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Aversive control of smoking behavior in a group context
Behav, Res. & Therapy, 1972, Vol. 10, pp, 97 to 104. Pergamon Press. Printed in England
AVERSIVE CONTROL OF SMOKING BEHAVIOR IN A GROUP CONTEXT* THOMAS L. WHITMANt University of Notre Dame, Notre Dame, Indiana, U.S.A. (Received 30 July 1971)
Summary-Two procedures designed to modify smoking behavior were compared. Each involved the selfadministration of an aversive taste substance contingent upon and concomitant with the smoking response. For one of the treatment groups, Ss received supervision and support through periodic group meetings while Ss in the other treatment group did not receive this group contact. Two control groups, one consisting of Ss who applied for but did not receive treatment and another of Ss who did not seek treatment, were used to evaluate extra-therapeutic and motivational factors. The smoking behavior of these groups was evaluated at the termination of treatment and at one and six-month follow-ups. At the termination of the clinic the group-aversive, individual-aversive and the apply control Ss all displayed a significant reduction in their smoking behavior, with the group-aversive Ss showing a reliably greater reduction than the latter two groups. At the one and six-month follow-ups the two treatment and the apply control groups, which still showed a significant reduction in smoking, were no longer reliably different from each other. In contrast, Ss who Iid not apply for treatment showed no changes in their smoking behavior during the study. The importance of the S motivation factor in self-control of smoking was discussed.
AMONG the wide range of behavioral methods designed to inhibit and extinguish smoking, more attention has been given to the development and evaluation of aversive control techniques than to any other single approach. The list of aversive stimuli applied to the smoking response include: shock, self and other-administered (Powell and Azrin, 1968; Whitman, 1969; Gendreau and Dodwell, 1968); hot smoky air (Wilde, 1964; Grimaldi and Lichtenstein, 1969; Lublin and Joslyn, 1968),covert images (Tooley and Frank, 1967), white noise (Green, 1964) and fear-arousing communications (Leventhal, Watts and Pagano,1967; and Ober, 1968). Aversive techniques attempt to modify smoking behavior in one of two ways: By making the aversive stimulus operantly contingent upon the occurrence of one aspect of the smoking act (e.g. shock administered as a person takes a cigarette out of the package), thus inhibiting the total response; or by pairing contiguously the total smoking response with a noxious stimulus, thus developing a conditioned aversion response within the subject and a consequent conditioned avoidance response. In developing an effectiveaversive technique for controlling smoking behavior, multiple factors need to be considered: (1) The "aversive" stimulus must indeed be aversive; (2) its mode of administration should be reasonably convenient; (3) if possible, it should be possible to administer the procedure wherever and whenever the response naturally occurs and (4) provision should be made to ensure that the smoker correctly utilizes the * This research was supported by grants from the St. Joseph Cancer Society and the Anti-Tobacco Center of America. t The author wishes to express his appreciation to Les Fox, Ann Kovas, Lou Kenny and Edie Parker for their assistance in the conducting of this study. Reprints may be obtained from the author, Department of Psychology, University of Notre Dame, Notre Dame, Indiana, U.S.A., 46556.
97
98
THOMAS L. WHITMAN
procedure . As implied in this last statement, the ultimate effectiveness of any smoking modification procedure is related to the subject's " motivation" to break his habit. As Keutzer, Lichtenstein and Mees (1968) point out, although differences in motivation to stop are widely recognized in the literature, behavior modification technology seldom takes this factor into consideration. The issue of subject motivation is important for two reasons. First, the failure of a technique to modify smoking behavior may not be due to the technique per se but to the subject's failure to use the technique. In applying and evaluating techniques which demand self-administration of an aversive stimulus, it would seem particularly important to insure that the subject utilizes the procedure. Second, the subject who has a greater motivation to break his habit may show improvement for reasons unrelated to the treatment administered. It has been pointed out in various therapeutic contexts (Bernstein, 1969; Whitman, 1969; Goldstein, 1962; and Rogers and Dymond, 1954) that subjects who apply for treatment and expect to receive help, but do not, often show improvement. This suggests that a "motivated" subject administers to himself his own modification program outside of the context of formal treatment. The present study sought to simultaneously examine: (I) the effectiveness of a selfadministered aversive procedure, (2) the utility of a structured motivation procedure , and (3) the importance of subject's initial motivation to give up smoking, as each of these factors related to sustained reduction in smoking behavior. The aversive agent, a noxious taste substance was self-administered in alI instances. One group of subjects received periodic supervision and support through group meetings with regard to the utilization of this procedure while a second group was not given this support. Frequency of utilization of the aversive procedure as well as reduction in smoking was monitored. The smoking behavior of two additional comparison groups of subjects, one who applied for but did not receive help and one who neither applied nor received help, was also evaluated. One and six-month follow-ups of the smoking behavior of all groups was conducted. METHOD Subjects InitialIy 146 subjects applied to a smoking clinic" which was advertised over the mass media. In addition 36 Ss who were smokers but who did not desire to join the clinic were obtained through a random telephone procedure. Twenty-four of the one-hundred and eighty-two Ss were not included in the final analysis either because they failed to attend at least four of the treatment sessions, or because complete data concerning their smoking behavior could not be obtained. The remaining 158 Ss included 68 males and 90 females (Mean age=41.45 years, Range= 16-73 years) who smoked 10or more cigarettes (X=30.06 cigarettes; Range=lo-60 cigarettes) for at least 2 years (X=21.90 years; Range=2-43 years).
Design andprocedure All subjects who applied to the smoking clinic attended an initial meeting where the basic background data concerning their smoking habits was obtained. Subjects, matched on the basis of age, sex, number of cigarettes smoked, and number of years smoked prior to the clinic were assigned to one of the two treatment groups or to a control group (ApplyControl). The second control group (No Apply-Control) which was obtained via the random telephone procedure smoked significantly less cigarettes per day (X=24.85; • This clinic was sponsored by the St. Joseph County Cancer Society in South Bend, Indiana.
AVERSIVE CONTROL OF SMOKING BEHAVIOR IN A GROUP CONTEXT
99
Range = 13-60) than the apply control and treatment groups but were not significantly different on any of the other aforementioned parameters. Group-aversive treatment (N=24). The group leaders were volunteers (one male, one female) from the South Bend community. Both group leaders were former smokers. Neither of the leaders had professional clinical training but both as part of their professional careers had experience in working with people in a variety of group situations. Prior to the clinic they were given formal training in leading their discussion groups. Each leader had 12 smokers assigned to his group. The purpose of this condition was: (1) to present to the subject basic information concerning the rationale for and method involved in administering the aversive technique and (2) to encourage the subject to utilize the techniques. Subjects attended six one-hour sessions over a six week period. The aversive agent was a pill containing a variety of food substances (ginger, licorice, coriander, clove, menthol and natural flavoring) which when placed in the mouth created, after about two minutes time, a burning sensation along with a bitter taste. Subjects utilizing the pill were instructed: (l) to change their brand of cigarettes, (2) to take (when they had a desire for a cigarette) a tablet and suck on it until it was about one-half dissolved and (3) then to light a cigarette when they had the partially consumed tablet in their mouth. In discussing the rationale for the aversive treatments subjects were told that people smoked because the act of smoking was associated with many pleasurable events. It was explained further that the pill, if taken properly, would disassociate pleasure from the smoking response thus creating an avoidance rather than an approach response to cigarettes. This basic information was provided at the first meeting and periodically reviewed during the remaining meetings. All subjects were given a large supply of pills at this first meeting and ready access to more if they happened to run out. During the five remaining meetings the group sessions were focused upon an inquiry concerning whether the technique was being utilized faithfully, and if it was not, finding out the Ss' reasons for being negligent. Smokers were continually encouraged to adhere to the prescribed procedure and were praised when such adherence occurred. Individual-aversive treatment (N=77). This treatment condition was identical to the aversive group treatment except that they did not attend the six group meetings. The procedure for taking the aversive agent, its rationale, and the importance of adhering to procedure were presented and stressed in a group context during an hour meeting. The subjects in this treatment condition were also given a large supply of tablets and ready access to more if they needed them. Apply control (N=30). This group of subjects was randomly drawn from the same population of subjects as the treatment groups. After the initial meeting where background information of the smokers applying to clinic was gathered and prior to the beginning of treatment, subjects in this group were informed that the quota of people the clinic could comfortably handle was reached and that they would be given an opportunity to participate in the next smoking clinic. No-apply control (N=27). Subjects in this group were drawn at random from the local telephone book and contacted via telephone. They were told that the South Bend Cancer Society was conducting a smoking survey tracing the smoking habits of people in the community and were asked if they would participate by answering some questions. If they agreed data concerning their age, number of years smoked and number of cigarettes
100
THOMAS L. WHITMAN
smoked daily was then obtained. They were then informed that as part of the survey they would be called two more times in the future to see how many cigarettes they were smoking.
Measurement of smoking behavior Before treatment, immediately upon the termination of treatment and one and six months after treatment smoking records were obtained from the treatment and control subjects. The subjects in the treatment groups were also required to keep track of the number of times they took the pills. Although daily smoking records were requested from these subjects this data was not systematically reported. RESULTS The dependent measures consisted of number of cigarettes smoked: (l) prior to treatment, (2) at the termination of treatment, and (3) one month and (4) six months after the termination of treatment. These data were available for all treatment groups and the apply control group. The smoking behavior of the no-apply control was not obtained at the termination of treatment but was recorded for the other periods. The mean number of cigarettes smoked by the treatment and control groups at these measurement periods can be obtained from Table 1. TABLE 1. NUMBER OF CTGARETIES SMOKED BY TREATMENT AND CONTROL GROUPS PRIOR TO TREATMENT (I), AT TERMINATION OF TREATMENT (In, AT ONE MONTH FOLLOW-UP (III), AND AT SIX MONTH FOLLOW-UP (IV)
I
II
III
IV
Group-aversive
31.29
13.08
20.75
22.54
Individual-aversive
31.44
20.65
21.48
22.16
Apply control
30.27
23.23
22.60
25.03
No-apply control*
24.85
24.48
24.93
Treatments
* The smoking rate of the No-Apply Control Group was not assessed at the termination of the clinic.
A 3 X 2 analysis of variance was performed compairing the number of cigarettes smoked by the two treatment groups and the apply control group prior to treatment with their smoking behavior at the termination of treatment. The analysis is summarized in Table 2 and the means may be obtained from Table 1. As seen, the treatments x measurement periods interaction was significant [F(2,128)=4.95, p
101
AVERSIVE CONTROL OF SMOKING BEHAVIOR IN A GROUP CONTEXT
TABLE 2. SUMMARIES OF ANALYSES OF VARIANCE COMPARING NUMBER OF CIGARETIES SMOKED BY THE TWO TREATMENT AND THE APPLY CONTROL GROUPS PRIOR TO TREATMENT (I), AT TERMINATION OF CLINIC (II) AND AT ONE MONTH FOLLOW-UP (11I)*
I-II Source Between Ss Groups (A)
df
MS
130
228.82
F
II-III p
MS
2
333.13
501.08
128
227.19
374.68
Within Ss
131
154.78
61.96
AXB Error
p
376.63
Error
Measurement periods (B)
F
8349.01
96.52
0.00
200.16
3.47
0.06
2
427.84
4.95
0.01
268.90
4.66
om
128
86.50
57.64
* Because the smoking behavior of the no apply control was not obtained at the termination of the clinic this group was not included in these two analyses. comparisons indicated a significant remission in the smoking behavior of subjects in the group-aversive condition while no significant changes in the smoking behavior of subjects in the individual-aversive and apply control conditions occurred. At this one month follow-up there were no longer any significant differences between the smoking behavior of the three groups. A 4 x 2 analysis of variance was performed comparing the number of cigarettes smoked by two treatment and two controls prior to treatment with their smoking behavior one month after treatment (see Table 3). The treatment x measurement periods interaction was significant [F(3,154)=5.54, p
I-III Source
F
I-IV
df
MS
157
242.69
212.90
3
45.96
78.10
Error
154
246.53
215.53
Within Ss
158
97.63
106.90
Between Ss Group (A)
Measurement periods (B)
p
MS
F
P
5024.03
82.42
0.00
3691.14
46.44
0.00
5.54
0.00
319.38
4.02
0.01
AXB
3
337.68
Error
154
60.96
79.49
102
THOMAS L. WHITMAN
In order to assess whether there were significant increments or decrements in the smoking behavior of two treatment and two control groups between the one month and six month follow-ups, a 4 x 2 analysis of variance was conducted. Nonsignificant measurement periods [F(l, 154)=0.18] and treatment x measurement period effects [F(3,154) = 1.23, p < 0.27] indicated that such changes did not occur. A 4 x 2 analysis of variance was also performed comparing the smoking behavior of the two treatment and two control groups prior to treatment with their smoking behavior six months after treatment (see Table 3). As at the one month follow-up the treatment x measurement periods interaction was significant [F(3,154)=4.02, p < 0.01]. Multiple comparisons similarly indicated that the reductions in the smoking behavior of the two treatment and the apply control groups were significant but that no significant change in the smoking behavior of the no-apply control group had occurred.
Therapist effectiveness The differential effectiveness of the two group discussion leaders was measured by the amount of reduction in smoking manifested by subjects in their respective groups. A simple analysis of variance indicated no significant difference between them (F < 1). Correlational and other data In order to evaluate the extent to which subjects followed the recommended aversive procedure smokers in the individual and group-aversive conditions kept records of the number of pills taken. Subjects in the individual-aversive conditions followed directions, that is, took a pill before taking a cigarette on an average of only 3 per cent of the time while subjects in the group-aversive condition took the pill 40 per cent of the time. Product-moment correlations between the average per cent of pills taken and the amount of reduction shown from the beginning to the termination of the clinic was low and nonsignificant for subjects in the individual-aversive condition (r=0.04) and low but significant for subjects in the group-aversive condition (r=0.41, p<0.025). Product-moment correlations between average per cent of pills by a subject and amount of reduction from beginning of clinic to six months after the clinic were low and nonsignificant for both subjects in the individual- (r= -0.02) and group-aversive conditions (r= -0.03). DISCUSSION In this study three factors seem to be operating in combination to promote a reduction in smoking: group meetings, the aversive procedure and subject motivation. First, subjects who met together as a group were more disposed to take the pills (41 per cent of the time) than subjects who were left unmonitored in their use of this aversive procedure (3 per cent of the time). Second, subjects who used the aversive procedure (pills) showed a greater initial (at termination of clinic) reduction in smoking than subjects who didn't use the procedure. That is, the group-aversive subjects showed a greater reduction in smoking when compared at the termination of the clinic with individual-aversive subjects. Further evidence that it was the aversive procedure that was responsible for the temporary reduction in smoking manifested by the group-aversive subjects, is pointed out by the significant correlation between number of pills taken and amount of reduction shown by these subjects. The third factor which appears to be related to reduction in smoking is subject motivation. Whitman (1969) has pointed out that control subjects who applied for but did not receive treatment nevertheless showed a significant and sustained reduction in smoking. A similar result was found in this study. The amount and trend of reduction of the apply
AVERSIVE CONTROL OF SMOKING BEHAVIOR IN A GROUP CONTEXT
103
control group is in marked contrast to the control Ss who did not seek treatment and who showed no change in their smoking behavior but is quite similar to that displayed by the individual-aversive subjects. Perhaps the similarity in performance of the individualaversive and apply control groups can be attributed to the fact that the individual-aversive group in essence rejected treatment by not utilizing the aversive procedure and thus were left without any systematic means of changing their smoking habit. The fact that both the individual-aversive and apply control groups did show a reduction in smoking suggests that Ss in both groups probably borrowed or developed of their own accord some alternate smoking modification method. The aversive procedure as a technique for reducing smoking appears to be useful; however, this study points out several of its undesirable aspects. Although the groupaversive subjects showed substantially more reduction in smoking than the apply control group at the termination of the clinic, at the one month follow-up this group displayed a significant increment in smoking and were no longer significantly different from the apply control subjects. Moreover, the low and nonsignificant correlation between the number of pills taken and the amount of reduction in smoking at the six-month follow-up suggests that the pill is no longer responsible for sustaining the reduction that occurred at this point. Thus, the pill appears to have only a temporary effect on smoking behavior. A second and already mentioned disadvantage of the aversive procedure is the fact that smokers do not use it when given the procedure in an unmonitored fashion. Moreover, even subjects who are supervised and encouraged to use the procedure via group meeting show resistance in using the procedure as prescribed. This is not, however, unique to only this type of procedure. Whitman (1969) has shown that subjects given self-control procedures based on operant conditioning principles also use them infrequently. At the present time the major problem in developing an approach for helping people to reduce or give up smoking may well not only be in finding the " right" treatment procedure but in motivating smokers to use already established techniques. That is, subjects who apply to smoking clinics and are apparently "motivated" to give up smoking need to be further motivated to use the recommended procedures . On the basis of this study, periodic group meetings appear to be a helpful procedure for sustaining motivation and insuring appropriate utilization of a suggested smoking control technique. However, the fact that the group-aversive Ss showed a significant remission in smoking at the one month follow-up suggests that it would be beneficial for the smokers to have the group procedure extended at least on an intermittent basis over a longer period of time. In general, in conducting a smoking clinic, regardless of what procedure is being employed to inhibit smoking behavior, it would seem advisable to gradually detach the smoker from the clinic and procedure rather than abruptly discontinuing treatment at a predetermined time. REFERENCES BERNSTEIN D. A. (1969) Modification of smoking: An evaluative review. Psychol. Bull. 71, 41~40. GENDREAU P. E. and DODWELL P. C. (1968) An aversive treatment for addicted cigarette smokers: Preliminary report. Can. Psychol. 9, 28-34. GOLDSTEIN A. (1962) Therapist-Patient Expectancies in Psychotherapy. Pergamon Press Book, MacMillan Co., New York. GREEN R. (1964) Modification of smoking behavior by free operant conditioning methods. Psychol. Rec. 14, 171-178.
GRIMALDI KAREN E. and LICHTENSTEIN E. (1969) Hot, smoky air as an aversive stimulus in the treatment of smoking. Behav. Res. & Therapy 7, 275-282. KEUTZER CAROL S., LICHTENSTEIN E. and MEES H. L. (1968) Modification of smoking behavior: a review. Psychol. Bull. 70, 520-533.
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LEVENTHAL H., WAITS J. and PAGANO F. (1967) Effects of fear and instructions on how to cope with danger. J. Person. soc. Psychol. 6, 313-321. LUBLIN I. and JOSLYN L. (1968) Aversive conditioning of cigarette addiction. Paper read at the meeting of the American Psychological Association, Los Angeles, September, 1968. OBER D. (1968) Modification of smoking behavior. J. consult. din. Psychol. 32, 543-549. POWELL J. and AZRIN N. (1969) The effects of shock as a punisher for cigarette smoking. J. appl. Behav, Anal. 1,63-71. ROGERS C. R. and DYMOND R. F. (Eds.) (1954) Psychotherapy and Personality Change. University of Chicago Press, Chicago. TOOLEY J. T. and PRATT S. (1967) An experimental procedure for the extinction of smoking behavior. Psychol. Rec. 17, 209-218. WmTMAN T. (1969) Modification of chronic smoking behavior: A comparison of three approaches. Behav. Res. & Therapy 7, 257-263. WILDE G. (1964) Behavior therapy of addicted cigarette smokers: A preliminary investigation. Behav. Res. & Therapy 2,107-109.
AVERSIVE CONTROL OF SMOKING BEHAVIOR IN A GROUP CONTEXT* THOMAS L. WHITMANt University of Notre Dame, Notre Dame, Indiana, U.S.A. (Received 30 July 1971)
Summary-Two procedures designed to modify smoking behavior were compared. Each involved the selfadministration of an aversive taste substance contingent upon and concomitant with the smoking response. For one of the treatment groups, Ss received supervision and support through periodic group meetings while Ss in the other treatment group did not receive this group contact. Two control groups, one consisting of Ss who applied for but did not receive treatment and another of Ss who did not seek treatment, were used to evaluate extra-therapeutic and motivational factors. The smoking behavior of these groups was evaluated at the termination of treatment and at one and six-month follow-ups. At the termination of the clinic the group-aversive, individual-aversive and the apply control Ss all displayed a significant reduction in their smoking behavior, with the group-aversive Ss showing a reliably greater reduction than the latter two groups. At the one and six-month follow-ups the two treatment and the apply control groups, which still showed a significant reduction in smoking, were no longer reliably different from each other. In contrast, Ss who Iid not apply for treatment showed no changes in their smoking behavior during the study. The importance of the S motivation factor in self-control of smoking was discussed.
AMONG the wide range of behavioral methods designed to inhibit and extinguish smoking, more attention has been given to the development and evaluation of aversive control techniques than to any other single approach. The list of aversive stimuli applied to the smoking response include: shock, self and other-administered (Powell and Azrin, 1968; Whitman, 1969; Gendreau and Dodwell, 1968); hot smoky air (Wilde, 1964; Grimaldi and Lichtenstein, 1969; Lublin and Joslyn, 1968),covert images (Tooley and Frank, 1967), white noise (Green, 1964) and fear-arousing communications (Leventhal, Watts and Pagano,1967; and Ober, 1968). Aversive techniques attempt to modify smoking behavior in one of two ways: By making the aversive stimulus operantly contingent upon the occurrence of one aspect of the smoking act (e.g. shock administered as a person takes a cigarette out of the package), thus inhibiting the total response; or by pairing contiguously the total smoking response with a noxious stimulus, thus developing a conditioned aversion response within the subject and a consequent conditioned avoidance response. In developing an effectiveaversive technique for controlling smoking behavior, multiple factors need to be considered: (1) The "aversive" stimulus must indeed be aversive; (2) its mode of administration should be reasonably convenient; (3) if possible, it should be possible to administer the procedure wherever and whenever the response naturally occurs and (4) provision should be made to ensure that the smoker correctly utilizes the * This research was supported by grants from the St. Joseph Cancer Society and the Anti-Tobacco Center of America. t The author wishes to express his appreciation to Les Fox, Ann Kovas, Lou Kenny and Edie Parker for their assistance in the conducting of this study. Reprints may be obtained from the author, Department of Psychology, University of Notre Dame, Notre Dame, Indiana, U.S.A., 46556.
97
98
THOMAS L. WHITMAN
procedure . As implied in this last statement, the ultimate effectiveness of any smoking modification procedure is related to the subject's " motivation" to break his habit. As Keutzer, Lichtenstein and Mees (1968) point out, although differences in motivation to stop are widely recognized in the literature, behavior modification technology seldom takes this factor into consideration. The issue of subject motivation is important for two reasons. First, the failure of a technique to modify smoking behavior may not be due to the technique per se but to the subject's failure to use the technique. In applying and evaluating techniques which demand self-administration of an aversive stimulus, it would seem particularly important to insure that the subject utilizes the procedure. Second, the subject who has a greater motivation to break his habit may show improvement for reasons unrelated to the treatment administered. It has been pointed out in various therapeutic contexts (Bernstein, 1969; Whitman, 1969; Goldstein, 1962; and Rogers and Dymond, 1954) that subjects who apply for treatment and expect to receive help, but do not, often show improvement. This suggests that a "motivated" subject administers to himself his own modification program outside of the context of formal treatment. The present study sought to simultaneously examine: (I) the effectiveness of a selfadministered aversive procedure, (2) the utility of a structured motivation procedure , and (3) the importance of subject's initial motivation to give up smoking, as each of these factors related to sustained reduction in smoking behavior. The aversive agent, a noxious taste substance was self-administered in alI instances. One group of subjects received periodic supervision and support through group meetings with regard to the utilization of this procedure while a second group was not given this support. Frequency of utilization of the aversive procedure as well as reduction in smoking was monitored. The smoking behavior of two additional comparison groups of subjects, one who applied for but did not receive help and one who neither applied nor received help, was also evaluated. One and six-month follow-ups of the smoking behavior of all groups was conducted. METHOD Subjects InitialIy 146 subjects applied to a smoking clinic" which was advertised over the mass media. In addition 36 Ss who were smokers but who did not desire to join the clinic were obtained through a random telephone procedure. Twenty-four of the one-hundred and eighty-two Ss were not included in the final analysis either because they failed to attend at least four of the treatment sessions, or because complete data concerning their smoking behavior could not be obtained. The remaining 158 Ss included 68 males and 90 females (Mean age=41.45 years, Range= 16-73 years) who smoked 10or more cigarettes (X=30.06 cigarettes; Range=lo-60 cigarettes) for at least 2 years (X=21.90 years; Range=2-43 years).
Design andprocedure All subjects who applied to the smoking clinic attended an initial meeting where the basic background data concerning their smoking habits was obtained. Subjects, matched on the basis of age, sex, number of cigarettes smoked, and number of years smoked prior to the clinic were assigned to one of the two treatment groups or to a control group (ApplyControl). The second control group (No Apply-Control) which was obtained via the random telephone procedure smoked significantly less cigarettes per day (X=24.85; • This clinic was sponsored by the St. Joseph County Cancer Society in South Bend, Indiana.
AVERSIVE CONTROL OF SMOKING BEHAVIOR IN A GROUP CONTEXT
99
Range = 13-60) than the apply control and treatment groups but were not significantly different on any of the other aforementioned parameters. Group-aversive treatment (N=24). The group leaders were volunteers (one male, one female) from the South Bend community. Both group leaders were former smokers. Neither of the leaders had professional clinical training but both as part of their professional careers had experience in working with people in a variety of group situations. Prior to the clinic they were given formal training in leading their discussion groups. Each leader had 12 smokers assigned to his group. The purpose of this condition was: (1) to present to the subject basic information concerning the rationale for and method involved in administering the aversive technique and (2) to encourage the subject to utilize the techniques. Subjects attended six one-hour sessions over a six week period. The aversive agent was a pill containing a variety of food substances (ginger, licorice, coriander, clove, menthol and natural flavoring) which when placed in the mouth created, after about two minutes time, a burning sensation along with a bitter taste. Subjects utilizing the pill were instructed: (l) to change their brand of cigarettes, (2) to take (when they had a desire for a cigarette) a tablet and suck on it until it was about one-half dissolved and (3) then to light a cigarette when they had the partially consumed tablet in their mouth. In discussing the rationale for the aversive treatments subjects were told that people smoked because the act of smoking was associated with many pleasurable events. It was explained further that the pill, if taken properly, would disassociate pleasure from the smoking response thus creating an avoidance rather than an approach response to cigarettes. This basic information was provided at the first meeting and periodically reviewed during the remaining meetings. All subjects were given a large supply of pills at this first meeting and ready access to more if they happened to run out. During the five remaining meetings the group sessions were focused upon an inquiry concerning whether the technique was being utilized faithfully, and if it was not, finding out the Ss' reasons for being negligent. Smokers were continually encouraged to adhere to the prescribed procedure and were praised when such adherence occurred. Individual-aversive treatment (N=77). This treatment condition was identical to the aversive group treatment except that they did not attend the six group meetings. The procedure for taking the aversive agent, its rationale, and the importance of adhering to procedure were presented and stressed in a group context during an hour meeting. The subjects in this treatment condition were also given a large supply of tablets and ready access to more if they needed them. Apply control (N=30). This group of subjects was randomly drawn from the same population of subjects as the treatment groups. After the initial meeting where background information of the smokers applying to clinic was gathered and prior to the beginning of treatment, subjects in this group were informed that the quota of people the clinic could comfortably handle was reached and that they would be given an opportunity to participate in the next smoking clinic. No-apply control (N=27). Subjects in this group were drawn at random from the local telephone book and contacted via telephone. They were told that the South Bend Cancer Society was conducting a smoking survey tracing the smoking habits of people in the community and were asked if they would participate by answering some questions. If they agreed data concerning their age, number of years smoked and number of cigarettes
100
THOMAS L. WHITMAN
smoked daily was then obtained. They were then informed that as part of the survey they would be called two more times in the future to see how many cigarettes they were smoking.
Measurement of smoking behavior Before treatment, immediately upon the termination of treatment and one and six months after treatment smoking records were obtained from the treatment and control subjects. The subjects in the treatment groups were also required to keep track of the number of times they took the pills. Although daily smoking records were requested from these subjects this data was not systematically reported. RESULTS The dependent measures consisted of number of cigarettes smoked: (l) prior to treatment, (2) at the termination of treatment, and (3) one month and (4) six months after the termination of treatment. These data were available for all treatment groups and the apply control group. The smoking behavior of the no-apply control was not obtained at the termination of treatment but was recorded for the other periods. The mean number of cigarettes smoked by the treatment and control groups at these measurement periods can be obtained from Table 1. TABLE 1. NUMBER OF CTGARETIES SMOKED BY TREATMENT AND CONTROL GROUPS PRIOR TO TREATMENT (I), AT TERMINATION OF TREATMENT (In, AT ONE MONTH FOLLOW-UP (III), AND AT SIX MONTH FOLLOW-UP (IV)
I
II
III
IV
Group-aversive
31.29
13.08
20.75
22.54
Individual-aversive
31.44
20.65
21.48
22.16
Apply control
30.27
23.23
22.60
25.03
No-apply control*
24.85
24.48
24.93
Treatments
* The smoking rate of the No-Apply Control Group was not assessed at the termination of the clinic.
A 3 X 2 analysis of variance was performed compairing the number of cigarettes smoked by the two treatment groups and the apply control group prior to treatment with their smoking behavior at the termination of treatment. The analysis is summarized in Table 2 and the means may be obtained from Table 1. As seen, the treatments x measurement periods interaction was significant [F(2,128)=4.95, p
101
AVERSIVE CONTROL OF SMOKING BEHAVIOR IN A GROUP CONTEXT
TABLE 2. SUMMARIES OF ANALYSES OF VARIANCE COMPARING NUMBER OF CIGARETIES SMOKED BY THE TWO TREATMENT AND THE APPLY CONTROL GROUPS PRIOR TO TREATMENT (I), AT TERMINATION OF CLINIC (II) AND AT ONE MONTH FOLLOW-UP (11I)*
I-II Source Between Ss Groups (A)
df
MS
130
228.82
F
II-III p
MS
2
333.13
501.08
128
227.19
374.68
Within Ss
131
154.78
61.96
AXB Error
p
376.63
Error
Measurement periods (B)
F
8349.01
96.52
0.00
200.16
3.47
0.06
2
427.84
4.95
0.01
268.90
4.66
om
128
86.50
57.64
* Because the smoking behavior of the no apply control was not obtained at the termination of the clinic this group was not included in these two analyses. comparisons indicated a significant remission in the smoking behavior of subjects in the group-aversive condition while no significant changes in the smoking behavior of subjects in the individual-aversive and apply control conditions occurred. At this one month follow-up there were no longer any significant differences between the smoking behavior of the three groups. A 4 x 2 analysis of variance was performed comparing the number of cigarettes smoked by two treatment and two controls prior to treatment with their smoking behavior one month after treatment (see Table 3). The treatment x measurement periods interaction was significant [F(3,154)=5.54, p
I-III Source
F
I-IV
df
MS
157
242.69
212.90
3
45.96
78.10
Error
154
246.53
215.53
Within Ss
158
97.63
106.90
Between Ss Group (A)
Measurement periods (B)
p
MS
F
P
5024.03
82.42
0.00
3691.14
46.44
0.00
5.54
0.00
319.38
4.02
0.01
AXB
3
337.68
Error
154
60.96
79.49
102
THOMAS L. WHITMAN
In order to assess whether there were significant increments or decrements in the smoking behavior of two treatment and two control groups between the one month and six month follow-ups, a 4 x 2 analysis of variance was conducted. Nonsignificant measurement periods [F(l, 154)=0.18] and treatment x measurement period effects [F(3,154) = 1.23, p < 0.27] indicated that such changes did not occur. A 4 x 2 analysis of variance was also performed comparing the smoking behavior of the two treatment and two control groups prior to treatment with their smoking behavior six months after treatment (see Table 3). As at the one month follow-up the treatment x measurement periods interaction was significant [F(3,154)=4.02, p < 0.01]. Multiple comparisons similarly indicated that the reductions in the smoking behavior of the two treatment and the apply control groups were significant but that no significant change in the smoking behavior of the no-apply control group had occurred.
Therapist effectiveness The differential effectiveness of the two group discussion leaders was measured by the amount of reduction in smoking manifested by subjects in their respective groups. A simple analysis of variance indicated no significant difference between them (F < 1). Correlational and other data In order to evaluate the extent to which subjects followed the recommended aversive procedure smokers in the individual and group-aversive conditions kept records of the number of pills taken. Subjects in the individual-aversive conditions followed directions, that is, took a pill before taking a cigarette on an average of only 3 per cent of the time while subjects in the group-aversive condition took the pill 40 per cent of the time. Product-moment correlations between the average per cent of pills taken and the amount of reduction shown from the beginning to the termination of the clinic was low and nonsignificant for subjects in the individual-aversive condition (r=0.04) and low but significant for subjects in the group-aversive condition (r=0.41, p<0.025). Product-moment correlations between average per cent of pills by a subject and amount of reduction from beginning of clinic to six months after the clinic were low and nonsignificant for both subjects in the individual- (r= -0.02) and group-aversive conditions (r= -0.03). DISCUSSION In this study three factors seem to be operating in combination to promote a reduction in smoking: group meetings, the aversive procedure and subject motivation. First, subjects who met together as a group were more disposed to take the pills (41 per cent of the time) than subjects who were left unmonitored in their use of this aversive procedure (3 per cent of the time). Second, subjects who used the aversive procedure (pills) showed a greater initial (at termination of clinic) reduction in smoking than subjects who didn't use the procedure. That is, the group-aversive subjects showed a greater reduction in smoking when compared at the termination of the clinic with individual-aversive subjects. Further evidence that it was the aversive procedure that was responsible for the temporary reduction in smoking manifested by the group-aversive subjects, is pointed out by the significant correlation between number of pills taken and amount of reduction shown by these subjects. The third factor which appears to be related to reduction in smoking is subject motivation. Whitman (1969) has pointed out that control subjects who applied for but did not receive treatment nevertheless showed a significant and sustained reduction in smoking. A similar result was found in this study. The amount and trend of reduction of the apply
AVERSIVE CONTROL OF SMOKING BEHAVIOR IN A GROUP CONTEXT
103
control group is in marked contrast to the control Ss who did not seek treatment and who showed no change in their smoking behavior but is quite similar to that displayed by the individual-aversive subjects. Perhaps the similarity in performance of the individualaversive and apply control groups can be attributed to the fact that the individual-aversive group in essence rejected treatment by not utilizing the aversive procedure and thus were left without any systematic means of changing their smoking habit. The fact that both the individual-aversive and apply control groups did show a reduction in smoking suggests that Ss in both groups probably borrowed or developed of their own accord some alternate smoking modification method. The aversive procedure as a technique for reducing smoking appears to be useful; however, this study points out several of its undesirable aspects. Although the groupaversive subjects showed substantially more reduction in smoking than the apply control group at the termination of the clinic, at the one month follow-up this group displayed a significant increment in smoking and were no longer significantly different from the apply control subjects. Moreover, the low and nonsignificant correlation between the number of pills taken and the amount of reduction in smoking at the six-month follow-up suggests that the pill is no longer responsible for sustaining the reduction that occurred at this point. Thus, the pill appears to have only a temporary effect on smoking behavior. A second and already mentioned disadvantage of the aversive procedure is the fact that smokers do not use it when given the procedure in an unmonitored fashion. Moreover, even subjects who are supervised and encouraged to use the procedure via group meeting show resistance in using the procedure as prescribed. This is not, however, unique to only this type of procedure. Whitman (1969) has shown that subjects given self-control procedures based on operant conditioning principles also use them infrequently. At the present time the major problem in developing an approach for helping people to reduce or give up smoking may well not only be in finding the " right" treatment procedure but in motivating smokers to use already established techniques. That is, subjects who apply to smoking clinics and are apparently "motivated" to give up smoking need to be further motivated to use the recommended procedures . On the basis of this study, periodic group meetings appear to be a helpful procedure for sustaining motivation and insuring appropriate utilization of a suggested smoking control technique. However, the fact that the group-aversive Ss showed a significant remission in smoking at the one month follow-up suggests that it would be beneficial for the smokers to have the group procedure extended at least on an intermittent basis over a longer period of time. In general, in conducting a smoking clinic, regardless of what procedure is being employed to inhibit smoking behavior, it would seem advisable to gradually detach the smoker from the clinic and procedure rather than abruptly discontinuing treatment at a predetermined time. REFERENCES BERNSTEIN D. A. (1969) Modification of smoking: An evaluative review. Psychol. Bull. 71, 41~40. GENDREAU P. E. and DODWELL P. C. (1968) An aversive treatment for addicted cigarette smokers: Preliminary report. Can. Psychol. 9, 28-34. GOLDSTEIN A. (1962) Therapist-Patient Expectancies in Psychotherapy. Pergamon Press Book, MacMillan Co., New York. GREEN R. (1964) Modification of smoking behavior by free operant conditioning methods. Psychol. Rec. 14, 171-178.
GRIMALDI KAREN E. and LICHTENSTEIN E. (1969) Hot, smoky air as an aversive stimulus in the treatment of smoking. Behav. Res. & Therapy 7, 275-282. KEUTZER CAROL S., LICHTENSTEIN E. and MEES H. L. (1968) Modification of smoking behavior: a review. Psychol. Bull. 70, 520-533.
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THOMAS L. WHITMAN
LEVENTHAL H., WAITS J. and PAGANO F. (1967) Effects of fear and instructions on how to cope with danger. J. Person. soc. Psychol. 6, 313-321. LUBLIN I. and JOSLYN L. (1968) Aversive conditioning of cigarette addiction. Paper read at the meeting of the American Psychological Association, Los Angeles, September, 1968. OBER D. (1968) Modification of smoking behavior. J. consult. din. Psychol. 32, 543-549. POWELL J. and AZRIN N. (1969) The effects of shock as a punisher for cigarette smoking. J. appl. Behav, Anal. 1,63-71. ROGERS C. R. and DYMOND R. F. (Eds.) (1954) Psychotherapy and Personality Change. University of Chicago Press, Chicago. TOOLEY J. T. and PRATT S. (1967) An experimental procedure for the extinction of smoking behavior. Psychol. Rec. 17, 209-218. WmTMAN T. (1969) Modification of chronic smoking behavior: A comparison of three approaches. Behav. Res. & Therapy 7, 257-263. WILDE G. (1964) Behavior therapy of addicted cigarette smokers: A preliminary investigation. Behav. Res. & Therapy 2,107-109.