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Nonsmoking reinforced by improvements in lung function
0306-4603/81/040313-03$02.00/O Copyright 0 198 I Pergamon Press Ltd
Addictive Behaviors, Vol. 6, pp. 313-315, 1981 Printed in the USA. All rights reserved.
NONSMOKING
REINFORCED BY IMPROVEMENTS FUNCTION
IN LUNG
ROGERPAXTON* Sale and Brooklands
SHIRLEY
Hospital,
U.K.
SCOTT
York University,
Toronto
Abstract-Because so many aversive consequences follow stopping smoking any naturally occurring reinforcing consequence would be important. To investigate the hypothesis that early improvements in lung function would help to maintain abstinence in Smoking Clinic attenders, a retrospective analysis of spirometry results for a total of 42 subjects was carried out. Subjects who stayed off cigarettes at least two months showed larger improvements in a lung function measure (FEV,) during the first three weeks than subjects who had resumed smoking by two months. Further research is needed to clarify whether the verbal feedback of improved lung function or the natural feedback of improved fitness was effective.
Pharmacological, psychological, social, and constitutional factors have all been proposed to account for the maintenance of the smoking habit, but it is still not fully understood (Jaffe & Kanzler, 1977; Surgeon General, 1979). From a behavioural point of view some of the puzzles concerning smokers’ motivation are resolved by considering the sequencing of the consequences of smoking. Smokers’ self-reports as well as physiological data (Russell, 1976) suggest that some of the consequences which maintain smoking occur very rapidly after the smoking act. Other consequences which might be expected to weaken smoking (notably deteriorating health and fitness) are delayed, often by many years. This makes understandable the now familiar failure of most attempts at stopping smoking (Bernstein & McAlister, 1976; Lichtenstein & Danaher, 1976; Paxton, 1979a; Surgeon General, 1979; Yates, 1975). This way of viewing the problem also suggests some directions in which smoking treatment research might proceed. A successful programme must not just suppress smoking; it must strengthen and maintain a broad class of nonsmoking behaviours. The difficulty here lies in identifying consequences of the ex-smoker’s behaviour which can be manipulated in order to reinforce nonsmoking. In our clinic, described in detail elsewhere (Paxton, 1979b) we try to alter the social and financial contingencies surrounding smoking. We also try to make more salient the improvements in physical fitness (measurable as changes in lung function) that usually follow cessation of smoking (Buist, Sexton, Nagy, & Ross, 1976; McCarthy, Craig, & Cherniack, 1976). We measure lung function, using a Vitalograph spirometer, before stopping smoking and at frequent regular intervals after the stopping date. Clinic attenders are informed of their lung function results each time the test is used. The results reported here investigate the hypothesis that early improvements in lung function will help to maintain nonsmoking and therefore that a group of clinic “successes” will tend to have shown larger improvements in lung function than a group of “failures.” These results were obtained from retrospective analyses of lung function results in a group of treatment “successes” and a group of “failures.”
*Requests Psychology,
for reprints should be sent to: Roger Paxton, Ph.D., Trafford Area Department of Clinical Willson House, Sale and Brooklands Hospital, Charlton Drive, Sale, Manchester U.K. 313
ROGER
314
PAXTON
and SHIRLEY
SCOTT
METHOD
Subjects All subjects were participants in a Smoking Clinic described elsewhere (Paxton, 1979b). The Fail group were all those for whom records were available who had smoked again within eight weeks of the stop smoking date. This group consisted of 15 people, 5 men and 10 women. Their mean age was 42.0 years (SD=1 1.0). They had smoked for a mean of 24.5 years (SD=1 1.5), and they smoked an average of 31.7 cigarettes per day (SD=15.0). For the purposes of this project the Success group was defined as those who had not smoked during the first eight weeks after the cessation date. Self reports of abstinence were verified by random collection of urine samples for nicotine analysis (Paxton & Bernacca, 1979). The Success group consisted of 27 people, 16 men and 11 women. Their mean age was 35.8 years (SD=1 1.3), and they had smoked for an average of 16.3 years (SD=9.2). Their mean cigarette consumption was 27.5 per day (SDz12.4). Procedure FEV, (volume of air produced in the first one second of forced exhalation) and FVC (total volume of air yielded by a forced exhalation) were measured for all subjects before stopping smoking, weekly during the first month without cigarettes, and then at set intervals thereafter. The equipment used for this was a Vitalograph spirometer with digital meter. Subjects were informed of their results, and told whether they had improved after each test. Maximum FEV, and FVC scores during the first three weeks after the cessation date were obtained for each subject. The differences between subjects’ maximum and baseline scores were then computed. The differences between groups were compared using 2 x 2 (Success/Failure x Sex) analyses of variance for FEV, and FVC.
RESULTS
For both FEV , and FVC, and in males and females the mean improvement scores were higher for the Success than for the Fail group. This is shown by Table 1. Unfortunately, the groups differed in their baseline scores. In particular, the mean FEV , baseline score for males was lower in the Fail than in the Success group. This can be seen from inspection of Table 2. It was because of this that the analysis of variance was used to investigate the significance of Sex as well as Success/Fail. To investigate further the effect of these differences in baseline scores on the results we computed correlation coefficients between baseline and improvement scores for all subjects. For FEV , , r -. 14, p > .36, 2-tailed. For FVC, r = -.32, p < .04, 2-tailed. Only one analysis of variance effect was significant. This was Success/Fail on FEV, (F( 1, 38) = 4.24, p < .05). The Sex effect was insignificant (F( 1.38) = .08) and so too was the Sex x Success/Fail interaction (F( 1, 38) = .lO). Looking at FVC scores there were no significant effects. The Success group showed significantly larger early improvement in one measure of lung function (FEV ,). Although the men in the Success group showed higher initial scores than the Fail group men on both FEV, and FVC it is unlikely that these differences accounted for the significant finding. The Sex and Sex x Success/ Fail analysis of variance effects were q
Table
1. Early improvements
in lung function
(litres BTPS)
Fail Males
FEV, FVC
Success Females
Males
Females
X
SD
X
SD
x
SD
X
SD
.03 .21
.ll .59
.I1 .21
.27 .26
.31 .47
.41 .49
.31 .35
.35 .51
Nonsmoking Table 2.
reinforced
Baseline
lung function
scores (litres BTPS) Success
Fail
FEV, FVC
Males
Females
Males
315
by lung function
Females
X
SD
K
SD
r
SD
x
SD
2.69 4.35
1.50 1.54
2.61 3.49
.50 .99
3.88 4.87
1.40 1.42
2.62 3.35
.89 .91
insignificant, and so too was the correlation between baseline and improvement FEV, scores. It appears that improved fitness occurring as a consequence of having stopped smoking was effective in helping to maintain nonsmoking. There was a significant inverse correlation between baseline and improvement scores on FVC but no significant analysis of variance effect was found for this measure. It may be that some of our subjects’ FVC scores were not yet impaired by their smoking. These people could be expected to have relatively high initial score and would be unlikely to show improvements. This is supported by unpublished data which show only negligible practice effects. It is not clear from the data presented here whether the important consequence was the verbal feedback given after test sessions or whether it was naturally occurring changes such as improved ability to walk or run. People whose lung function improved probably experienced both. In the future we intend to investigate this by monitoring lung function without providing subjects with information on their results. Whatever the precise change which was effective we regard it as important and encouraging to have found a naturally occurring and easily measurable consequence which appears to reinforce nonsmoking. It may be helpful to find other ways of making improved lung function more salient, perhaps by suggesting certain physical exercises. It would be useful also to find some other effective consequence for the unlucky people whose lung function does not improve. Acknowledgements-Thanks to Elizabeth O’Shaughnessy for comments on an earlier draft, to Jack Rachman for discussions on research matters, to Patrick Mullin for encouraging clinical work with smokers, and to Ann Baxter for typing the manuscript. We are grateful to Vitalograph Limited, Buckingham, England for supplying the spirometry equipment.
REFERENCES Bernstein, D.A., & McAlister, A. The modification of smoking behavior: progress and problems. Addictive Behaviors, 1976, 1, 89-102. Buist, A.S.. Sexton, G.J., Nagy, J.M., & Ross, B.B. The effect of smoking cessation and modification on lung function. American Review of Respiratory Disease, 1976, 114, 115-122. Jaffe, J.H., & Kanzler. M. Smoking as an addictive disorder. In N.A. Krasnegor (Ed.), Cigurette smoking as a dependence process (NIDA Research Monograph 23). Rockville, Maryland: U.S. Department of Health. Education, & Welfare, 1977. 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. 3). New York: Academic Press, 1976. McCarthy, D.S., Craig, D.B., & Cherniack. R.M. Effect of modification of the smoking habit on lung function. American Review of Respiratory Disease, 1976, 114, 103-I 13. Paxton, R. Do methods matter in smoking clinics? He&h Bulletin, 1979, 37, 1644167. (a) Paxton, R. The effects of a deposit contract as a component in a behavioural programme for stopping smoking. Behaviour Research and Therapy, 1979, in press. (b) Paxton, R., & Bernacca, G. Urinary nicotine concentration as a function of time since last cigarette: Implications for detecting faking in smoking clinics. Behaviour Therapy, 1979, IO 523-528. Russell, M.A.H. Tobacco smoking and nicotine dependence. In R.J. Gibbins, Y. Israel. H. Kalant. R.E. Popham, W. Schmidt, & R.G. Smart (Eds.), Research advances in alcohol and drugproblems (Vol. 3). New York: Wiley. 1976. Surgeon General. Smoking and health. Rockville, Maryland: US. Department of Health, Education, and Welfare. 1979. Yates, A.J. Theory and practice in behavior therapy. New York: Wiley, 1975.
Addictive Behaviors, Vol. 6, pp. 313-315, 1981 Printed in the USA. All rights reserved.
NONSMOKING
REINFORCED BY IMPROVEMENTS FUNCTION
IN LUNG
ROGERPAXTON* Sale and Brooklands
SHIRLEY
Hospital,
U.K.
SCOTT
York University,
Toronto
Abstract-Because so many aversive consequences follow stopping smoking any naturally occurring reinforcing consequence would be important. To investigate the hypothesis that early improvements in lung function would help to maintain abstinence in Smoking Clinic attenders, a retrospective analysis of spirometry results for a total of 42 subjects was carried out. Subjects who stayed off cigarettes at least two months showed larger improvements in a lung function measure (FEV,) during the first three weeks than subjects who had resumed smoking by two months. Further research is needed to clarify whether the verbal feedback of improved lung function or the natural feedback of improved fitness was effective.
Pharmacological, psychological, social, and constitutional factors have all been proposed to account for the maintenance of the smoking habit, but it is still not fully understood (Jaffe & Kanzler, 1977; Surgeon General, 1979). From a behavioural point of view some of the puzzles concerning smokers’ motivation are resolved by considering the sequencing of the consequences of smoking. Smokers’ self-reports as well as physiological data (Russell, 1976) suggest that some of the consequences which maintain smoking occur very rapidly after the smoking act. Other consequences which might be expected to weaken smoking (notably deteriorating health and fitness) are delayed, often by many years. This makes understandable the now familiar failure of most attempts at stopping smoking (Bernstein & McAlister, 1976; Lichtenstein & Danaher, 1976; Paxton, 1979a; Surgeon General, 1979; Yates, 1975). This way of viewing the problem also suggests some directions in which smoking treatment research might proceed. A successful programme must not just suppress smoking; it must strengthen and maintain a broad class of nonsmoking behaviours. The difficulty here lies in identifying consequences of the ex-smoker’s behaviour which can be manipulated in order to reinforce nonsmoking. In our clinic, described in detail elsewhere (Paxton, 1979b) we try to alter the social and financial contingencies surrounding smoking. We also try to make more salient the improvements in physical fitness (measurable as changes in lung function) that usually follow cessation of smoking (Buist, Sexton, Nagy, & Ross, 1976; McCarthy, Craig, & Cherniack, 1976). We measure lung function, using a Vitalograph spirometer, before stopping smoking and at frequent regular intervals after the stopping date. Clinic attenders are informed of their lung function results each time the test is used. The results reported here investigate the hypothesis that early improvements in lung function will help to maintain nonsmoking and therefore that a group of clinic “successes” will tend to have shown larger improvements in lung function than a group of “failures.” These results were obtained from retrospective analyses of lung function results in a group of treatment “successes” and a group of “failures.”
*Requests Psychology,
for reprints should be sent to: Roger Paxton, Ph.D., Trafford Area Department of Clinical Willson House, Sale and Brooklands Hospital, Charlton Drive, Sale, Manchester U.K. 313
ROGER
314
PAXTON
and SHIRLEY
SCOTT
METHOD
Subjects All subjects were participants in a Smoking Clinic described elsewhere (Paxton, 1979b). The Fail group were all those for whom records were available who had smoked again within eight weeks of the stop smoking date. This group consisted of 15 people, 5 men and 10 women. Their mean age was 42.0 years (SD=1 1.0). They had smoked for a mean of 24.5 years (SD=1 1.5), and they smoked an average of 31.7 cigarettes per day (SD=15.0). For the purposes of this project the Success group was defined as those who had not smoked during the first eight weeks after the cessation date. Self reports of abstinence were verified by random collection of urine samples for nicotine analysis (Paxton & Bernacca, 1979). The Success group consisted of 27 people, 16 men and 11 women. Their mean age was 35.8 years (SD=1 1.3), and they had smoked for an average of 16.3 years (SD=9.2). Their mean cigarette consumption was 27.5 per day (SDz12.4). Procedure FEV, (volume of air produced in the first one second of forced exhalation) and FVC (total volume of air yielded by a forced exhalation) were measured for all subjects before stopping smoking, weekly during the first month without cigarettes, and then at set intervals thereafter. The equipment used for this was a Vitalograph spirometer with digital meter. Subjects were informed of their results, and told whether they had improved after each test. Maximum FEV, and FVC scores during the first three weeks after the cessation date were obtained for each subject. The differences between subjects’ maximum and baseline scores were then computed. The differences between groups were compared using 2 x 2 (Success/Failure x Sex) analyses of variance for FEV, and FVC.
RESULTS
For both FEV , and FVC, and in males and females the mean improvement scores were higher for the Success than for the Fail group. This is shown by Table 1. Unfortunately, the groups differed in their baseline scores. In particular, the mean FEV , baseline score for males was lower in the Fail than in the Success group. This can be seen from inspection of Table 2. It was because of this that the analysis of variance was used to investigate the significance of Sex as well as Success/Fail. To investigate further the effect of these differences in baseline scores on the results we computed correlation coefficients between baseline and improvement scores for all subjects. For FEV , , r -. 14, p > .36, 2-tailed. For FVC, r = -.32, p < .04, 2-tailed. Only one analysis of variance effect was significant. This was Success/Fail on FEV, (F( 1, 38) = 4.24, p < .05). The Sex effect was insignificant (F( 1.38) = .08) and so too was the Sex x Success/Fail interaction (F( 1, 38) = .lO). Looking at FVC scores there were no significant effects. The Success group showed significantly larger early improvement in one measure of lung function (FEV ,). Although the men in the Success group showed higher initial scores than the Fail group men on both FEV, and FVC it is unlikely that these differences accounted for the significant finding. The Sex and Sex x Success/ Fail analysis of variance effects were q
Table
1. Early improvements
in lung function
(litres BTPS)
Fail Males
FEV, FVC
Success Females
Males
Females
X
SD
X
SD
x
SD
X
SD
.03 .21
.ll .59
.I1 .21
.27 .26
.31 .47
.41 .49
.31 .35
.35 .51
Nonsmoking Table 2.
reinforced
Baseline
lung function
scores (litres BTPS) Success
Fail
FEV, FVC
Males
Females
Males
315
by lung function
Females
X
SD
K
SD
r
SD
x
SD
2.69 4.35
1.50 1.54
2.61 3.49
.50 .99
3.88 4.87
1.40 1.42
2.62 3.35
.89 .91
insignificant, and so too was the correlation between baseline and improvement FEV, scores. It appears that improved fitness occurring as a consequence of having stopped smoking was effective in helping to maintain nonsmoking. There was a significant inverse correlation between baseline and improvement scores on FVC but no significant analysis of variance effect was found for this measure. It may be that some of our subjects’ FVC scores were not yet impaired by their smoking. These people could be expected to have relatively high initial score and would be unlikely to show improvements. This is supported by unpublished data which show only negligible practice effects. It is not clear from the data presented here whether the important consequence was the verbal feedback given after test sessions or whether it was naturally occurring changes such as improved ability to walk or run. People whose lung function improved probably experienced both. In the future we intend to investigate this by monitoring lung function without providing subjects with information on their results. Whatever the precise change which was effective we regard it as important and encouraging to have found a naturally occurring and easily measurable consequence which appears to reinforce nonsmoking. It may be helpful to find other ways of making improved lung function more salient, perhaps by suggesting certain physical exercises. It would be useful also to find some other effective consequence for the unlucky people whose lung function does not improve. Acknowledgements-Thanks to Elizabeth O’Shaughnessy for comments on an earlier draft, to Jack Rachman for discussions on research matters, to Patrick Mullin for encouraging clinical work with smokers, and to Ann Baxter for typing the manuscript. We are grateful to Vitalograph Limited, Buckingham, England for supplying the spirometry equipment.
REFERENCES Bernstein, D.A., & McAlister, A. The modification of smoking behavior: progress and problems. Addictive Behaviors, 1976, 1, 89-102. Buist, A.S.. Sexton, G.J., Nagy, J.M., & Ross, B.B. The effect of smoking cessation and modification on lung function. American Review of Respiratory Disease, 1976, 114, 115-122. Jaffe, J.H., & Kanzler. M. Smoking as an addictive disorder. In N.A. Krasnegor (Ed.), Cigurette smoking as a dependence process (NIDA Research Monograph 23). Rockville, Maryland: U.S. Department of Health. Education, & Welfare, 1977. 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. 3). New York: Academic Press, 1976. McCarthy, D.S., Craig, D.B., & Cherniack. R.M. Effect of modification of the smoking habit on lung function. American Review of Respiratory Disease, 1976, 114, 103-I 13. Paxton, R. Do methods matter in smoking clinics? He&h Bulletin, 1979, 37, 1644167. (a) Paxton, R. The effects of a deposit contract as a component in a behavioural programme for stopping smoking. Behaviour Research and Therapy, 1979, in press. (b) Paxton, R., & Bernacca, G. Urinary nicotine concentration as a function of time since last cigarette: Implications for detecting faking in smoking clinics. Behaviour Therapy, 1979, IO 523-528. Russell, M.A.H. Tobacco smoking and nicotine dependence. In R.J. Gibbins, Y. Israel. H. Kalant. R.E. Popham, W. Schmidt, & R.G. Smart (Eds.), Research advances in alcohol and drugproblems (Vol. 3). New York: Wiley. 1976. Surgeon General. Smoking and health. Rockville, Maryland: US. Department of Health, Education, and Welfare. 1979. Yates, A.J. Theory and practice in behavior therapy. New York: Wiley, 1975.