population quit rates, see Bernstein, 1969), that of the EfC and ExC groups (especially the latter) shows immediate changes. The superior performance of ExC relative to EfC seems to confirm the intuitive notion that Ss who expect outside help following an unaided attempt at quitting wiil not do as well as S who cannot expect such hefp. At1 SPR Ss were successful in reducing smoking behavior below 25 per cent of baseline and three of four GPL Ss did so. Of the eight EfC Ss, only one was successful on his own while two of four ExC Ss ended the iirst two weeks below 25 per cent of baseline. Two EfC Ss refused treatment after their delay period through neither reduced smoking significantly while waiting. The remaining six EfC Ss were run in either GPL or SPR and all were successful in reducing their smoking during both delayed treatments.
138
DOUGLAS
A. BERNSTEIN
36 t 0 32 i
16 k :I2 $8 $4 r 0
0 3 5 7 1012 1417 19 21 24262831333538 DAYS SINCE
TREATMENT
FIG. 3. Follow-up
data:
Study Il.
Follow-up assessments (see Fig. 3), indicated that, while frequency of contact was not an effective variable (at least the frequencies employed) in maintaining treatment period gains, the post-treatment relationship between SPR and GPL curves found in Study I again obtained here. The differences were even more clear cut in this case, however, with SPR Ss smoking at about 15 per cent of their pretreatment rate (only one relapsed) as compared to the two of three successful GPL Ss who had essentially returned to their old rate. Follow-up data on EfC Ss who received delayed GPL or SPR treatment show no comparable difference in relapse rate (one in each group relapsed). STUDY The final experiment represents a replication important differences should be noted.
III and expansion
of Study II, though several
Subjects A total of 23 male and 25 female Northwestern University undergraduate volunteers served as Ss. Females were included due to a lack of sufficient numbers of male volunteers. Pre-assessments As a supplement to the information collected at the standard screening interview, all Ss were administered the Pittsburgh Social Extroversion-Introversion and Emotionality Scales (which contain the MMPI L scale) (Bendig, 1962), the Rotter Internal-External Control Scale (I-E) (Rotter, Seeman and Liverant, 1962), and the Barber Suggestibility Scale (BBS). The principal investigator conducted all interviews but had no further contact with the Ss. Experimenters Two male first-year graduate students in psychology were paid to act as experimenters and were trained by the principal investigator. Neither E was informed of the results of Studies I and II. Each E conducted one group of six Ss in each of the four conditions of the experiment.
THE MODIFICATION
OF SMOKING BEHAVIOR:
A SEARCH FOR EFFECTIVE VARIABLES
139
Procedure
A total of 12 Ss were assigned Because of the paucity of acceptable
to each
of four
SPR, GPL, was dropped.
groups:
Ss, the CC condition
EfC and ExC.
Post-assessments
At the conclusion of the second treatment week, follow-up calls began on either a high frequency (HF) or a low frequency (LF) basis. Attempts were made to contact Ss randomly assigned to HF three times each week while LF Ss received a call once a month. Since the follow-up variable was not effective in Study II, this increase in the contact intensity difference between HF and LF was aimed at increasing the probability of picking up some effect of frequency (even if it only meant greater relapse at very low frequency). In an attempt to minimize expectancy effects (Rosenthal, 1966) which might influence the data generated in this experiment, the following procedures were adopted: (a) no data, collected by either E, were available for inspection by the principal investigator until all Ss (including those receiving delayed treatment) were in the follow-up stage, (b) neither E was informed that the GPL procedure was a placebo condition, and (c) the research assistant making the follow-up calls turned in her data in written form for examination by the principal investigator. In order to assess Es’ expectancies about the study, each was asked to provide, prior to contacting any Ss, but after training, a written results he expected to be generated by the research design.
statement
detailing
the
RESULTS A total of seven Ss dropped out of the study prior to completion and, thus, the bulk of the data reported in this section is based upon the performance of the remaining 39 Ss. Pre-assessments
One way analyses of variance were performed for each of the six pre-assessment scales. There were no significant main effects for any of these analyses, indicating that the treatment groups did not differ in terms of the personality measures employed. A repeated measures analysis of variance was performed on the smoking data reported over the seven days of the baseline period and showed no differences between groups in terms of level of pretreatment period smoking, no significant change in smoking level during the baseline period and no significant interaction between treatment groups and time. In addition, there was no significant difference between males and females in terms of the number of cigarettes smoked over the baseline period (t= l-62, df=37).* Since it seemed at least indirectly relevant to the issue of accuracy of self-report data, each S’s estimate of his average daily consumption (as reported at the screening interview) was correlated with his mean daily consumption data collected during the baseline week. The product-moment coefficient was +O-69 (p> O-0005) and the mean of the actual performance data was less than that of the estimates.
* Summary tables and raw data relevant to all analyses reported in this paper, as well as data for Ss receiving delayed treatment are available from the author upon request.
DOCGLAS
110
.A. BERNSTEIN
Treatment
Treatment group means for each day of the treatment period are plotted in Fig, 4. The difference bft\veen mean baseline performance and mean first treatment day performance for SPR, GPL and E\C groups \\;is significant (f=9.05, dJ-= 33. p
24 t k 0 227
,kl
EfC
iN
II)
SPR
!N
9)
91
IO)
0’Bose-’ llne
! I
I
2
’
3
DAYS
i
4* OF
I
I
/
4
I
I
6
7
a
9
to
II
TREATMENT
FIG. 3. Daily group means during treatment period:
Study III
More detailed assessment of the treatment main effect was accomplished by a Duncan Multiple Range Test, corrected for unequal IV (Edwards, 1963; Kramer, 1956), performed on the mean total number of cigarettes smoked per day over the entire treatment period for the four treatment groups. The results indicated that the EfC and ExC groups each differed significantly (p-cO.01,r/f=31) from each other and (in opposite directions) from the SPR and GPL groups, kvhich did not themselves differ significantly. The main effect of Days was si_cnificant (~-CO-OOS),as \vas its linear component (p< 0.005), attesting to the overall increase in smoking over the treatment period which, at first glance, looks to be due in large measure to the performance of thz EfC Ss. (The performance of those Ss at the end of treatment was not significantly different from their baseline rates: t= 145, df= 10). However, mean performance scores for the other three groups combined also showed a significant increase from first to last day of treatment (t=2*70, df=27,p
THE MODIFICATION
OF S!.lOKISG
0’
FIG. 5. Group
I
SPR
BEHAVIOR:
1
A SEARCH FOR EFFECTIVE VARLkBLES
I
GPL EfC CONDITION
141
I
EXC
treatment period means plotted by experimenter: Study III.
As was the case during baseline, there was no significant difference performance of males and females during treatment (t=0.51, 4’=37).
between the overall
Since to many researchers interested in the modification of smoking behavior, presentation of data in terms of absolute levels of smoking is unsatisfactory, a supplementary analysis of the treatment period data was performed in which S’s reduction was assessed in The treatment variable was again found to be terms of percentage of his own baseline. significant. Behavior change over treatment was also examined in relation to the personality data collected prior to the experimental manipulation. This involved correlation, within each treatment group, of scores on five of the six personality scales (BSS performance, Rotter I-E, Extroversion, Emotionality and L Scale) with mean daily consumption during the last two days of treatment. The BSS subjective involvement score was not included in the analysis since it is so dependent upon the BSS performance score (the correlation between the two for the present sample was +0.89, p
30 28
Although LF Ss smolied more during that follow-up period tlmn did HF Ss, it seems clear that this is the result of the initial difference present at the onst’t of rht: follow-up period. This replicated the finding of Study II which indicated that follow-up contact
THE MODlFICATION
OF S?tOKING
BEHAVIOR:
X SEARCH
FOR EFFECTIVE
VhRIABLES
143
frequency was not an effective variable in terms of maintenance of behavior change. It is of some interest to note, incidentally, that the marked increase in smoking at 24 days after treatment corresponded exactly to the beginning of a week of final examinations.
28 26
il8g 165 14 6 IZg IOii
80 SPR IN 6,6.6,6.4) 0 GPL (N 8.5.5,6,7) a ExC (N: 9,6,5,7.6)
Z6 ‘;14 2-
I
FIG. 7. Follow-up
I
I
3
24
period data sent changing
I
87 59 DAYS SINCE TREATMENT
I
115
plotted by treatment condition. (Figures in parentheses N per data point over the follow-up period.)
repre-
As can be seen in Fig. 7, where follow-up performance is plotted by treatment condition, earlier findings indicating superiority of SPR over GPL in terms of reduction maintenance were not replicated. The impressive posttreatment performance of ExC, Ss apparent in Fig. 3, also failed to replicate. DISCUSSION Perhaps the most significant replicated finding was that involving the treatment period performance of the SPR and GPL groups. As had been the case in both earlier studies, there was no difference in Study III between the groups in terms of their response to treatment. Thus, treatment data for the SPR and GPL groups in these studies support the hypothesis that the sufficient conditions for initial smoking behavior change in volunteer groups are met by the non-specific factors found in the GPL condition employed, namely participation in an experiment, expectation of change, suggestion, contact with an experimenter or leader and the like (e.g. Keutzer, 1968; Mees, 1966). They also fall into line with the growing body of data which indicates that some treatment is better than none, but that the specific nature of that treatment is not crucial (e.g. Keutzer, 1968; Koenig and Masters, 1965; Mees, 1966; Ober, 1966). Of equal significance was replication in the treatment period of Study III of the ExC effect in the second pilot study. If this effect is a general one (a total of only 14 Ss have been run in the ExC condition to date), it is clear that validation of any treatment requires demonstration of its superiority relative to both attention placebo “treatments” arzd individual effort (without expectation of help).
DOtiGLAS
111
A. BERNSTEIN
The magnitude of the reduction in smoking by SPR and GPL groups, both in terms of initial change and maintenance of change, was not as great in the final study as had been found earlier. In both Studies I and II, the means for SPR and GPL dropped immediately to nearly 0 and. in most cases, remained below 2.00 throughout treatment. In Study III neither mean dropped below 3.00 initially and, as was noted earlier, there was a general tendency to increase smoking significantly during the treatment period. It is as though the erfects found in the earlier studies are present but have been diluted, and since the treatment techniques themselves vvere changed in the third esperiment only in the direction of increased potency (e.g. luxurious reclining chairs and high quality earphones were employed in the GPL condition, and both SPR and GPL were run in a nearly soundproof laboratory), it seems reasonable to seek an explanation for this “washing-out” of effects in terms of (a) decreased ‘motivation” on the part of Northwestern Ss and (b) reduced competence of the esperirnenters involved in Study III. Lack of interest in the project at Northwestern was evidenced by the fact that three weeks of sustained advertising was required to recruit 48 acceptable Ss, and even that was accomplished only by opening the experiment to females. At Illinois, an adequate number of Ss was obtained through a single announcement. The graduate student experimenters, though trained for a month prior to Study III, were not as knowledgeable about smoking and its modification as the principal investigator (who had conducted Studies I and II). It is highly probable that their relativte lack of information and confidence had an impact upon their Ss (Rosenthal, 1966). The question of vvhy, when other effects were being diluted by these factors, the ExC effect was apparently unaffected during the treatment period, must remain unanswered at this point. Perhaps a single ExC contact with a less than fully competent E is insufhcient to dilute the effect of ExC instructions. Methodological
considerations
Several methodological isssues relating to smoking modification research in general deserve consideration here. One of these, relating to the acceptability of self-report measures in such research, had been discussed elsewhere (Bernstein, 1969) and will be mentioned again only briefly in order to relate certain aspects of the present results to it. No efforts were made to assess the accuracy of the self-report data obtained in the experiments reported here since no reasonable technique for doing so reliably and nonreactively has yet been developed. However, the significant (p <0.0005) correlation of + 0.69 obtained between baseline estimates and baseline recording reports was encouraging, especially when it was noted that, on the average, Ss’ estimates tended to exceed their subsequent reports. This finding contradicts that of Hoinville and Biggs (1966) and Todd and Laws (1959), which described the opposite relationship between unrecorded estimates and behavior. The discrepancy might be explained in terms of the effect of baseline recording. It can be argued that the baseline recording procedures themselves are reacti1.e measures and thus, by drawing S’s attention to his smokin g, or whatever, reduce the amount of smoking If this were the case in the present study,‘and it occurring during the baseline period. cannot be ruled out as impossible, the effect was immediate and constant since the analysis of variance on the baseline data for all Ss revealed no significant effect of time on baseline performance. Still, it was not possible in the present series of studies to determine precisely the degree to which Ss’ reports of smoking behavior reflected actual frequencies. This problem, though
THE SlODIFICATION
common alchouglt
OF S?.fOI;ING
to all smoking modj~cation its solution is a prerequisite
BEHAVIOR:
A SEARCH
FOR EFFECTIVE VARIABLES
research, has not received serious attention for truly adequate research in the area.
I45
to date,
Another issue involving method is at least as crucial as that of data accuracy and concerns assurance that the data, however accurate, will, in fact, be collectable. In the present research, the factor mainly responsible for the difficulty encountered in attempting interpretation, or even description of experimental effects was that of incomplete contact with Ss, both during and after treatment. While absences during treatment do not usually result in irrevocable data loss, they can, if frequent enough, compromise the reasonableness of including the Ss involved in their assigned groups for purposes of analysis. After treatment has been concluded, gaps in contact are obviously more serious. An exce&nt technique for reducing the probability of treatment period attribution has been employed by Mees (1966) but did not come to the present author’s attention until after Study III was underway. Mees (1966) and Keutzer (1968) required each 5” to place a $20 deposit which was returned at the conclusion of treatment. Modification of the refund contingency such that one or more absences from treatment sessions would result in forfeit of the deposit might be extremely effective in keeping attendence at near 100 per cent throughout the treatment period. The problems of maintaining post-treatment contact are somewhat more difficult. One solution might be to arrange to pay Ss for phonin g or mailing their follow-up data at specified intervals. It would have to be made clear to the Ss, of course, that payment will be made regardless of the nature of the report, thus placing the emphasis on accuracy rather than “goodness” in the data. If one’s interest in follow-up data is primarily in terms of smoking (in any amount) vs. non-smoking, an alternative procedure might be developed where paid research assistants observe .Ss in public places where smoking is permitted and record the presence or absence of smoking behavior. The observations could be made at several sites and at varying times of the day, week and semester (if college Ss are used) such that the probability of a systematic bias (resulting in an excessive number of false negatives) would be reduced. Systematic observation of Ss in specially contrived, though non-reactive waiting areas where “pull” or temptation to smoke can be varied experimentally might also provide valuable, though incomplete data. These suggestions are meant only to indicate the direction in which more reliable followup contact procedures might evolve. The range of alternatives which are testable is limited onIy by the bounds of the experimenter’s ingenuity. The point is that the lack of more sophisticated techniques makes the need for more imaginative use and development of presently available tools a necessity if the status of research on the modification of smoking behavior is to be elevated.
REFERENCES T. S. and CALVERLEYD. S. (1963) “Hyunotic-1ike” sff~~estibility in _sot. Psycho/. 66,589~597. . -BENDIG A. W. (1962) The Pittsburgh scales of social extroversion-introversion BARBER
children and adults. 1. &norm. and emotionality, J. Psychol.
53, 199-209. BERNSTEIN D. A. (in press) The modification of smoking behavior: an evaluative review. Psychol. Bull. BROWN J. A. C. (1963) The nature and treatment of smoking, Med. Wd Land. 98, 187-192.
146
DOUGLAS .A. BERSSTEIN
EDWARDS A. L. (1960)
Experinrmfal
Design in Psychological
Research.
Holt. Rinehart &
\\‘inston,
Sew
York. f-bCHBAW4
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