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Behavioral treatment of excessive coffee and tea drinking: A case study and partial replication
BEHAVIOR THERAPY 12, 543--548 (1981)
Behavioral Treatment of Excessive Coffee and Tea Drinking: A Case Study and Partial Replication MICHAEL E. BERNARD University of Melbourne, Australia
SHIRLEY DENNEHY Special Services Division, Education Department of Victoria, Australia LINDA W . KEEFAUVER
University of Wyoming The present case study serves as a partial replication of the only study in the literature that has employed behavioral techniques in the treatment of caffeinism (Foxx & Rubinoff, 1979). The novelty of the present study is that different investigators, in a different country (Australia), independently designed a study that incorporated virtually all important aspects of the Foxx and Rubinoff study. The objective of the present study was to reduce excessive coffee and tea drinking in a 40 year-old female subject through the use of a behavioral program that included self-monitoring, response cost, and social praise procedures. In addition, the methodological and clinical utility of the changing-criterion design was examined. Coffee and tea drinking was reduced from an average daily intake of 11 cups during baseline to less than six cups at the end of treatment. The treatment effect continued during a 105 day follow-up period with the subject averaging between three and four cups per day.
Recent reports in the popular press as well as in scientific journals indicate the potential deleterious effects of drinking excessive amounts of coffee and tea (Greden, 1974; Reimann, 1967). Foxx and Rubinoff (1979) indicate that the following physiological symptoms have been observed in individuals who consume excessive amounts of caffeine-containing substances: nervous irritability, muscle twitching, insomnia, sensory disturbances, tachypnea, palpitations, flushing, cardiac arrhythmias, Requests for reprints should be sent to Michael E. Bernard, Department of Education, University of Melbourne, Parkville, Victoria, 3052, Australia. 543 0005-7894/81/0543-054851.00/0 Copyright1981by Associationfor Advancementof BehaviorTherapy All rightsof reproductionin any formreserved.
544
BERNARD, D E N N E H Y , AND KEEFAUVER
diuresis, and gastrointestinal disorders. Greden has indicated that individuals who drink more than 8 cups of coffee are at risk for the variety of potentially harmful short-term and long-term effects of caffeine addiction. Long-term effects include chromosomal damage, arteriosclerosis, and coronary heart disease (Punke, 1974). The addicting properties of caffeine are becoming increasingly documented (Ray, 1974). Caffeine addiction presents a twofold problem. For the addict, increasingly larger intakes of caffeine may be required over time thereby increasing potential risks. For the therapist treating the addiction, the psychological dependence and related behavioral symptoms and effects (tolerance and withdrawal) of the addict may pose greater problems than would the treatment of other non-drug related disorders. The present study is a partial replication of the only study reported in the literature that has employed behavioral techniques in the treatment of caffeinism (Foxx & Rubinoff, 1979), and had the following two objectives: first, the reduction of excessive coffee and tea drinking in a client through the use of a self-monitoring, response cost, and social praise behavioral program, and second, to further examine the methodological and clinical utility of the changing-criterion design (Hartmann & Hall, 1976). The novelty of the present study is that different investigators, in different countries, independently designed a study that incorporated virtually all important aspects of the Foxx and Rubinoff study. The only major exception was that the present study employed a response cost procedure along with social praise as the behavioral treatment, whereas, in the Foxx and Rubinoff study, positive reinforcement took the form of monetary incentives.
METHOD Subject and Setting Mary, a woman in her early forties, held a senior administrative post within a large organization in Melbourne, Victoria, Australia. She reported concern regarding the large number of cups of coffee and tea she drank each day. In the past, she reported that she had, in an unsystematic way, attempted to reduce the number of cups that she drank, but she felt that any reduction lasted only for a brief period of time and that she quickly returned to her previous habits.
Experimental Design and Procedures A changing-criterion design was employed with the aim of reducing the number of combined cups of coffee and tea consumed per day over a period of 1 month from the implementation of the treatment procedure. Baseline. During a baseline period of 13 days, the subject recorded the number of cups of coffee and tea she drank each day at work and at home. The subject recorded each cup consumed by placing a plastic disc into a special container provided by the therapist (second author). At the
EXCESSIVE COFFEE AND TEA DRINKING
545
end of each day, the subject plotted the combined total number of cups of coffee and tea on a graph that was provided by the therapist. Treatment. Intervention consisted of the use of response cost and social praise procedures that were combined along with self-monitoring in a changing-criterion design. At the postbaseline meeting the subject met with the therapist. The terminal treatment goal that was agreed upon was to reduce the consumption of coffee and tea to a total of 6 cups by the end of a 30-day period. The criterion level was set at 11 cups on the 14th day. This was the nearest whole number below the mean number of cups consumed during the baseline period. The criterion was reduced successively by one cup on the 18th, 24th, 27th, 34th, and 37th day. The changing-criterion level was based on a stepwise reduction of one cup per day below the previous phase's criterion level. The nature of a response cost procedure was explained to the subject, and she agreed to pay $5.00 into a fund to be donated to a specified charity if she exceeded the criterion level by one cup. For each additional excessive cup consumed, she agreed to pay a further $2.00 into the fund. Social praise was administered to the subject on those occasions when she met or was under her goal. The content of social praise remained constant irrespective of whether the goal was met or bettered and consisted basically of the verbalization: "That's very good. You've proved to yourself again that you can exercise self-control." The therapist met with the subject once a week. During the intervention period, the subject continued to record and plot the total number of cups of coffee she consumed. If the subject had achieved criterion level or was under it, the therapist would praise her for her success. If the subject exceeded the criterion level, response cost was instituted. No negative feedback was delivered to the subject if the goal for a particular week was not achieved. Maintenance and follow-up. Maintenance data were collected during the 9 days that immediately followed the termination of the treatment period (days 44-52). In addition, 105 days after the end of the maintenance data collection period, the subject was recontacted and asked to reinstitute data collection procedures for 5 days. The subject telephoned the therapist each day of the maintenance and follow-up phases to report her previous day's level of coffee and tea intake.
Reliability of Assessment Treatment and maintenance reliability. There are a number of problems associated with the measurement of the reliability of data collected in self-control studies where a subject self-records his/her own behavior. To insure that the subject's self-report on the number of cups consumed was a reliable measure and not falsifted, the report of a " significant other" was employed as corroborative evidence (Lichenstein & Danaher, 1976). The "significant other" in this study was the subject's secretary at work.
546
BERNARD, D E N N E H Y , AND KEEFAUVER
During the treatment and maintenance phases of the study, "subjective evaluation" was employed as a means for independently validating the effects of treatment (Kazdin, 1977). The secretary was contacted on the last day of the maintenance period (day 52) and was asked whether she had observed any noticeable change in the subject's rate of coffee and tea drinking. The secretary indicated she had noticed a definite large decrease in the amount of coffee and tea consumed by the subject. Additionally, she indicated that she had noticed that the subject had 3 weeks previously switched from a larger drinking mug (approximately 9 ounces) to a smaller coffee cup (approximately 5 ounces). Follow-up reliability. In order to maximize the reliability of the follow-up data, a quantitative measure of inter-observer agreement was employed. The secretary was telephoned previous to data collection and was asked to record on an observation form the number of cups of coffee and tea she observed the subject consumed during the week at work. The secretary posted the observation form to the therapist at the end of the week. During the same period, the subject was asked to record her coffee and tea intake before, during, and after work. A comparison of the secretary's and subject's total frequencies for cups consumed during the week revealed 89% agreement (Kazdin, 1978). While it is acknowledged that the reliability observed in the subject's work setting does not necessarily correspond with reliability of data gathered at home (Kazdin, 1979), the high inter-observer agreement obtained during work hours lends support to the reliability of the treatment effects. It is further recognized that the high reliability observed during follow-up does not guarantee similar levels of reliability during the treatment phase when the incentive for the client to report unreliably is the greatest.
RESULTS AND DISCUSSION Table 1 and Fig. l depict the baseline, treatment, maintenance, and follow-up phases of the study. The data indicate that during the treatment period, the intervention procedures resulted in a 48% reduction in the number of cups of coffee and tea the subject consumed. During this time the subject never exceeded criterion levels and behavioral variability was reduced to almost zero. This reduction continued during the maintenance period and was further reduced to 69% during the follow-up period. These findings replicate those of Foxx and Rubinoff (1979) and indicate that an individualized changing-criterion program composed of self-monitoring, social praise, and response cost is a reasonable method of reducing coffee and tea intake to a more moderate and safer level. It should be noted that these intervention procedures have been used in a variety of other self-control studies which have dealt with the reduction of behaviors such as sucking and body weight as well as the increase of exercise. It should also be indicated that whereas the Foxx and Rubinoff (1979) study focused on reducing the amount of caffeine consumed in all bev-
547
EXCESSIVE COFFEE AND TEA DRINKING Baseline "O o~
16
E
1,/_1 2 3 4
Maintenance Follow-up
Treatment Phases
0 ~ 12, ~ 10. f, .
~ s. ~
•
~. s. ~
-
0 E z
•
~" ~" ~" ;, ; o ' i z ' 1 4 , 8
~8 z o z z z 4
26"z's'so's~" s,; ss'3"s" ,;o',,~'£=',,'6"4"s'~o" " ~&" "~o9 Days
FIG. 1. Subject's daily coffee and tea intake during baseline, treatment, maintenance, and follow-up. The criterion level for each treatment phase was one cup less than the previous treatment phase•
erages, the present study only provided data on the number of cups of coffee and tea consumed• As such it is difficult to conclude unequivocably that the program led to a reduction in caffeine consumption• For example, the subject may have increased her consumption of other caffeine-containing beverages (e.g., soda). It is acknowledged that it would have been more informative if the total number of caffeine containing beverages was monitored as well as the level of caffeine consumed in both coffee and tea. The relative contributions of the various components of the behavioral program which produced the rapid treatment effects cannot be ascerTABLE 1 MEAN NUMBER OF CUPS OF COFFEE CONSUMED PER DAY
Condition
Length of phase (days)
Mean number of cups
Baseline Treatment phase 1 Treatment phase 2 Treatment phase 3 Treatment phase 4 Treatment phase 5 Treatment phase 6 Maintenance Follow-up (3V/month)
13 4 6 3 7 3 7 9 5
11.54 10.50 9.83 9.00 8.00 7.00 6.00 5.78 3.60
548
BERNARD, DENNEHY, AND KEEFAUVER
tained. Other possible factors that may have influenced the subject include (1) increased motivation and arousal occasioned by the subject's participation in the experiment, (2) the effects that accrued from informing others in her environment that she was trying to reduce her coffee and tea drinking, (3) increased self-awareness of her level of coffee and tea intake which may have by itself over the course of treatment led to a reduction, and (4) the fear of failure in not satisfying experimental demands and expectations. The long-term maintenance of behavior change indicates that behavioral programs that do not systematically build in maintenance factors may produce stable and enduring behavioral change. As the subject was not advised at the end of treatment that follow-up measures were to be collected, it is likely that maintenance resulted from either naturally occurring changes in the subject's cognitions ("I can control my drinking urges") or in the discriminative stimulus properties of the subject's environment (different coffee mug; fewer "coffee breaks"). The replication of the results of the Foxx and Rubinoff (1979) study increases the external validity of the present findings. The success of such a program across experimenters, subjects, and situations increases our confidence in the clinical utility of these procedures when applied to the treatment of an addictive behavior such as caffeinism. That is, the effectiveness of these procedures apparently resides more in the procedures themselves than in factors endemic to particular experimenters, subjects, or situations.
REFERENCES Foxx, R. M., & Rubinoff, A. Behavioral treatment of caffeinism: Reducing excessive coffee drinking. Journal of Applied Behavioral Analysis, 1979, 12, 335-344. Greden, J . F . Anxiety or caffeinism: A diagnostic dilemma. American Journal of Psychiatry, 1974, 131, 1089-1092. Hartmann, D. P., & Hall, R . V . The changing-criterion design. Journal of Applied Behavior Analysis, 1976, 9, 527-532. Kazdin, A. Assessing the clinical or applied importance of behavior change through social validation. Behavior Modification, 1977, 1,427-451. Kazdin, A. Methodology of applied behavior analysis. In A. C. Catania & T. A. Brigham (Eds.), Handbook of applied behavior analysis: Social and instructional processes. New York: Irvington/Naiburg, 1978. Kazdin, A. Situational specificity: The two-edged sword of behavioral assessment. Behavioral Assessment, 1979, 1, 57-75. Lichtenstein, E., & Danaher, B . G . Modification of smoking behavior: A critical analysis of theory, research, and practice. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. III). New York: Academic Press, 1976. Punke, H . H . Caffeine in America's food and drug habits. The Journal of School Health, 1974, 44, 551-562. Ray, O . S . Drugs, society, and human behavior (2nd ed.). St. Louis: C. V. Mosby, 1974. Reimann, H . A . Caffeinism: A case of long-continued, low-grade fever. Journal of the American MedicalAssociation, 1967, 202, 1105-1106. RECEIVED: August 22, 1980 F1NAL ACCEPTANCE:November 6, 1980
Behavioral Treatment of Excessive Coffee and Tea Drinking: A Case Study and Partial Replication MICHAEL E. BERNARD University of Melbourne, Australia
SHIRLEY DENNEHY Special Services Division, Education Department of Victoria, Australia LINDA W . KEEFAUVER
University of Wyoming The present case study serves as a partial replication of the only study in the literature that has employed behavioral techniques in the treatment of caffeinism (Foxx & Rubinoff, 1979). The novelty of the present study is that different investigators, in a different country (Australia), independently designed a study that incorporated virtually all important aspects of the Foxx and Rubinoff study. The objective of the present study was to reduce excessive coffee and tea drinking in a 40 year-old female subject through the use of a behavioral program that included self-monitoring, response cost, and social praise procedures. In addition, the methodological and clinical utility of the changing-criterion design was examined. Coffee and tea drinking was reduced from an average daily intake of 11 cups during baseline to less than six cups at the end of treatment. The treatment effect continued during a 105 day follow-up period with the subject averaging between three and four cups per day.
Recent reports in the popular press as well as in scientific journals indicate the potential deleterious effects of drinking excessive amounts of coffee and tea (Greden, 1974; Reimann, 1967). Foxx and Rubinoff (1979) indicate that the following physiological symptoms have been observed in individuals who consume excessive amounts of caffeine-containing substances: nervous irritability, muscle twitching, insomnia, sensory disturbances, tachypnea, palpitations, flushing, cardiac arrhythmias, Requests for reprints should be sent to Michael E. Bernard, Department of Education, University of Melbourne, Parkville, Victoria, 3052, Australia. 543 0005-7894/81/0543-054851.00/0 Copyright1981by Associationfor Advancementof BehaviorTherapy All rightsof reproductionin any formreserved.
544
BERNARD, D E N N E H Y , AND KEEFAUVER
diuresis, and gastrointestinal disorders. Greden has indicated that individuals who drink more than 8 cups of coffee are at risk for the variety of potentially harmful short-term and long-term effects of caffeine addiction. Long-term effects include chromosomal damage, arteriosclerosis, and coronary heart disease (Punke, 1974). The addicting properties of caffeine are becoming increasingly documented (Ray, 1974). Caffeine addiction presents a twofold problem. For the addict, increasingly larger intakes of caffeine may be required over time thereby increasing potential risks. For the therapist treating the addiction, the psychological dependence and related behavioral symptoms and effects (tolerance and withdrawal) of the addict may pose greater problems than would the treatment of other non-drug related disorders. The present study is a partial replication of the only study reported in the literature that has employed behavioral techniques in the treatment of caffeinism (Foxx & Rubinoff, 1979), and had the following two objectives: first, the reduction of excessive coffee and tea drinking in a client through the use of a self-monitoring, response cost, and social praise behavioral program, and second, to further examine the methodological and clinical utility of the changing-criterion design (Hartmann & Hall, 1976). The novelty of the present study is that different investigators, in different countries, independently designed a study that incorporated virtually all important aspects of the Foxx and Rubinoff study. The only major exception was that the present study employed a response cost procedure along with social praise as the behavioral treatment, whereas, in the Foxx and Rubinoff study, positive reinforcement took the form of monetary incentives.
METHOD Subject and Setting Mary, a woman in her early forties, held a senior administrative post within a large organization in Melbourne, Victoria, Australia. She reported concern regarding the large number of cups of coffee and tea she drank each day. In the past, she reported that she had, in an unsystematic way, attempted to reduce the number of cups that she drank, but she felt that any reduction lasted only for a brief period of time and that she quickly returned to her previous habits.
Experimental Design and Procedures A changing-criterion design was employed with the aim of reducing the number of combined cups of coffee and tea consumed per day over a period of 1 month from the implementation of the treatment procedure. Baseline. During a baseline period of 13 days, the subject recorded the number of cups of coffee and tea she drank each day at work and at home. The subject recorded each cup consumed by placing a plastic disc into a special container provided by the therapist (second author). At the
EXCESSIVE COFFEE AND TEA DRINKING
545
end of each day, the subject plotted the combined total number of cups of coffee and tea on a graph that was provided by the therapist. Treatment. Intervention consisted of the use of response cost and social praise procedures that were combined along with self-monitoring in a changing-criterion design. At the postbaseline meeting the subject met with the therapist. The terminal treatment goal that was agreed upon was to reduce the consumption of coffee and tea to a total of 6 cups by the end of a 30-day period. The criterion level was set at 11 cups on the 14th day. This was the nearest whole number below the mean number of cups consumed during the baseline period. The criterion was reduced successively by one cup on the 18th, 24th, 27th, 34th, and 37th day. The changing-criterion level was based on a stepwise reduction of one cup per day below the previous phase's criterion level. The nature of a response cost procedure was explained to the subject, and she agreed to pay $5.00 into a fund to be donated to a specified charity if she exceeded the criterion level by one cup. For each additional excessive cup consumed, she agreed to pay a further $2.00 into the fund. Social praise was administered to the subject on those occasions when she met or was under her goal. The content of social praise remained constant irrespective of whether the goal was met or bettered and consisted basically of the verbalization: "That's very good. You've proved to yourself again that you can exercise self-control." The therapist met with the subject once a week. During the intervention period, the subject continued to record and plot the total number of cups of coffee she consumed. If the subject had achieved criterion level or was under it, the therapist would praise her for her success. If the subject exceeded the criterion level, response cost was instituted. No negative feedback was delivered to the subject if the goal for a particular week was not achieved. Maintenance and follow-up. Maintenance data were collected during the 9 days that immediately followed the termination of the treatment period (days 44-52). In addition, 105 days after the end of the maintenance data collection period, the subject was recontacted and asked to reinstitute data collection procedures for 5 days. The subject telephoned the therapist each day of the maintenance and follow-up phases to report her previous day's level of coffee and tea intake.
Reliability of Assessment Treatment and maintenance reliability. There are a number of problems associated with the measurement of the reliability of data collected in self-control studies where a subject self-records his/her own behavior. To insure that the subject's self-report on the number of cups consumed was a reliable measure and not falsifted, the report of a " significant other" was employed as corroborative evidence (Lichenstein & Danaher, 1976). The "significant other" in this study was the subject's secretary at work.
546
BERNARD, D E N N E H Y , AND KEEFAUVER
During the treatment and maintenance phases of the study, "subjective evaluation" was employed as a means for independently validating the effects of treatment (Kazdin, 1977). The secretary was contacted on the last day of the maintenance period (day 52) and was asked whether she had observed any noticeable change in the subject's rate of coffee and tea drinking. The secretary indicated she had noticed a definite large decrease in the amount of coffee and tea consumed by the subject. Additionally, she indicated that she had noticed that the subject had 3 weeks previously switched from a larger drinking mug (approximately 9 ounces) to a smaller coffee cup (approximately 5 ounces). Follow-up reliability. In order to maximize the reliability of the follow-up data, a quantitative measure of inter-observer agreement was employed. The secretary was telephoned previous to data collection and was asked to record on an observation form the number of cups of coffee and tea she observed the subject consumed during the week at work. The secretary posted the observation form to the therapist at the end of the week. During the same period, the subject was asked to record her coffee and tea intake before, during, and after work. A comparison of the secretary's and subject's total frequencies for cups consumed during the week revealed 89% agreement (Kazdin, 1978). While it is acknowledged that the reliability observed in the subject's work setting does not necessarily correspond with reliability of data gathered at home (Kazdin, 1979), the high inter-observer agreement obtained during work hours lends support to the reliability of the treatment effects. It is further recognized that the high reliability observed during follow-up does not guarantee similar levels of reliability during the treatment phase when the incentive for the client to report unreliably is the greatest.
RESULTS AND DISCUSSION Table 1 and Fig. l depict the baseline, treatment, maintenance, and follow-up phases of the study. The data indicate that during the treatment period, the intervention procedures resulted in a 48% reduction in the number of cups of coffee and tea the subject consumed. During this time the subject never exceeded criterion levels and behavioral variability was reduced to almost zero. This reduction continued during the maintenance period and was further reduced to 69% during the follow-up period. These findings replicate those of Foxx and Rubinoff (1979) and indicate that an individualized changing-criterion program composed of self-monitoring, social praise, and response cost is a reasonable method of reducing coffee and tea intake to a more moderate and safer level. It should be noted that these intervention procedures have been used in a variety of other self-control studies which have dealt with the reduction of behaviors such as sucking and body weight as well as the increase of exercise. It should also be indicated that whereas the Foxx and Rubinoff (1979) study focused on reducing the amount of caffeine consumed in all bev-
547
EXCESSIVE COFFEE AND TEA DRINKING Baseline "O o~
16
E
1,/_1 2 3 4
Maintenance Follow-up
Treatment Phases
0 ~ 12, ~ 10. f, .
~ s. ~
•
~. s. ~
-
0 E z
•
~" ~" ~" ;, ; o ' i z ' 1 4 , 8
~8 z o z z z 4
26"z's'so's~" s,; ss'3"s" ,;o',,~'£=',,'6"4"s'~o" " ~&" "~o9 Days
FIG. 1. Subject's daily coffee and tea intake during baseline, treatment, maintenance, and follow-up. The criterion level for each treatment phase was one cup less than the previous treatment phase•
erages, the present study only provided data on the number of cups of coffee and tea consumed• As such it is difficult to conclude unequivocably that the program led to a reduction in caffeine consumption• For example, the subject may have increased her consumption of other caffeine-containing beverages (e.g., soda). It is acknowledged that it would have been more informative if the total number of caffeine containing beverages was monitored as well as the level of caffeine consumed in both coffee and tea. The relative contributions of the various components of the behavioral program which produced the rapid treatment effects cannot be ascerTABLE 1 MEAN NUMBER OF CUPS OF COFFEE CONSUMED PER DAY
Condition
Length of phase (days)
Mean number of cups
Baseline Treatment phase 1 Treatment phase 2 Treatment phase 3 Treatment phase 4 Treatment phase 5 Treatment phase 6 Maintenance Follow-up (3V/month)
13 4 6 3 7 3 7 9 5
11.54 10.50 9.83 9.00 8.00 7.00 6.00 5.78 3.60
548
BERNARD, DENNEHY, AND KEEFAUVER
tained. Other possible factors that may have influenced the subject include (1) increased motivation and arousal occasioned by the subject's participation in the experiment, (2) the effects that accrued from informing others in her environment that she was trying to reduce her coffee and tea drinking, (3) increased self-awareness of her level of coffee and tea intake which may have by itself over the course of treatment led to a reduction, and (4) the fear of failure in not satisfying experimental demands and expectations. The long-term maintenance of behavior change indicates that behavioral programs that do not systematically build in maintenance factors may produce stable and enduring behavioral change. As the subject was not advised at the end of treatment that follow-up measures were to be collected, it is likely that maintenance resulted from either naturally occurring changes in the subject's cognitions ("I can control my drinking urges") or in the discriminative stimulus properties of the subject's environment (different coffee mug; fewer "coffee breaks"). The replication of the results of the Foxx and Rubinoff (1979) study increases the external validity of the present findings. The success of such a program across experimenters, subjects, and situations increases our confidence in the clinical utility of these procedures when applied to the treatment of an addictive behavior such as caffeinism. That is, the effectiveness of these procedures apparently resides more in the procedures themselves than in factors endemic to particular experimenters, subjects, or situations.
REFERENCES Foxx, R. M., & Rubinoff, A. Behavioral treatment of caffeinism: Reducing excessive coffee drinking. Journal of Applied Behavioral Analysis, 1979, 12, 335-344. Greden, J . F . Anxiety or caffeinism: A diagnostic dilemma. American Journal of Psychiatry, 1974, 131, 1089-1092. Hartmann, D. P., & Hall, R . V . The changing-criterion design. Journal of Applied Behavior Analysis, 1976, 9, 527-532. Kazdin, A. Assessing the clinical or applied importance of behavior change through social validation. Behavior Modification, 1977, 1,427-451. Kazdin, A. Methodology of applied behavior analysis. In A. C. Catania & T. A. Brigham (Eds.), Handbook of applied behavior analysis: Social and instructional processes. New York: Irvington/Naiburg, 1978. Kazdin, A. Situational specificity: The two-edged sword of behavioral assessment. Behavioral Assessment, 1979, 1, 57-75. Lichtenstein, E., & Danaher, B . G . Modification of smoking behavior: A critical analysis of theory, research, and practice. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. III). New York: Academic Press, 1976. Punke, H . H . Caffeine in America's food and drug habits. The Journal of School Health, 1974, 44, 551-562. Ray, O . S . Drugs, society, and human behavior (2nd ed.). St. Louis: C. V. Mosby, 1974. Reimann, H . A . Caffeinism: A case of long-continued, low-grade fever. Journal of the American MedicalAssociation, 1967, 202, 1105-1106. RECEIVED: August 22, 1980 F1NAL ACCEPTANCE:November 6, 1980