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Playfulness, arousal-seeking and rebelliousness during smoking cessation
Personality and Individual Dierences 29 (2000) 671±683
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Playfulness, arousal-seeking and rebelliousness during smoking cessation Kathleen A. O'Connell a,*, 1, Mary M. Gerkovich b, Marge Bott a, Mary R. Cook b, Saul Shiman c a
School of Nursing, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160-7502, USA b Midwest Research Institute, Kansas City, MO, USA c University of Pittsburgh, Pittsburgh, PA, USA Received 18 June 1999; accepted 1 October 1999
Abstract Whereas prior research has indicated that negative aect states contribute to lapses during cessation attempts, studies using retrospective interviews have shown that the reversal theory states of playfulness and rebelliousness also increase the likelihood of lapsing. Using ecological momentary assessment techniques, the relationship of playfulness, arousal-seeking and rebelliousness to other subjective states, situational variables, the use of coping strategies and to lapsing were investigated in 36 subjects who were attempting to quit smoking. Playfulness was signi®cantly ( p < 0.01) related to the use of fewer coping responses during urge episodes. Within-subjects analyses of 11 subjects who lapsed during the study showed that playfulness scores were signi®cantly higher ( p < 0.02) during lapse as compared to highly tempting situations. Rebelliousness was related to higher urge levels during coping episodes ( p < 0.01). Results support the construct validity of the scales and the utility of reversal theory variables in explaining outcomes of smoking cessation attempts. 7 2000 Elsevier Science Ltd. All rights reserved. Keywords: Reversal theory; Playfulness; Arousal-seeking; Rebelliousness; Smoking cessation; Coping strategies
* Corresponding author. Tel.: +1-913-588-3377; fax: +1-913-588-1660. E-mail address: [email protected] (K.A. O'Connell). 1 Present address. Columbia University, Isabel Maitland Stewart Chair and Professor of Nursing Education, Box 35 Teachers College, 525 W. 120th Street, New York, NY 10027, USA. Tel.: +1-212-678-3120; fax: +1-212-6784048; e-mail: o'[email protected]. 0191-8869/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 1 9 1 - 8 8 6 9 ( 9 9 ) 0 0 2 2 4 - X
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1. Introduction Smoking is a health-damaging behavior practiced by more than one-quarter of the US population (CDC, 1997; Shopland et al., 1996). Although new pharmacological interventions have doubled quit rates in recent years, the relapse rates remain at 80% or higher at 12 months after a cessation attempt (Silagy, Mant, Fowler & Lodge, 1994). Experiencing a single lapse during a cessation attempt is highly predictive of returning to regular smoking (Brandon, Tiany & Baker, 1986). Whereas prior research has indicated that negative aect states contribute to lapses (Marlatt & Gordon, 1980; O'Connell & Martin, 1987; O'Connell & Shiman, 1988), studies based on reversal theory have shown that playful states also increase the likelihood of lapsing (Cook, Gerkovich, O'Connell & Potocky, 1995; Gerkovich, Cook, O'Connell & Potocky, 1993; O'Connell, Cook, Gerkovich, Potocky & Swan, 1990; Potocky, Gerkovich, O'Connell & Cook, 1991). Reversal theory is a general theory of psychology, which holds that individuals are inherently inconsistent. Reversals occur between the members of opposing pairs of metamotivational states; they are called ``metamotivational'' because they are not about motivation, itself, but pertain to how certain motivational variables (e.g. arousal) are interpreted. Experience is interpreted dierently in opposing states. The theory identi®es four pairs of metamotivational states: telic/paratelic, negativistic/conformist, mastery/sympathy and autic/alloic. This manuscript focuses on the ®rst two pairs of states. Individuals in the telic state are serious-minded, goal oriented, planning ahead and usually arousal-avoidant. Individuals in the paratelic state are playful, sensation-oriented, spontaneous and usually arousal-seeking. Individuals in the negativistic state are rebellious, oriented toward breaking rules and often angry. Individuals in the conformist state are compliant, oriented toward following rules and usually not angry. According to reversal theory, hedonic tone or aect is conceptually independent of metamotivational state. It is possible to experience either positive or negative aect in each state. Nevertheless, many negative aect states (with the exception of boredom, which can be experienced in paratelic states) are probably experienced in the telic state, because negative aect states tend to induce serious-mindedness. Most negativistic states are associated with the unpleasant aect anger, which is the combination of telic and negativistic states, but some negativistic states can be associated with positive aect, such as the experience of playful rebelliousness, which is the combination of paratelic and negativistic states. Although many positive aect states are experienced in the paratelic state, positive aect states related to work performance and goal attainment can be experienced in the telic state. Thus, we expected that paratelic states would contain a preponderance of positive aect states, while telic states would contain a preponderance of negative aect states. We speculated that people in paratelic states were likely to lapse because they failed to use coping strategies. Invoking coping strategies has been shown to be highly related to resisting the urge to smoke (e.g. Baer, Lichtenstein, Kamarck & Ransom, 1989; Bliss, Garvey, Heinold & Hitchcock, 1989; Shiman, 1984; Shiman, Gnys, Richards, Paty & Hickcox, 1996a). However, engaging in coping strategies may require a serious-mindedness that is uncharacteristic of paratelic states. Moreover, the strategies that are usually recommended, such as thinking of the negative consequences of smoking, reminding oneself of the reasons for
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quitting, or trying to calm down, have decidedly serious and arousal-avoidant tones that might be eschewed by individuals in paratelic states. We reasoned that individuals in negativistic states would be more likely to lapse because they consider smoking a rebellious activity consistent with the desire to break rules. Many associate smoking with being rebellious during their youth. In addition, smoking during a cessation attempt constitutes breaking self-imposed rules and can satisfy a desire to feel rebellious in situations where breaking rules imposed by others might be too costly. O'Connell et al. (1990) and Gerkovich et al. (1993) showed that highly tempting situations that coincided with paratelic states or negativistic states were much more likely to result in a lapse than those that coincided with telic and conformist states. Using a within-subjects analysis of lapses and episodes of temptation that did not result in lapses, Potocky et al. (1991) showed that this eect was not due to enduring individual dierences, but rather to transient states. The ®nding that paratelic states were related to lapses was replicated, but the ®ndings with respect to negativistic states were not replicated in a subsequent study (Cook et al., 1995). Our prior work has several limitations. First, our prior studies were based on retrospective accounts of highly tempting situations, which might have been subject to bias in reporting; Shiman et al. (1997) have shown that retrospective reports of lapse episodes dier signi®cantly from reports taken within minutes of an event. Secondly, the determination of metamotivational state was made by coders on the basis of interviews about highly tempting situations. Self-ratings might generate very dierent ®ndings. Third, we could only speculate that the mechanism for the deleterious eects of paratelic states was the failure to use coping strategies, because we did not have adequate measures of coping. This paper reports a study using near real-time data collection techniques and self-ratings of state to address some of these limitations. Telic/paratelic states are operationalized in this study by two continuous measures, the Playfulness and the Arousal-Seeking Scales. Negativistic states are operationalized by the continuous measure, the Rebelliousness Scale. After examining the reliability of the measures of playfulness, arousal-seeking and rebelliousness and addressing the frequency of those states, we tested ®ve hypotheses. First, playfulness and arousal-seeking will be inversely related to negative aect. Second, because of the anger component of the Rebelliousness Scale, rebelliousness will be positively related negative aect. Third, playfulness and arousal-seeking will be low in work settings and high in leisure settings, i.e. in bars and restaurants. Fourth, playfulness will be related to the use of fewer coping strategies. And ®fth, compared to episodes in which subjects resist the urge to smoke, lapse episodes will be characterized by higher playfulness, arousal-seeking and rebelliousness scores. In addition to the hypothesis testing, exploratory analyses were carried out to determine the relationship of reversal theory states to environmental variables and other state variables. Also, we investigated whether lapses and urge episodes diered on the negative aect, as has been found in other studies.
2. Method Using palm-top computers and hand-held tape recorders, individuals who were trying to quit smoking reported on occasions in which they performed coping in support of their eorts.
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Other ®ndings from this data set that are unrelated to reversal theory variables are reported in O'Connell et al. (1998). 2.1. Subjects Subjects were 43 cigarette smokers who were enrolled in one of several group smoking cessation programs in a large midwestern metropolitan area. Subjects were randomly assigned to one of 5 overlapping three-day blocks spanning the ®rst 10 days of cessation. Block assignment was carried out such that subjects who dropped out of the study or who relapsed prior to the day when they would start the study were replaced. Except for subjects in Block 1 (Days 1, 2 and 3 of cessation), who began the study on their quit day, subjects had to be abstinent or abstinent with only an occasional lapse on the day prior to study participation. Of the 43 subjects who entered the study, 36 completed participation (5 were not compliant and 2 did not quit smoking). The sample included 58% women; 92% of the sample were Caucasian and 8% were African American. Thirty-three percent of the sample had obtained a college degree, while an additional 50% had some education beyond a high school diploma; 61% were married; and 67% were employed outside the home. The average age of the participants was 40.5 yr (S.D.=10.5) and they had been smoking an average of 17 yr (S.D.=3.2). Prior to quitting smoking, subjects reported smoking an average of 24 cigarettes per day (S.D.=10.7). Ninety-seven percent had tried to quit previously. The sample had an average of 4.7 prior quit attempts (S.D.=4.2). 2.2. Measures 2.2.1. Computer-administered instruments A palmtop computer, called the Electronic Diary (ED) (Shiman et al., 1996a) administered a total of 51 items, which included assessments of situation, activity, negative aect, arousal, playfulness, arousal-seeking and negativism. Except for measures of reversal theory states, the assessment was derived from prior studies of smoking and relapse (Shiman et al., 1996a; Shiman, Paty, Gnys, Kassell & Hickcox, 1996b). Subjects responded to one item at a time, without being able to see responses given during previous episodes. Situational characteristics that were assessed included the intensity of smoking urges, rated on a 1-to-11 scale; the location of the episode; whether cigarettes were available; smoking regulations; and whether the subject was interacting with others, eating, or consuming alcohol. The Negative Aect Scale alpha 0:67 included happy (reverse coded), miserable, tense and overall feeling. Higher scores indicated more negative aect. The Tired Factor alpha 0:74 included tired, sleepy and overall arousal level and was scored such that higher scores indicated higher levels of tiredness. The Negative Aect and Tired Scales jointly covered the domain of emotion de®ned by the circumplex model of aect (Russell, 1980). The Playfulness and Arousal-Seeking Scales were based on scales developed by Cook, Gerkovich, Potocky & O'Connell (1993) and Calhoun (1995). The Playfulness Scale score was the sum of three items all rated on a 4-point scale (Feeling serious versus Feeling playful; Wanting to do something important versus Wanting to do something frivolous; Trying to accomplish something versus Trying to have fun). Higher scores on the Playfulness Scale indicate more playfulness (and less serious-
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mindedness). The Arousal-Seeking Scale was the sum of scores on three items, also assessed on a 4-point scale representing the extent to which the subject preferred emotional arousal at the time (Cautious vs Adventurous, Want calm vs Want excitement, Want peace and quiet vs Want adventure). Higher scores indicate more arousal-seeking (and less arousal-avoidance). The Rebelliousness Scale consisted of two unipolar items (angry and rebellious), each assessed on a 4-point scale ranging from yes to no and one bipolar item (Compliant vs De®ant) also assessed on a 4-point scale. Higher scores indicate more rebelliousness (and less compliance). A preliminary factor analysis indicated that each scale was represented by its own factor, with all items loading at 0.35 or greater and no items cross-loading. The Playfulness Scale has a Cronbach's alpha of 0.73. The Arousal-Seeking Scale had a Cronbach's alpha of 0.78 and the Rebelliousness Scale had a Cronbach's alpha of 0.67. As expected the correlation between playfulness and arousal-seeking scores was 0.548, replicating the moderate relationship between these two constructs that has been found in other studies (Apter, 1982; Calhoun, 1995). 2.3. Procedures Subjects were recruited during the introductory sessions of their smoking cessation programs. Baseline data were collected prior to quitting smoking. At baseline, at the training session and at the end of each day of data collection, CO was measured with a Breathco carbon monoxide monitor (Vitalograph, Lenexa, KS), with values >8 ppm indicating smoking. CO monitoring was also used to encourage truthful reporting. Subjects were paid $50 for each data collection day. 2.3.1. Training Subjects were trained during a 2 to 3 h period immediately prior to their assessment days. During the training session, the subjects were taught to use the palm-top computer, which was called the Electronic Diary (ED) and the cassette tape-recorder, which the project team called ETHEL (Electronic Tape Held Experience Log). 2.3.2. Computer hardware and software The ED system was implemented on a PSION Organizer II LZ 64 (PSION, Ltd., London, England), a palm-top computer with a 4-line, 20-character per line LCD screen, a clock/ calendar and an audio speaker (see Shiman, 1996a). 2.3.3. Assessment occasions The subject was instructed to carry out the assessment procedures for three types of experiences: (1) after situations in which they initiated coping, (2) after lapses and (3) in response to computer-initiated random prompts. In order to avoid disruption of natural coping responses, the subjects were instructed to wait until they had ®nished coping before reporting. Subjects were encouraged to report both anticipatory and immediate coping responses. Anticipatory coping is performed to prevent urges and immediate coping is performed to deal with ongoing urges (Wills & Shiman, 1985). Because few anticipatory responses were recorded, only the immediate coping responses reported during urge episodes are included in this paper.
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2.3.4. Assessments For urge and lapse episodes, assessment procedures involved having the subject turn on ED, which immediately asked the subjects to indicate whether they were reporting an urge episode (which did not involve smoking) or a lapse episode (which involved smoking and may or may not have included coping responses). Then ED instructed the subject to turn on the taperecorder and to read into the recorder a code, which was an encryption of the date and time. Then, ED prompted the subjects to record on ETHEL a brief description of the situations they were in and all the coping responses they used during that situation. After ®nishing the taperecording, the subject responded to the questionnaire administered by ED. Each recording episode took approximately two minutes. In order to assess times when subjects were not coping with urges, subjects were randomly prompted by ED about ®ve times per day to answer the same questionnaire. If a prompt happened to occur when the subject was experiencing an urge or lapse, subjects were instructed to indicate this in response to the initial ED questionnaire item; ED then prompted them to carry out the reporting procedures for an urge or a lapse, as appropriate. At the end of each study day, (approximately 24 h period), a project sta member met with the subjects to review his/her data, identify problems, answer questions about the electronic equipment, collect a breath sample for CO measurement and conduct an interview. 2.3.5. Coding of coping responses All tape-recorded entries were transcribed. Coping responses were identi®ed and coded by two independent coders using a slight modi®cation of a classi®cation system developed by Shiman (1988). The resulting classi®cation system had 62 discrete classes. Intercoder reliability assessed with Cohen's Kappa was 0.81. For analysis purposes, the 62 classes were collapsed along two dimensions into four categories: behavioral versus cognitive and distraction versus substitution. Within each dimension the categories were mutually exclusive. The Behavioral-Cognitive dimension encompassed virtually all coping responses (excluding only those rare responses where it was unclear whether they were behaviors or thoughts). The Distraction-Substitution dimension included approximately 75% of the coping responses. The distraction category included both cognitive distraction and behavioral distraction; the substitution category included breathing exercises, food and drink and other oral strategies. More details about the coping strategy results are reported in O'Connell et al. (1998). 2.4. Data analyses A regression approach was used to address the ®rst four hypotheses concerning the relationship of the three reversal theory scales to other subjective state and environmental variables and the relationship of reversal theory states to the use of coping strategies. As this data set had varying numbers of observations per participant, it was not amenable to analysis by ordinary regression. Instead, we used random-eects regression models, which can handle repeated-measures data with varying numbers of observations per participant (Gibbons et al., 1993; Hedeker, Gibbons & Flay, 1994). The method used for this study estimated the models using Generalized Estimating Equations (Hill et al., 1994; Zeger, Liang & Albert, 1988). These analyses follow the form of traditional regression analyses, while adjusting for the clustering
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and autocorrelation of data within subjects. Based on examination of the autocorrelations, we speci®ed a lag-1 autoregression structure; GEE models are very robust in relation to misspeci®cation of this parameter (Zeger & Liang, 1992). In our analyses, the model considered the joint contributions of the several variables in each set (i.e., with all variables in the set simultaneously controlled for in the model) to the following dependent variables: scores on reversal theory scales, use of particular coping responses (expressed as a used/not used dichotomy) and the total number of coping responses per episode. GEE models can handle both continuous and dichotomous dependent variables; we used Gaussian and logistic link functions as appropriate for each kind of data. The ®fth hypothesis was tested in two ways. First, a between subjects t-test was performed comparing scores from the ®rst lapse of the subjects who smoked during the assessment period with scores from the highest urge episodes of subjects who did not smoke during the assessment period. Second, a paired t-test on data from subjects who smoked during the assessment period, comparing scores from the ®rst lapse with scores from the same subject's most highly tempting situation occurring prior to this lapse. 3. Results The sample of 36 subjects recorded 389 urge episodes, during which they reported using 1047 strategies to cope with urges to smoke. One subject reported only one urge episode during the assessment period. Because GEE analyses of coping data require more than one episode, this episode was dropped from the data set, leaving 388 urge episodes. The subject's prompt episodes were retained in the data set. Subjects reported an average of 10.8 urge episodes over the three days of their participation, with an average of 3.6 episodes per day and an average of 2.7 responses reported in each episode. The subjects also responded to a total of 516 random prompts. Eleven subjects reported a total of 36 lapse episodes. In order to determine the frequency of playful, arousal-seeking and rebellious states, we used a dichotomous scoring procedure. If the self-ratings were in the playful direction for at least two of the three items of the Playfulness Scale, the subject was scored as playful during the episode; if the ratings were in the serious direction for at least two of the three items, then the rating was scored as serious. A similar technique was used for dichotomizing the ArousalSeeking Scale into arousal-seeking and arousal-avoiding and for dichotomizing the Rebelliousness Scale into rebellious and conformist. As expected, the subjects in this study spent 71% of their time in serious states and 29% of their time in playful states. Subjects were in the arousal-avoidant state 73% of the time and in the arousal-seeking state 27% of the time. Subjects were in conformist states 86% of the time and rebellious states 14% of the time. 3.1. Subjective state and environmental variables To address the ®rst two hypotheses concerning the relationship of negative aect to playfulness, arousal-seeking and rebelliousness, GEE analyses were carried out using the combination of urge and prompt episodes N 904). Each of the reversal theory scales (Playfulness, Arousal-Seeking and Rebelliousness) was separately regressed on the subjective
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state variables of urge level, negative aect, tired and type of episode (whether the subject was reporting an urge or responding to a prompt). The eect of each subjective state variable was evaluated controlling for the eects of the other subjective state variables in the analysis. The top portion of Table 1 displays the regression coecients and standard errors for these. The analyses revealed that playfulness was inversely related to negative aect coefficient ÿ0:251, p < 0.001). Tired, type of episode and the level of urge were unrelated to playfulness. Using arousal-seeking as the dependent variable in a similar analysis indicated that arousal-seeking was inversely related to negative aect coefficient ÿ0:125, p < 0.05), unrelated to urge levels or type of episode and inversely related to feeling tired coefficient ÿ0:222, p < 0.001), indicating that subjects who rated themselves as adventurous rated themselves as less tired and sleepy. Using rebelliousness as the dependent variable, GEE analysis indicated that feeling rebellious or angry was signi®cantly positively related to higher urge levels coefficient 0:195, p < 0.01) and to higher levels of negative aect coefficient 0:347, p < 0.001), but unrelated to feeling tired and type of episode. Table 1 Regression coecients and Z-robust standard errors of GEE analyses regressing reversal theory state scores on ratings of other subjective states and on environmental variables Reversal theory state scores playfulness
arousal-seeking
rebelliousness
Coecient
Robust SE
Coecient
Robust SE
Coecient
Robust SE
Subjective states Urge Level Negative aect Tired/sleepy Prompt vs cope episode
0.156 ÿ0.251b 0.036 0.127
0.084 0.044 0.041 0.154
0.074 ÿ0.125c ÿ0.222b ÿ0.059
0.083 0.050 0.044 0.216
0.195a 0.347b ÿ0.005 ÿ0.178
0.072 0.045 0.028 0.121
Environmental variables Location Work Bar/restaurant Vehicle Outside Smoking allowed Cigarette availability Other smoking Alone Interacting Food Alcohol Prompt vs urge episode
ÿ1.260b 0.998a ÿ0.185 0.564 0.074 0.522c 0.002 ÿ0.154 0.219 0.110 0.129 ÿ0.144
0.244 0.364 0.197 0.397 0.232 0.234 0.161 0.175 0.220 0.149 0.561 0.133
ÿ0.712a 0.549 ÿ0.235 0.873c ÿ0.380 0.554c ÿ0.180 ÿ0.020 0.133 0.185 ÿ0.014 ÿ0.135
0.218 0.609 0.245 0.384 0.233 0.257 0.240 0.166 0.223 0.142 0.873 0.181
0.045 0.504c 0.000 ÿ0.427 0.142 ÿ0.327c 0.210 0.266 0.322 ÿ0.179 0.322 0.647b
0.147 0.247 0.112 0.237 0.207 0.149 0.193 0.185 0.183 0.141 0.369 0.127
a
p < 0.01. p < 0.001. c p < 0.05.
b
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The third hypothesis was addressed by a second set of GEE analyses, which separately regressed each of the reversal theory variables on four location variables represented by eects coding (work, bar/restaurant, vehicle and outside with ``other'' as the reference category) and the variables of smoking regulations Not allowed 0, allowed 1), cigarette availability Not easily available 0, easily available 1), whether alone (no/yes), interacting with others (no/yes), whether others were smoking (no, in my view, in my group) and whether food or alcohol had recently been consumed and type of episode (whether prompt or urge). In these simultaneous models the eect of each environment variable is evaluated while controlling for all other environment variables in the set. The results indicated that playfulness was inversely related to being at work coefficient ÿ1:26, p < 0.001) and directly related to being in bars and restaurants coefficient 0:998, p < 0.01). In addition, easy cigarette availability was related to higher playfulness coefficient 0:234, p < 0.05). No other environmental variable was related to playfulness. In a similar analysis, arousal-seeking was found to be signi®cantly lower in work settings coefficient ÿ0:712, p < 0.01) and signi®cantly higher in outdoor settings coefficient 0:973, p < 0.05) and where cigarettes were easily available coefficient 0:554, p < 0.05). No other environment variable was related to arousal-seeking. Another GEE analyses showed that rebelliousness was signi®cantly higher in bars and restaurants coefficient 0:504, p < 0.05) and signi®cantly lower in situations where cigarettes were easily available coefficient ÿ0:327, p < 0.05). This analysis also indicated that rebelliousness was signi®cantly more likely to occur in urge episodes than in prompt episodes coefficient 0:647, p < 0.001). 3.2. Playfulness and coping The fourth hypothesis that paratelic states would be characterized by fewer coping strategies than telic states was supported. GEE analysis with 388 urge episodes using the playfulness, arousal-seeking and rebelliousness scores as independent variables and number of strategies used per episode as the dependent variable indicated that higher playfulness scores were signi®cantly related to the use of fewer coping strategies during an episode coefficient ÿ0:133, p < 0.01). Neither arousal-seeking nor rebelliousness accounted for a signi®cant portion of unique variance in the number of strategies used in an episode. Four similar analyses regressed the use or non-use of the four types of coping strategies on the reversal theory variables. The use of distraction strategies was inversely related to playfulness and arousal-seeking scores coefficient ÿ0:170, p < 0.05 and ÿ0.140. p < 0.05, respectively), but unrelated to rebelliousness. Substitution strategy use was inversely related to playfulness coefficient ÿ0:170 p < 0.05), but unrelated to arousal-seeking and rebelliousness. Neither cognitive nor behavioral strategy use had signi®cant relationships to any of the reversal theory variables. 3.3. Dierences in urges vs lapses Both between-subjects and within-subjects analyses were carried out to test the ®fth hypothesis that playfulness scores would be higher for lapse episodes than for episodes where the subject resisted the urge to smoke (urge episodes). Only 11 of 36 subjects lapsed during the
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time they were in the study. When the ®rst lapse episodes of the 11 subjects who smoked during the assessment period were compared with the highest urge episodes of the 25 subjects who did not experience lapses, there were no signi®cant dierences between the two groups in playfulness, arousal-seeking, rebelliousness, or negative aect scores. However, a withinsubjects analysis comparing the ®rst lapse episode with the highest urge episode for those 11 subjects with lapses, showed a signi®cant dierence for playfulness, t 2:71, d:f: 10, p 0:02; lapse episodes M 7:2, S:D: 1:6; urge episodes M 5:4, S:D: 1:7: No dierences between the types of episodes were found for arousal-seeking, rebelliousness, or negative aect scores.
4. Discussion This study used near real-time data collection techniques to investigate reversal theory variables during smoking cessation. The ®ndings supported the hypothesis that fewer coping strategies are used when urges are experienced in playful states. It should be noted that the analyses relating coping strategies to reversal theory states included only those episodes where the individual resisted the urge to smoke. There were too few lapse episodes to determine the relationship of state variables to coping strategies during lapse episodes. Therefore, this study indicated that urge episodes experienced in playful states were associated with use of fewer strategies than those experienced in serious states. This ®nding cannot be attributed to lower urge levels in paratelic states because other analyses indicated that urge level was unrelated to playfulness. The ®nding might indicate it is easier to cope with urges in paratelic states because fewer strategies are needed. However, the ®ndings comparing the lapse and urge episodes also indicate that subjects are more likely to lapse in paratelic states. Subjects may exert less coping eort in paratelic states than in telic states. Sometimes, this eort is adequate and the urge is successfully resisted; on other occasions, it is not adequate and lapses result. The association of playfulness with lapses may also be related to a third variable, such as consumption of alcohol, which has been shown to predict lapsing (Shiman & Balabanis, 1996). Too few lapses were available in this data set to test the eect of the interaction of coping, playfulness and alcohol use on the occurrence of lapses. Other than playfulness, we found no variables that distinguished urge episodes from lapses. These negative ®ndings are at odds with prior reports that lapses are associated with aective disturbance (e.g. Shiman et al., 1996a,b). The small sample of lapses may have precluded adequate tests of these relationships. The results of the analyses relating reversal theory variables to other subjective state variables and to environmental variables gave evidence for the validity of the scales used in this study. As expected, both components of paratelic states, playfulness and arousal-seeking, were inversely related to negative aect and to being in work settings. As expected, playfulness was directly related to being in bars and restaurants, but unexpectedly, arousal-seeking was unrelated to this location type. As expected, rebelliousness was directly related to negative aect, indicating that being in the negativistic state is highly related to feeling tense, unhappy and miserable. Though not predicted, other ®ndings make logical sense. For instance, it is easy to see that
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people who endorse being tired and sleepy are unlikely to be feeling adventurous or wanting excitement. The ®nding that playfulness and arousal-seeking are related to having cigarettes easily available may indicate that environments that induce paratelic states may be those where cigarettes are freely available. Alternatively, it is possible that freely available cigarettes induce paratelic states in individuals who are trying to quit smoking. The inverse relationship between rebelliousness and cigarette availability is harder to explain. Situations that limit cigarette availability, such as work settings, may be ones that are particularly prone to inducing angry feelings. Alternatively, just the fact of being kept from cigarettes may induce rebellious states in inveterate smokers. The results indicate that this sample was in negativistic states only 14% of the time. However, strong urges accompany negativistic states. Whether these urges cause a negativistic reversal or whether negativistic states increase urges is not known. The dichotomous variable indexing an urge episode versus a prompt episode was signi®cantly related to rebelliousness in the analysis of environment variables but unrelated in the analyses of subjective states. This disparity is caused by the inclusion of urge level in the subjective data set. Rebelliousness was positively correlated with urge intensity. Once urge intensity was accounted for, rebelliousness during urge episodes was no dierent than it was in prompt episodes. Aside from the modest sample size, the study reported here has several limitations. Subjects participated in the study for only three days during their ®rst 10 days of cessation. Although subjects were randomly assigned to the three-day blocks, the cross-sectional design and the few days of participation may have limited the statistical power of the study. Because this was the ®rst study to include reversal theory variables in an ecological momentary assessment study of smoking cessation and because the particular scales used in this study were new, many analyses were carried out to explore the relationship of these scales to other variables. The multiple analyses increase the probability of Type I errors. We considered these analyses to be exploratory in nature and that it was important not to miss pertinent ®ndings in this unique data set. There is also the possibility that ®ndings produced by this study are not generalizable because the EMA methods used were reactive or because the type of person who would volunteer for such a study would be unrepresentative of smokers in general. Despite the study limitations, the ®ndings are consistent with our prior research, which used a completely dierent method that included retrospective interviews about situations that occurred two weeks to three months prior to the interview and coders' ratings of the transcribed interviews as assessments of metamotivational state. Together these studies indicate that the likelihood of resisting the urge to smoke during smoking cessation attempts varies as a function of metamotivational state. Paratelic states are particularly vulnerable, possibly because paratelic states are related to the use of fewer coping strategies. It should be noted that other analyses of this data set (O'Connell et al., 1998) revealed that a measure of negative aect was not related to the number of strategies or to any speci®c type of strategy use. Similarly, the current study showed that there was no relationship between coping responses and a particular kind of negative aect state, rebelliousness, which is characterized by rebelliousness and anger. However, unlike playfulness and arousal-seeking, rebelliousness was related to urge levels. The ®ndings of this study illustrate why smoking cessation is so dicult. The decision to quit smoking is usually made when the smoker is in a telic (goal-oriented) and conformist state, wherein such a decision seems highly warranted. However, the decision must be sustained
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through paratelic and negativistic states during which the person values living for the moment, seeking arousal and being rebellious. Reversal theory posits that motivations dier depending on one's metamotivational state. This implies that eective strategies for resisting the urge to smoke are dierent in telic states than they are in paratelic states. Strategies that will be eective in conformist states may not be eective in negativistic states. The very motivation or capability to produce coping responses may wax and wane with current psychological state. Thus, relapse episodes may result from transient changes in state, making lapsing both hard to study and hard to prevent. References Apter, M. J. (1982). The experience of motivation: the theory of psychological reversals. London: Academic Press. Baer, J. S., Lichtenstein, E., Kamarck, T., & Ransom, C. C. (1989). Prediction of smoking relapse: analysis of temptations and transgressions after initial cessation. Journal of Consulting and Clinical Psychology, 57(5), 623± 627. Bliss, R. E., Garvey, A. J., Heinold, J. W., & Hitchcock, J. L. (1989). The in¯uence of situation coping on relapse crisis outcomes after smoking cessation. Journal of Consulting and Clinical Psychology, 57, 443±449. Brandon, T. H., Tiany, S. T., & Baker, T. B. (1986). The process of smoking relapse. In F. M. Tims, & G. G. Leukefeld, Relapse and recovery in drug abuse (pp. 104±117). Rockville, MD: U.S. Department of Health and Human Services. Calhoun J. E. (1995). Construct validity of the telic/paratelic state instrument. Kansas City, KS. Unpublished doctoral dissertation. CDC (1997). Cigarette smoking among adults Ð United States, 1995. Morbidity and Mortality Weekly Report, 46, 1217±1220. Cook, M. R., Gerkovich, M. M., O'Connell, K. A., & Potocky, M. (1995). Reversal theory constructs and cigarette availability predict lapse early in smoking cessation. Research in Nursing and Health, 18, 217±224. Cook, M. R., Gerkovich, M. M., Potocky, M., & O'Connell, K. A. (1993). Instruments for the assessment of reversal theory states. Patient Education and Counseling, 22, 99±106. Gerkovich, M. M., Cook, M. R., O'Connell, K. A., & Potocky, M. (1993). Reversal theory analysis of relapse crises following smoking cessation. Patient Education and Counseling, 22, 91±97. Gibbons, R. D., Hedeker, D., Elkin, I., Waternaux, C., Kraemer, H. C., Greenhouse, J. B., Shea, T., Imber, S. D., Sotsky, S. M., & Watkins, J. T. (1993). Some conceptual and statistical issues in analysis of longitudinal psychiatric data: Application to the NIMH treatment of depression collaborative research program dataset. Archives of General Psychiatry, 50, 739±750. Hedeker, D., Gibbons, R. D., & Flay, B. R. (1994). Random-eects regression models for clustered data with an example from smoking prevention research. Journal of Consulting and Clinical Psychology, 62, 757±765. Hill, H. A., Schoenbach, V. J., Kleinbaum, D. G., Strecher, V. J., Orleans, C. T., Gebski, V. J., & Kaplan, B. H. (1994). A longitudinal analysis of predictors of quitting smoking among participants in a self-help intervention trial. Addictive Behaviors, 19, 159±173. Marlatt, G. A., & Gordon, J. R. (1980). Determinants of relapse: Implications for maintenance of behavior change. In P. O. Davidson, & S. M. Davidson, Behavioral medicine: changing health life-styles (pp. 410±452). New York: Brunner/Mazel. O'Connell, K. A., & Martin, E. J. (1987). Highly tempting situations associated with abstinence, temporary lapse and relapse among participants in smoking cessation programs. Journal of Consulting and Clinical Psychology, 55, 367±371. O'Connell, K. A., & Shiman, S. (1988). Negative aect and smoking relapse. Journal of Substance Abuse, 1, 25±33. O'Connell, K. A., Cook, M. R., Gerkovich, M. M., Potocky, M., & Swan, G. E. (1990). Reversal theory and smoking: a state-based approach to ex-smokers' highly tempting situations. Journal of Consulting and Clinical Psychology, 58, 489±494.
K.A. O'Connell et al. / Personality and Individual Dierences 29 (2000) 671±683
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O'Connell, K. A., Gerkovich, M. M., Cook, M. R., Shiman, S., Hickcox, M., & Kakolewski, K. E. (1998). Coping in real time: Using ecological momentary assessment techniques to assess coping with the urge to smoke. Research in Nursing and Health, 21, 487±497. Potocky, M., Gerkovich, M. M., O'Connell, K. A., & Cook, M. R. (1991). State-outcome consistency in smoking relapse crises: a reversal theory approach. Journal of Consulting and Clinical Psychology, 59, 351±353. Russell, J. A. (1980). A circumplex model of aect. Journal of Personality and Social Psychology, 39, 1161±1178. Shiman, S. (1984). Coping with temptations to smoke. Journal of Consulting and Clinical Psychology, 52, 261±267. Shiman, S. (1988). Behavioral assessment. In D. M. Donovan, & G. A. Marlatt, Assessment of addictive behaviors: the Guilford behavioral assessment series (pp. 139±188). New York: Guilford. Shiman, S., & Balabanis, M. (1996). Do drinking and smoking go together? Alcohol Health and Research World, 20(2), 107±110. Shiman, S., Gnys, M., Richards, T. J., Paty, J. A., & Hickcox, M. (1996a). Temptation to smoke after quitting: a comparison of lapsers and quitters. Health Psychology, 15, 455±461. Shiman, S., Paty, J. A., Gnys, M., Kassell, J. A., & Hickcox, M. (1996b). First lapses to smoking: within-subjects analysis of real-time reports. Journal of Consulting and Clinical Psychology, 64, 366±379. Shiman, S., Huord, M., Hickcox, M., Paty, J. A., Gnys, M., & Kassel, J. D. (1997). Remember that? A comparison of real-time vs retrospective recall of smoking lapses. Journal of Consulting and Clinical Psychology, 65, 292±300. Shopland, D. R., Hartman, A. M., Gibson, J. T., Mueller, M. D., Kessler, L. G., & Lynn, W. R. (1996). Cigarette smoking among U.S. adults by state and region: estimates from the current population survey. Journal of the National Cancer Institute, 88, 1748±1758. Silagy, C., Mant, D., Fowler, G., & Lodge, M. (1994). Meta-analysis on ecacy of nicotine replacement therapies in smoking cessation. The Lancet, 343, 139±142. Wills, T. A., & Shiman, S. (1985). Coping and substance abuse: a conceptual framework. In S. Shiman, & T. A. Wills, Coping and substance abuse (pp. 3±24). San Diego: Academic Press. Zeger, S. L., & Liang, K. (1992). An overview of methods for the analysis of longitudinal data. Statistics in Medicine, 11, 1825±1839. Zeger, S. L., Liang, K., & Albert, P. S. (1988). Models for longitudinal data: a generalized estimating equation approach. Biometrics, 44, 1049±1060.
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Playfulness, arousal-seeking and rebelliousness during smoking cessation Kathleen A. O'Connell a,*, 1, Mary M. Gerkovich b, Marge Bott a, Mary R. Cook b, Saul Shiman c a
School of Nursing, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160-7502, USA b Midwest Research Institute, Kansas City, MO, USA c University of Pittsburgh, Pittsburgh, PA, USA Received 18 June 1999; accepted 1 October 1999
Abstract Whereas prior research has indicated that negative aect states contribute to lapses during cessation attempts, studies using retrospective interviews have shown that the reversal theory states of playfulness and rebelliousness also increase the likelihood of lapsing. Using ecological momentary assessment techniques, the relationship of playfulness, arousal-seeking and rebelliousness to other subjective states, situational variables, the use of coping strategies and to lapsing were investigated in 36 subjects who were attempting to quit smoking. Playfulness was signi®cantly ( p < 0.01) related to the use of fewer coping responses during urge episodes. Within-subjects analyses of 11 subjects who lapsed during the study showed that playfulness scores were signi®cantly higher ( p < 0.02) during lapse as compared to highly tempting situations. Rebelliousness was related to higher urge levels during coping episodes ( p < 0.01). Results support the construct validity of the scales and the utility of reversal theory variables in explaining outcomes of smoking cessation attempts. 7 2000 Elsevier Science Ltd. All rights reserved. Keywords: Reversal theory; Playfulness; Arousal-seeking; Rebelliousness; Smoking cessation; Coping strategies
* Corresponding author. Tel.: +1-913-588-3377; fax: +1-913-588-1660. E-mail address: [email protected] (K.A. O'Connell). 1 Present address. Columbia University, Isabel Maitland Stewart Chair and Professor of Nursing Education, Box 35 Teachers College, 525 W. 120th Street, New York, NY 10027, USA. Tel.: +1-212-678-3120; fax: +1-212-6784048; e-mail: o'[email protected]. 0191-8869/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 1 9 1 - 8 8 6 9 ( 9 9 ) 0 0 2 2 4 - X
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1. Introduction Smoking is a health-damaging behavior practiced by more than one-quarter of the US population (CDC, 1997; Shopland et al., 1996). Although new pharmacological interventions have doubled quit rates in recent years, the relapse rates remain at 80% or higher at 12 months after a cessation attempt (Silagy, Mant, Fowler & Lodge, 1994). Experiencing a single lapse during a cessation attempt is highly predictive of returning to regular smoking (Brandon, Tiany & Baker, 1986). Whereas prior research has indicated that negative aect states contribute to lapses (Marlatt & Gordon, 1980; O'Connell & Martin, 1987; O'Connell & Shiman, 1988), studies based on reversal theory have shown that playful states also increase the likelihood of lapsing (Cook, Gerkovich, O'Connell & Potocky, 1995; Gerkovich, Cook, O'Connell & Potocky, 1993; O'Connell, Cook, Gerkovich, Potocky & Swan, 1990; Potocky, Gerkovich, O'Connell & Cook, 1991). Reversal theory is a general theory of psychology, which holds that individuals are inherently inconsistent. Reversals occur between the members of opposing pairs of metamotivational states; they are called ``metamotivational'' because they are not about motivation, itself, but pertain to how certain motivational variables (e.g. arousal) are interpreted. Experience is interpreted dierently in opposing states. The theory identi®es four pairs of metamotivational states: telic/paratelic, negativistic/conformist, mastery/sympathy and autic/alloic. This manuscript focuses on the ®rst two pairs of states. Individuals in the telic state are serious-minded, goal oriented, planning ahead and usually arousal-avoidant. Individuals in the paratelic state are playful, sensation-oriented, spontaneous and usually arousal-seeking. Individuals in the negativistic state are rebellious, oriented toward breaking rules and often angry. Individuals in the conformist state are compliant, oriented toward following rules and usually not angry. According to reversal theory, hedonic tone or aect is conceptually independent of metamotivational state. It is possible to experience either positive or negative aect in each state. Nevertheless, many negative aect states (with the exception of boredom, which can be experienced in paratelic states) are probably experienced in the telic state, because negative aect states tend to induce serious-mindedness. Most negativistic states are associated with the unpleasant aect anger, which is the combination of telic and negativistic states, but some negativistic states can be associated with positive aect, such as the experience of playful rebelliousness, which is the combination of paratelic and negativistic states. Although many positive aect states are experienced in the paratelic state, positive aect states related to work performance and goal attainment can be experienced in the telic state. Thus, we expected that paratelic states would contain a preponderance of positive aect states, while telic states would contain a preponderance of negative aect states. We speculated that people in paratelic states were likely to lapse because they failed to use coping strategies. Invoking coping strategies has been shown to be highly related to resisting the urge to smoke (e.g. Baer, Lichtenstein, Kamarck & Ransom, 1989; Bliss, Garvey, Heinold & Hitchcock, 1989; Shiman, 1984; Shiman, Gnys, Richards, Paty & Hickcox, 1996a). However, engaging in coping strategies may require a serious-mindedness that is uncharacteristic of paratelic states. Moreover, the strategies that are usually recommended, such as thinking of the negative consequences of smoking, reminding oneself of the reasons for
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quitting, or trying to calm down, have decidedly serious and arousal-avoidant tones that might be eschewed by individuals in paratelic states. We reasoned that individuals in negativistic states would be more likely to lapse because they consider smoking a rebellious activity consistent with the desire to break rules. Many associate smoking with being rebellious during their youth. In addition, smoking during a cessation attempt constitutes breaking self-imposed rules and can satisfy a desire to feel rebellious in situations where breaking rules imposed by others might be too costly. O'Connell et al. (1990) and Gerkovich et al. (1993) showed that highly tempting situations that coincided with paratelic states or negativistic states were much more likely to result in a lapse than those that coincided with telic and conformist states. Using a within-subjects analysis of lapses and episodes of temptation that did not result in lapses, Potocky et al. (1991) showed that this eect was not due to enduring individual dierences, but rather to transient states. The ®nding that paratelic states were related to lapses was replicated, but the ®ndings with respect to negativistic states were not replicated in a subsequent study (Cook et al., 1995). Our prior work has several limitations. First, our prior studies were based on retrospective accounts of highly tempting situations, which might have been subject to bias in reporting; Shiman et al. (1997) have shown that retrospective reports of lapse episodes dier signi®cantly from reports taken within minutes of an event. Secondly, the determination of metamotivational state was made by coders on the basis of interviews about highly tempting situations. Self-ratings might generate very dierent ®ndings. Third, we could only speculate that the mechanism for the deleterious eects of paratelic states was the failure to use coping strategies, because we did not have adequate measures of coping. This paper reports a study using near real-time data collection techniques and self-ratings of state to address some of these limitations. Telic/paratelic states are operationalized in this study by two continuous measures, the Playfulness and the Arousal-Seeking Scales. Negativistic states are operationalized by the continuous measure, the Rebelliousness Scale. After examining the reliability of the measures of playfulness, arousal-seeking and rebelliousness and addressing the frequency of those states, we tested ®ve hypotheses. First, playfulness and arousal-seeking will be inversely related to negative aect. Second, because of the anger component of the Rebelliousness Scale, rebelliousness will be positively related negative aect. Third, playfulness and arousal-seeking will be low in work settings and high in leisure settings, i.e. in bars and restaurants. Fourth, playfulness will be related to the use of fewer coping strategies. And ®fth, compared to episodes in which subjects resist the urge to smoke, lapse episodes will be characterized by higher playfulness, arousal-seeking and rebelliousness scores. In addition to the hypothesis testing, exploratory analyses were carried out to determine the relationship of reversal theory states to environmental variables and other state variables. Also, we investigated whether lapses and urge episodes diered on the negative aect, as has been found in other studies.
2. Method Using palm-top computers and hand-held tape recorders, individuals who were trying to quit smoking reported on occasions in which they performed coping in support of their eorts.
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Other ®ndings from this data set that are unrelated to reversal theory variables are reported in O'Connell et al. (1998). 2.1. Subjects Subjects were 43 cigarette smokers who were enrolled in one of several group smoking cessation programs in a large midwestern metropolitan area. Subjects were randomly assigned to one of 5 overlapping three-day blocks spanning the ®rst 10 days of cessation. Block assignment was carried out such that subjects who dropped out of the study or who relapsed prior to the day when they would start the study were replaced. Except for subjects in Block 1 (Days 1, 2 and 3 of cessation), who began the study on their quit day, subjects had to be abstinent or abstinent with only an occasional lapse on the day prior to study participation. Of the 43 subjects who entered the study, 36 completed participation (5 were not compliant and 2 did not quit smoking). The sample included 58% women; 92% of the sample were Caucasian and 8% were African American. Thirty-three percent of the sample had obtained a college degree, while an additional 50% had some education beyond a high school diploma; 61% were married; and 67% were employed outside the home. The average age of the participants was 40.5 yr (S.D.=10.5) and they had been smoking an average of 17 yr (S.D.=3.2). Prior to quitting smoking, subjects reported smoking an average of 24 cigarettes per day (S.D.=10.7). Ninety-seven percent had tried to quit previously. The sample had an average of 4.7 prior quit attempts (S.D.=4.2). 2.2. Measures 2.2.1. Computer-administered instruments A palmtop computer, called the Electronic Diary (ED) (Shiman et al., 1996a) administered a total of 51 items, which included assessments of situation, activity, negative aect, arousal, playfulness, arousal-seeking and negativism. Except for measures of reversal theory states, the assessment was derived from prior studies of smoking and relapse (Shiman et al., 1996a; Shiman, Paty, Gnys, Kassell & Hickcox, 1996b). Subjects responded to one item at a time, without being able to see responses given during previous episodes. Situational characteristics that were assessed included the intensity of smoking urges, rated on a 1-to-11 scale; the location of the episode; whether cigarettes were available; smoking regulations; and whether the subject was interacting with others, eating, or consuming alcohol. The Negative Aect Scale alpha 0:67 included happy (reverse coded), miserable, tense and overall feeling. Higher scores indicated more negative aect. The Tired Factor alpha 0:74 included tired, sleepy and overall arousal level and was scored such that higher scores indicated higher levels of tiredness. The Negative Aect and Tired Scales jointly covered the domain of emotion de®ned by the circumplex model of aect (Russell, 1980). The Playfulness and Arousal-Seeking Scales were based on scales developed by Cook, Gerkovich, Potocky & O'Connell (1993) and Calhoun (1995). The Playfulness Scale score was the sum of three items all rated on a 4-point scale (Feeling serious versus Feeling playful; Wanting to do something important versus Wanting to do something frivolous; Trying to accomplish something versus Trying to have fun). Higher scores on the Playfulness Scale indicate more playfulness (and less serious-
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mindedness). The Arousal-Seeking Scale was the sum of scores on three items, also assessed on a 4-point scale representing the extent to which the subject preferred emotional arousal at the time (Cautious vs Adventurous, Want calm vs Want excitement, Want peace and quiet vs Want adventure). Higher scores indicate more arousal-seeking (and less arousal-avoidance). The Rebelliousness Scale consisted of two unipolar items (angry and rebellious), each assessed on a 4-point scale ranging from yes to no and one bipolar item (Compliant vs De®ant) also assessed on a 4-point scale. Higher scores indicate more rebelliousness (and less compliance). A preliminary factor analysis indicated that each scale was represented by its own factor, with all items loading at 0.35 or greater and no items cross-loading. The Playfulness Scale has a Cronbach's alpha of 0.73. The Arousal-Seeking Scale had a Cronbach's alpha of 0.78 and the Rebelliousness Scale had a Cronbach's alpha of 0.67. As expected the correlation between playfulness and arousal-seeking scores was 0.548, replicating the moderate relationship between these two constructs that has been found in other studies (Apter, 1982; Calhoun, 1995). 2.3. Procedures Subjects were recruited during the introductory sessions of their smoking cessation programs. Baseline data were collected prior to quitting smoking. At baseline, at the training session and at the end of each day of data collection, CO was measured with a Breathco carbon monoxide monitor (Vitalograph, Lenexa, KS), with values >8 ppm indicating smoking. CO monitoring was also used to encourage truthful reporting. Subjects were paid $50 for each data collection day. 2.3.1. Training Subjects were trained during a 2 to 3 h period immediately prior to their assessment days. During the training session, the subjects were taught to use the palm-top computer, which was called the Electronic Diary (ED) and the cassette tape-recorder, which the project team called ETHEL (Electronic Tape Held Experience Log). 2.3.2. Computer hardware and software The ED system was implemented on a PSION Organizer II LZ 64 (PSION, Ltd., London, England), a palm-top computer with a 4-line, 20-character per line LCD screen, a clock/ calendar and an audio speaker (see Shiman, 1996a). 2.3.3. Assessment occasions The subject was instructed to carry out the assessment procedures for three types of experiences: (1) after situations in which they initiated coping, (2) after lapses and (3) in response to computer-initiated random prompts. In order to avoid disruption of natural coping responses, the subjects were instructed to wait until they had ®nished coping before reporting. Subjects were encouraged to report both anticipatory and immediate coping responses. Anticipatory coping is performed to prevent urges and immediate coping is performed to deal with ongoing urges (Wills & Shiman, 1985). Because few anticipatory responses were recorded, only the immediate coping responses reported during urge episodes are included in this paper.
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2.3.4. Assessments For urge and lapse episodes, assessment procedures involved having the subject turn on ED, which immediately asked the subjects to indicate whether they were reporting an urge episode (which did not involve smoking) or a lapse episode (which involved smoking and may or may not have included coping responses). Then ED instructed the subject to turn on the taperecorder and to read into the recorder a code, which was an encryption of the date and time. Then, ED prompted the subjects to record on ETHEL a brief description of the situations they were in and all the coping responses they used during that situation. After ®nishing the taperecording, the subject responded to the questionnaire administered by ED. Each recording episode took approximately two minutes. In order to assess times when subjects were not coping with urges, subjects were randomly prompted by ED about ®ve times per day to answer the same questionnaire. If a prompt happened to occur when the subject was experiencing an urge or lapse, subjects were instructed to indicate this in response to the initial ED questionnaire item; ED then prompted them to carry out the reporting procedures for an urge or a lapse, as appropriate. At the end of each study day, (approximately 24 h period), a project sta member met with the subjects to review his/her data, identify problems, answer questions about the electronic equipment, collect a breath sample for CO measurement and conduct an interview. 2.3.5. Coding of coping responses All tape-recorded entries were transcribed. Coping responses were identi®ed and coded by two independent coders using a slight modi®cation of a classi®cation system developed by Shiman (1988). The resulting classi®cation system had 62 discrete classes. Intercoder reliability assessed with Cohen's Kappa was 0.81. For analysis purposes, the 62 classes were collapsed along two dimensions into four categories: behavioral versus cognitive and distraction versus substitution. Within each dimension the categories were mutually exclusive. The Behavioral-Cognitive dimension encompassed virtually all coping responses (excluding only those rare responses where it was unclear whether they were behaviors or thoughts). The Distraction-Substitution dimension included approximately 75% of the coping responses. The distraction category included both cognitive distraction and behavioral distraction; the substitution category included breathing exercises, food and drink and other oral strategies. More details about the coping strategy results are reported in O'Connell et al. (1998). 2.4. Data analyses A regression approach was used to address the ®rst four hypotheses concerning the relationship of the three reversal theory scales to other subjective state and environmental variables and the relationship of reversal theory states to the use of coping strategies. As this data set had varying numbers of observations per participant, it was not amenable to analysis by ordinary regression. Instead, we used random-eects regression models, which can handle repeated-measures data with varying numbers of observations per participant (Gibbons et al., 1993; Hedeker, Gibbons & Flay, 1994). The method used for this study estimated the models using Generalized Estimating Equations (Hill et al., 1994; Zeger, Liang & Albert, 1988). These analyses follow the form of traditional regression analyses, while adjusting for the clustering
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and autocorrelation of data within subjects. Based on examination of the autocorrelations, we speci®ed a lag-1 autoregression structure; GEE models are very robust in relation to misspeci®cation of this parameter (Zeger & Liang, 1992). In our analyses, the model considered the joint contributions of the several variables in each set (i.e., with all variables in the set simultaneously controlled for in the model) to the following dependent variables: scores on reversal theory scales, use of particular coping responses (expressed as a used/not used dichotomy) and the total number of coping responses per episode. GEE models can handle both continuous and dichotomous dependent variables; we used Gaussian and logistic link functions as appropriate for each kind of data. The ®fth hypothesis was tested in two ways. First, a between subjects t-test was performed comparing scores from the ®rst lapse of the subjects who smoked during the assessment period with scores from the highest urge episodes of subjects who did not smoke during the assessment period. Second, a paired t-test on data from subjects who smoked during the assessment period, comparing scores from the ®rst lapse with scores from the same subject's most highly tempting situation occurring prior to this lapse. 3. Results The sample of 36 subjects recorded 389 urge episodes, during which they reported using 1047 strategies to cope with urges to smoke. One subject reported only one urge episode during the assessment period. Because GEE analyses of coping data require more than one episode, this episode was dropped from the data set, leaving 388 urge episodes. The subject's prompt episodes were retained in the data set. Subjects reported an average of 10.8 urge episodes over the three days of their participation, with an average of 3.6 episodes per day and an average of 2.7 responses reported in each episode. The subjects also responded to a total of 516 random prompts. Eleven subjects reported a total of 36 lapse episodes. In order to determine the frequency of playful, arousal-seeking and rebellious states, we used a dichotomous scoring procedure. If the self-ratings were in the playful direction for at least two of the three items of the Playfulness Scale, the subject was scored as playful during the episode; if the ratings were in the serious direction for at least two of the three items, then the rating was scored as serious. A similar technique was used for dichotomizing the ArousalSeeking Scale into arousal-seeking and arousal-avoiding and for dichotomizing the Rebelliousness Scale into rebellious and conformist. As expected, the subjects in this study spent 71% of their time in serious states and 29% of their time in playful states. Subjects were in the arousal-avoidant state 73% of the time and in the arousal-seeking state 27% of the time. Subjects were in conformist states 86% of the time and rebellious states 14% of the time. 3.1. Subjective state and environmental variables To address the ®rst two hypotheses concerning the relationship of negative aect to playfulness, arousal-seeking and rebelliousness, GEE analyses were carried out using the combination of urge and prompt episodes N 904). Each of the reversal theory scales (Playfulness, Arousal-Seeking and Rebelliousness) was separately regressed on the subjective
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state variables of urge level, negative aect, tired and type of episode (whether the subject was reporting an urge or responding to a prompt). The eect of each subjective state variable was evaluated controlling for the eects of the other subjective state variables in the analysis. The top portion of Table 1 displays the regression coecients and standard errors for these. The analyses revealed that playfulness was inversely related to negative aect coefficient ÿ0:251, p < 0.001). Tired, type of episode and the level of urge were unrelated to playfulness. Using arousal-seeking as the dependent variable in a similar analysis indicated that arousal-seeking was inversely related to negative aect coefficient ÿ0:125, p < 0.05), unrelated to urge levels or type of episode and inversely related to feeling tired coefficient ÿ0:222, p < 0.001), indicating that subjects who rated themselves as adventurous rated themselves as less tired and sleepy. Using rebelliousness as the dependent variable, GEE analysis indicated that feeling rebellious or angry was signi®cantly positively related to higher urge levels coefficient 0:195, p < 0.01) and to higher levels of negative aect coefficient 0:347, p < 0.001), but unrelated to feeling tired and type of episode. Table 1 Regression coecients and Z-robust standard errors of GEE analyses regressing reversal theory state scores on ratings of other subjective states and on environmental variables Reversal theory state scores playfulness
arousal-seeking
rebelliousness
Coecient
Robust SE
Coecient
Robust SE
Coecient
Robust SE
Subjective states Urge Level Negative aect Tired/sleepy Prompt vs cope episode
0.156 ÿ0.251b 0.036 0.127
0.084 0.044 0.041 0.154
0.074 ÿ0.125c ÿ0.222b ÿ0.059
0.083 0.050 0.044 0.216
0.195a 0.347b ÿ0.005 ÿ0.178
0.072 0.045 0.028 0.121
Environmental variables Location Work Bar/restaurant Vehicle Outside Smoking allowed Cigarette availability Other smoking Alone Interacting Food Alcohol Prompt vs urge episode
ÿ1.260b 0.998a ÿ0.185 0.564 0.074 0.522c 0.002 ÿ0.154 0.219 0.110 0.129 ÿ0.144
0.244 0.364 0.197 0.397 0.232 0.234 0.161 0.175 0.220 0.149 0.561 0.133
ÿ0.712a 0.549 ÿ0.235 0.873c ÿ0.380 0.554c ÿ0.180 ÿ0.020 0.133 0.185 ÿ0.014 ÿ0.135
0.218 0.609 0.245 0.384 0.233 0.257 0.240 0.166 0.223 0.142 0.873 0.181
0.045 0.504c 0.000 ÿ0.427 0.142 ÿ0.327c 0.210 0.266 0.322 ÿ0.179 0.322 0.647b
0.147 0.247 0.112 0.237 0.207 0.149 0.193 0.185 0.183 0.141 0.369 0.127
a
p < 0.01. p < 0.001. c p < 0.05.
b
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The third hypothesis was addressed by a second set of GEE analyses, which separately regressed each of the reversal theory variables on four location variables represented by eects coding (work, bar/restaurant, vehicle and outside with ``other'' as the reference category) and the variables of smoking regulations Not allowed 0, allowed 1), cigarette availability Not easily available 0, easily available 1), whether alone (no/yes), interacting with others (no/yes), whether others were smoking (no, in my view, in my group) and whether food or alcohol had recently been consumed and type of episode (whether prompt or urge). In these simultaneous models the eect of each environment variable is evaluated while controlling for all other environment variables in the set. The results indicated that playfulness was inversely related to being at work coefficient ÿ1:26, p < 0.001) and directly related to being in bars and restaurants coefficient 0:998, p < 0.01). In addition, easy cigarette availability was related to higher playfulness coefficient 0:234, p < 0.05). No other environmental variable was related to playfulness. In a similar analysis, arousal-seeking was found to be signi®cantly lower in work settings coefficient ÿ0:712, p < 0.01) and signi®cantly higher in outdoor settings coefficient 0:973, p < 0.05) and where cigarettes were easily available coefficient 0:554, p < 0.05). No other environment variable was related to arousal-seeking. Another GEE analyses showed that rebelliousness was signi®cantly higher in bars and restaurants coefficient 0:504, p < 0.05) and signi®cantly lower in situations where cigarettes were easily available coefficient ÿ0:327, p < 0.05). This analysis also indicated that rebelliousness was signi®cantly more likely to occur in urge episodes than in prompt episodes coefficient 0:647, p < 0.001). 3.2. Playfulness and coping The fourth hypothesis that paratelic states would be characterized by fewer coping strategies than telic states was supported. GEE analysis with 388 urge episodes using the playfulness, arousal-seeking and rebelliousness scores as independent variables and number of strategies used per episode as the dependent variable indicated that higher playfulness scores were signi®cantly related to the use of fewer coping strategies during an episode coefficient ÿ0:133, p < 0.01). Neither arousal-seeking nor rebelliousness accounted for a signi®cant portion of unique variance in the number of strategies used in an episode. Four similar analyses regressed the use or non-use of the four types of coping strategies on the reversal theory variables. The use of distraction strategies was inversely related to playfulness and arousal-seeking scores coefficient ÿ0:170, p < 0.05 and ÿ0.140. p < 0.05, respectively), but unrelated to rebelliousness. Substitution strategy use was inversely related to playfulness coefficient ÿ0:170 p < 0.05), but unrelated to arousal-seeking and rebelliousness. Neither cognitive nor behavioral strategy use had signi®cant relationships to any of the reversal theory variables. 3.3. Dierences in urges vs lapses Both between-subjects and within-subjects analyses were carried out to test the ®fth hypothesis that playfulness scores would be higher for lapse episodes than for episodes where the subject resisted the urge to smoke (urge episodes). Only 11 of 36 subjects lapsed during the
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time they were in the study. When the ®rst lapse episodes of the 11 subjects who smoked during the assessment period were compared with the highest urge episodes of the 25 subjects who did not experience lapses, there were no signi®cant dierences between the two groups in playfulness, arousal-seeking, rebelliousness, or negative aect scores. However, a withinsubjects analysis comparing the ®rst lapse episode with the highest urge episode for those 11 subjects with lapses, showed a signi®cant dierence for playfulness, t 2:71, d:f: 10, p 0:02; lapse episodes M 7:2, S:D: 1:6; urge episodes M 5:4, S:D: 1:7: No dierences between the types of episodes were found for arousal-seeking, rebelliousness, or negative aect scores.
4. Discussion This study used near real-time data collection techniques to investigate reversal theory variables during smoking cessation. The ®ndings supported the hypothesis that fewer coping strategies are used when urges are experienced in playful states. It should be noted that the analyses relating coping strategies to reversal theory states included only those episodes where the individual resisted the urge to smoke. There were too few lapse episodes to determine the relationship of state variables to coping strategies during lapse episodes. Therefore, this study indicated that urge episodes experienced in playful states were associated with use of fewer strategies than those experienced in serious states. This ®nding cannot be attributed to lower urge levels in paratelic states because other analyses indicated that urge level was unrelated to playfulness. The ®nding might indicate it is easier to cope with urges in paratelic states because fewer strategies are needed. However, the ®ndings comparing the lapse and urge episodes also indicate that subjects are more likely to lapse in paratelic states. Subjects may exert less coping eort in paratelic states than in telic states. Sometimes, this eort is adequate and the urge is successfully resisted; on other occasions, it is not adequate and lapses result. The association of playfulness with lapses may also be related to a third variable, such as consumption of alcohol, which has been shown to predict lapsing (Shiman & Balabanis, 1996). Too few lapses were available in this data set to test the eect of the interaction of coping, playfulness and alcohol use on the occurrence of lapses. Other than playfulness, we found no variables that distinguished urge episodes from lapses. These negative ®ndings are at odds with prior reports that lapses are associated with aective disturbance (e.g. Shiman et al., 1996a,b). The small sample of lapses may have precluded adequate tests of these relationships. The results of the analyses relating reversal theory variables to other subjective state variables and to environmental variables gave evidence for the validity of the scales used in this study. As expected, both components of paratelic states, playfulness and arousal-seeking, were inversely related to negative aect and to being in work settings. As expected, playfulness was directly related to being in bars and restaurants, but unexpectedly, arousal-seeking was unrelated to this location type. As expected, rebelliousness was directly related to negative aect, indicating that being in the negativistic state is highly related to feeling tense, unhappy and miserable. Though not predicted, other ®ndings make logical sense. For instance, it is easy to see that
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people who endorse being tired and sleepy are unlikely to be feeling adventurous or wanting excitement. The ®nding that playfulness and arousal-seeking are related to having cigarettes easily available may indicate that environments that induce paratelic states may be those where cigarettes are freely available. Alternatively, it is possible that freely available cigarettes induce paratelic states in individuals who are trying to quit smoking. The inverse relationship between rebelliousness and cigarette availability is harder to explain. Situations that limit cigarette availability, such as work settings, may be ones that are particularly prone to inducing angry feelings. Alternatively, just the fact of being kept from cigarettes may induce rebellious states in inveterate smokers. The results indicate that this sample was in negativistic states only 14% of the time. However, strong urges accompany negativistic states. Whether these urges cause a negativistic reversal or whether negativistic states increase urges is not known. The dichotomous variable indexing an urge episode versus a prompt episode was signi®cantly related to rebelliousness in the analysis of environment variables but unrelated in the analyses of subjective states. This disparity is caused by the inclusion of urge level in the subjective data set. Rebelliousness was positively correlated with urge intensity. Once urge intensity was accounted for, rebelliousness during urge episodes was no dierent than it was in prompt episodes. Aside from the modest sample size, the study reported here has several limitations. Subjects participated in the study for only three days during their ®rst 10 days of cessation. Although subjects were randomly assigned to the three-day blocks, the cross-sectional design and the few days of participation may have limited the statistical power of the study. Because this was the ®rst study to include reversal theory variables in an ecological momentary assessment study of smoking cessation and because the particular scales used in this study were new, many analyses were carried out to explore the relationship of these scales to other variables. The multiple analyses increase the probability of Type I errors. We considered these analyses to be exploratory in nature and that it was important not to miss pertinent ®ndings in this unique data set. There is also the possibility that ®ndings produced by this study are not generalizable because the EMA methods used were reactive or because the type of person who would volunteer for such a study would be unrepresentative of smokers in general. Despite the study limitations, the ®ndings are consistent with our prior research, which used a completely dierent method that included retrospective interviews about situations that occurred two weeks to three months prior to the interview and coders' ratings of the transcribed interviews as assessments of metamotivational state. Together these studies indicate that the likelihood of resisting the urge to smoke during smoking cessation attempts varies as a function of metamotivational state. Paratelic states are particularly vulnerable, possibly because paratelic states are related to the use of fewer coping strategies. It should be noted that other analyses of this data set (O'Connell et al., 1998) revealed that a measure of negative aect was not related to the number of strategies or to any speci®c type of strategy use. Similarly, the current study showed that there was no relationship between coping responses and a particular kind of negative aect state, rebelliousness, which is characterized by rebelliousness and anger. However, unlike playfulness and arousal-seeking, rebelliousness was related to urge levels. The ®ndings of this study illustrate why smoking cessation is so dicult. The decision to quit smoking is usually made when the smoker is in a telic (goal-oriented) and conformist state, wherein such a decision seems highly warranted. However, the decision must be sustained
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through paratelic and negativistic states during which the person values living for the moment, seeking arousal and being rebellious. Reversal theory posits that motivations dier depending on one's metamotivational state. This implies that eective strategies for resisting the urge to smoke are dierent in telic states than they are in paratelic states. Strategies that will be eective in conformist states may not be eective in negativistic states. The very motivation or capability to produce coping responses may wax and wane with current psychological state. Thus, relapse episodes may result from transient changes in state, making lapsing both hard to study and hard to prevent. References Apter, M. J. (1982). The experience of motivation: the theory of psychological reversals. London: Academic Press. Baer, J. S., Lichtenstein, E., Kamarck, T., & Ransom, C. C. (1989). Prediction of smoking relapse: analysis of temptations and transgressions after initial cessation. Journal of Consulting and Clinical Psychology, 57(5), 623± 627. Bliss, R. E., Garvey, A. J., Heinold, J. W., & Hitchcock, J. L. (1989). The in¯uence of situation coping on relapse crisis outcomes after smoking cessation. Journal of Consulting and Clinical Psychology, 57, 443±449. Brandon, T. H., Tiany, S. T., & Baker, T. B. (1986). The process of smoking relapse. In F. M. Tims, & G. G. Leukefeld, Relapse and recovery in drug abuse (pp. 104±117). Rockville, MD: U.S. Department of Health and Human Services. Calhoun J. E. (1995). Construct validity of the telic/paratelic state instrument. Kansas City, KS. Unpublished doctoral dissertation. CDC (1997). Cigarette smoking among adults Ð United States, 1995. Morbidity and Mortality Weekly Report, 46, 1217±1220. Cook, M. R., Gerkovich, M. M., O'Connell, K. A., & Potocky, M. (1995). Reversal theory constructs and cigarette availability predict lapse early in smoking cessation. Research in Nursing and Health, 18, 217±224. Cook, M. R., Gerkovich, M. M., Potocky, M., & O'Connell, K. A. (1993). Instruments for the assessment of reversal theory states. Patient Education and Counseling, 22, 99±106. Gerkovich, M. M., Cook, M. R., O'Connell, K. A., & Potocky, M. (1993). Reversal theory analysis of relapse crises following smoking cessation. Patient Education and Counseling, 22, 91±97. Gibbons, R. D., Hedeker, D., Elkin, I., Waternaux, C., Kraemer, H. C., Greenhouse, J. B., Shea, T., Imber, S. D., Sotsky, S. M., & Watkins, J. T. (1993). Some conceptual and statistical issues in analysis of longitudinal psychiatric data: Application to the NIMH treatment of depression collaborative research program dataset. Archives of General Psychiatry, 50, 739±750. Hedeker, D., Gibbons, R. D., & Flay, B. R. (1994). Random-eects regression models for clustered data with an example from smoking prevention research. Journal of Consulting and Clinical Psychology, 62, 757±765. Hill, H. A., Schoenbach, V. J., Kleinbaum, D. G., Strecher, V. J., Orleans, C. T., Gebski, V. J., & Kaplan, B. H. (1994). A longitudinal analysis of predictors of quitting smoking among participants in a self-help intervention trial. Addictive Behaviors, 19, 159±173. Marlatt, G. A., & Gordon, J. R. (1980). Determinants of relapse: Implications for maintenance of behavior change. In P. O. Davidson, & S. M. Davidson, Behavioral medicine: changing health life-styles (pp. 410±452). New York: Brunner/Mazel. O'Connell, K. A., & Martin, E. J. (1987). Highly tempting situations associated with abstinence, temporary lapse and relapse among participants in smoking cessation programs. Journal of Consulting and Clinical Psychology, 55, 367±371. O'Connell, K. A., & Shiman, S. (1988). Negative aect and smoking relapse. Journal of Substance Abuse, 1, 25±33. O'Connell, K. A., Cook, M. R., Gerkovich, M. M., Potocky, M., & Swan, G. E. (1990). Reversal theory and smoking: a state-based approach to ex-smokers' highly tempting situations. Journal of Consulting and Clinical Psychology, 58, 489±494.
K.A. O'Connell et al. / Personality and Individual Dierences 29 (2000) 671±683
683
O'Connell, K. A., Gerkovich, M. M., Cook, M. R., Shiman, S., Hickcox, M., & Kakolewski, K. E. (1998). Coping in real time: Using ecological momentary assessment techniques to assess coping with the urge to smoke. Research in Nursing and Health, 21, 487±497. Potocky, M., Gerkovich, M. M., O'Connell, K. A., & Cook, M. R. (1991). State-outcome consistency in smoking relapse crises: a reversal theory approach. Journal of Consulting and Clinical Psychology, 59, 351±353. Russell, J. A. (1980). A circumplex model of aect. Journal of Personality and Social Psychology, 39, 1161±1178. Shiman, S. (1984). Coping with temptations to smoke. Journal of Consulting and Clinical Psychology, 52, 261±267. Shiman, S. (1988). Behavioral assessment. In D. M. Donovan, & G. A. Marlatt, Assessment of addictive behaviors: the Guilford behavioral assessment series (pp. 139±188). New York: Guilford. Shiman, S., & Balabanis, M. (1996). Do drinking and smoking go together? Alcohol Health and Research World, 20(2), 107±110. Shiman, S., Gnys, M., Richards, T. J., Paty, J. A., & Hickcox, M. (1996a). Temptation to smoke after quitting: a comparison of lapsers and quitters. Health Psychology, 15, 455±461. Shiman, S., Paty, J. A., Gnys, M., Kassell, J. A., & Hickcox, M. (1996b). First lapses to smoking: within-subjects analysis of real-time reports. Journal of Consulting and Clinical Psychology, 64, 366±379. Shiman, S., Huord, M., Hickcox, M., Paty, J. A., Gnys, M., & Kassel, J. D. (1997). Remember that? A comparison of real-time vs retrospective recall of smoking lapses. Journal of Consulting and Clinical Psychology, 65, 292±300. Shopland, D. R., Hartman, A. M., Gibson, J. T., Mueller, M. D., Kessler, L. G., & Lynn, W. R. (1996). Cigarette smoking among U.S. adults by state and region: estimates from the current population survey. Journal of the National Cancer Institute, 88, 1748±1758. Silagy, C., Mant, D., Fowler, G., & Lodge, M. (1994). Meta-analysis on ecacy of nicotine replacement therapies in smoking cessation. The Lancet, 343, 139±142. Wills, T. A., & Shiman, S. (1985). Coping and substance abuse: a conceptual framework. In S. Shiman, & T. A. Wills, Coping and substance abuse (pp. 3±24). San Diego: Academic Press. Zeger, S. L., & Liang, K. (1992). An overview of methods for the analysis of longitudinal data. Statistics in Medicine, 11, 1825±1839. Zeger, S. L., Liang, K., & Albert, P. S. (1988). Models for longitudinal data: a generalized estimating equation approach. Biometrics, 44, 1049±1060.