- Email: [email protected]
Self-management treatment of smoking behavior
Addictiue &him,
Vol. 1. pp
287-292
Pergamon
Press
1976.
Printed
in Great
Britain
SELF-MANAGEMENT TREATMENT SMOKING BEHAVIOR*
OF
MICHAELJ. MCGRATH~ and SHARONMARTINELLIHALLS University
of Wisconsin-Milwaukee
Abstract-Twenty nine habitual smokers were randomly assigned to one of three treatments: (1) self-management treatment (SMT), (2) self-monitoring plus social reinforcement (SMSR), and (3) no-treatment control (NT). An analysis of covariance of mean smoking frequency, with pretreatment smoking frequency as the covariate, revealed that at treatment termination (7 weeks) SMT and SMSR means were significantly lower than the NT mean and there was no significant difference between the former 2 groups. At follow-up, 80 days after treatment termination, the SMT mean was significantly lower than either of the other 2 group means and there was no significant difference between these latter 2 groups. Further analyses indicated that both SMT and SMSR groups had significantly reduced means at both treatment termination and follow-up, relative to pretreatment. Further, neither SMT nor SMSR groups revealed significant relapses over the follow-up interim. Self-report data revealed significant relapses over the follow-up interim. Self-report data revealed a substantial (0.77) and significant partial correlation between consistency of use of SMT techniques and treatment gains. Results were interpreted self-management treatment package and as suggesting: (1) the efficacy of a “comprehensive” (2) the potential importance of extended treatment durations.
Studies concerning self-management treatment of cigarette smoking (Gutmann & Marston, 1967; Marston & McFall, 1971; Ober, 1968; Sachs, Bean & Morrow, 1970; Whitman, 1969) reveal that such treatment leads to significant reductions in smoking frequency at treatment termination and a substantial relapse at follow-up. Of the studies employing self-management procedures, only Ober (1968) and Whitman (1969) provide comprehensive self-management treatment programs. However, both authors employed relatively short treatment durations (4 and 5 weeks, respectively). Perhaps, these short treatment durations do not allow subjects sufficient time to develop self-management behaviors which can be employed following treatment. The present study was intended to test the efficacy of a comprehensive treatment program of more extended duration. Such a program would provide a longer period in which to learn new behaviors and an instructional program providing a variety of techniques and opportunities to individualize those techniques. Self-management treatment (SMT) was compared with a self-monitoring plus social reinforcement (SMSR) control and a no-treatment control (NT). The SMSR was included to control for such factors as motivation, social reinforcement, structured participation, self-monitoring, and expectation of success. A 3 month follow-up was conducted. METHOD
Subjects
Subjects were recruited via questionnaires completed in undergraduate psychology classes. No inducements (e.g., course credits) for participating in treatment were offered. Twelve males and 17 females participated in the study. Mean smoking frequency for the group was 23.3 cigarettes per day; mean number of years smoking was 6.6 and mean age was 24.1 yr. Sixteen subjects previously had been able to abstain from smoking for periods ranging from: 1 week to 6 months (Median: 1 month). Within limitations imposed by individual differences in availability for treatment sessions, subjects were randomly assigned to either SMT (N = 10; 3 males, 7 females), * Based upon the senior author’s Master’s thesis, submitted to the Department of Psychology, University of Wisconsin, Milwaukee and supported by a grant from the University of Wisconsin-Milwaukee School to the junior author, and in part by NIDA grant No. DA4RG012. t Now at University of Texas, Austin, Texas. $ Now at the Langley Porter Neuropsychiatric Institute, University of California-SanFrancisco, cisco, California, 94143. Request for reprints should be sent to the junior author at this address. 287
Graduate
San Fran-
288
MICHAEL J. MCGRATH and SHARON MARTINELLIHALL
SMSR (N = 10; 5 males, 5 females) or NT (N = 9; 4 males, 5 females), and to 1 of 2 therapists within treatments. There were no significant differences between groups in terms of self-monitored mean daily smoking frequency, mean number of years smoked, or mean age (F < 1 for all analyses). Because of the small number of volunteers, it was necessary to accept subjects who did not wish to become abstinent. Eight such subjects, none of whom indicated a treatment termination goal of more than 5 daily cigarettes, were randomly distributed among the 3 groups such that 3 were assigned to SMT, 2 to SMSR, and 3 to NT. Therapists
A second year psychology graduate student and an advanced undergraduate psychology student served as therapists. Each therapist treated 5 subjects in each of the 2 treatment groups, with males and females divided proportionately between therapists. Sessions were tape-recorded and recordings were exchanged weekly between therapists to ensure similar presentation of material. Dependent variable
The dependent variable was daily smoking frequency based upon 7 consecutive days of self-monitored data. Subjects were provided with cards to be maintained with their cigarette pack. Prior to smoking a cigarette, subjects recorded a tally mark on the card next to the hour during which the cigarette was smoked. PROCEDURE
At orientation meetings, therapists introduced themselves as persons knowledgeable about smoking cessation techniques and noted that the treatment program would involve techniques of demonstrated utility. At these meetings anamnestic data, smoking behavior data, and treatment goals were assessed via questionnaires. No details as to the treatment techniques were given. Subjects were informed that a $12 deposit, refundable at the rate of $1 per treatment session attended was required for participation in treatment. The final portion of the deposit ($4) was to be refunded upon submission of follow-up data. It was emphasized that the refund of the deposit was contingent only upon the subject attending weekly treatment sessions and submitting data; not upon reduction or cessation of smoking frequency. Subjects were provided with sufficient self-monitoring cards to self-monitor their daily smoking frequency for the next 7 consecutive days. Subjects were to return with their deposits and self-monitoring data to a second meeting the following week. The second meeting was devoted simply to collecting the previous week’s self-monitoring data (which was to serve as baseline data) and subjects’ deposits. The first treatment session began 10 days after the second orientation meeting. In both SMT and SMSR treatments, 7 weekly 50 min treatment sessions were conducted. An eighth weekly meeting was devoted to collecting the previous week’s selfmonitoring data. Subjects in both treatments monitored their daily smoking rate throughout the 7 week treatment period. The need for accurate self-monitoring data was emphasized throughout the treatment program. Subjects returned completed monitoring packets and provided graphic data of their daily smoking frequency at each treatment session. If possible, individual meetings were arranged for subjects who were unable to attend a given treatment session. At treatment termination, SMT and SMSR subjects completed similar questionnaires concerning their assessment of the treatment program. The SMT protocol included questions concerning the “consistency” and “difficulty” with which each self-management technique (excluding social committment) was applied. Subjects estimated “consistency” on a scale of t&100 (0 = never, 50 = half of the time, 100 = always) and “difficulty” on a similar scale (0 = extremely difficult, 50 = moderately difficult, 100 = extremely easy).
Self-management
treatment
of smoking
behavior
289
Self-management treatment (SMT) During the first treatment meeting the SMT rationale was presented. It was noted that smoking could be considered a learned behavior and hence could be modified (“shaped”) by appropriate training. Because each individual’s smoking behavior involved idiosyncracies, each subject was ultimately to be responsible for molding the techniques to apply to his/her own behavior. Each subsequent treatment meeting was initiated by the therapist reviewing subjects’ graphic data, praising subjects for reduction in smoking frequency, and urging continued striving for reductions. During the first treatment meeting 2 specific techniques (social commitment, environmental restraints) were presented. During each of the next 4 meetings, all previous techniques (except social commitment) were briefly reviewed and a new technique (self-reinforcement, physical aids, incompatible responses, and chaining, respectively, each week) was presented. The final 2 meetings were spent reviewing all techniques except social commitment. At the conclusion of the treatment program subjects were urged to continue using the treatment techniques in the future. Selfmonitoring
plus social reinforcment (SMSR)
The first SMSR meeting was devoted primarily to providing a rationale for the treatment program. It was noted that though psychologists had provided smokers with a variety of smoking modification techniques all of those techniques had typically proven to be ineffective. Such inefficacy was attributed to the fact that the techniques had not been “personally relevant” to smokers’ idiosyncratic patterns of smoking. Further, it was noted that 2 prerequisities necessary for long term success were: individuals motivated to quit/reduce and the development of “personal self-control.” It was argued that since the subjects were clearly motivated, having already paid deposits, the purpose of the program was to provide subjects with the opportunity to practice and perfect the skill (s) of “personal self-control.” It was suggested that small group meetings provided a convenient and structured framework in which to develop their own “personally relevant” smoking modification techniques during the treatment program. They were instructed to begin immediately developing such “personally relevant” techniques. It was left to subjects’ discretion to determine when, if ever, they would attempt to achieve abstinence. Each meeting subsequent to the first was initiated by the therapist reviewing subjects’ graphic data, praising subjects for smoking frequency reductions and urging continued striving for reductions. The remainder of each session was devoted to discussing general questions concerning smoking. Therapists did not suggest specific smoking reduction techniques. If subjects cited specific techniques the therapist refrained from evaluating the techniques, though no effort was made purposely to divert discussion from such techniques. No-treatment control (NT) During the period between the second orientation and first treatment meeting NT subjects were told that, because of the large number of volunteers for the program, they could not be provided treatment. They were assured of later treatment and were told that they would be contacted again in approximately 8 weeks. Their deposits were refunded. Prior to the final week of the treatment program, therapists met with NT subjects, provided them with self-monitoring packets, and briefly reviewed the self-monitoring procedure. Subjects again self-monitored their smoking frequency for 7 consecutive days during the final week of the treatment program. Subsequent to collection of these data, subjects were informed that treatment would begin in approximately 3 months. Subjects were next contacted during follow-up. The NT subjects accepted treatment at this time. Follow-up During approximately
the twelfth week following treatment
termination
all subjects
290
MICHAEL J. MCGRATH and SHARON MART~NELLI HALL
again were provided with self-monitoring packets and instructions. monitored their smoking frequency for 7 consecutive days. Changes
in smoking frequency
Subjects again self-
RESULTS
Dependent measures consisted of the mean daily smoking frequency (1) during the week which concluded 10 days prior to the first treatment session (pre-treatment), (2) during the week following the seventh treatment session (treatment termination), and (3) during the week which began approximately 80 days following the seventh treatment session (follow-up). Only data relating to subjects who had attended at least 5 treatment sessions were analyzed. Both SMT and SMSR lost one subject during treatment. Hence, data analysis involved 9 subjects per group. During the follow-up week, 1 SMSR subject incurred injuries which prevented him from smoking. He estimated that he had been smoking 2&40 daily cigarettes prior to his injuries. Hence, his follow-up data were statistically estimated via procedures suggested by Anderson (1946). Correlation analyses revealed substantial product-moment correlations between pretreatment and treatment termination (r = 0.41) and between pre-treatment and follow-up smoking frequencies (r = 0.35) for SMT and SMSR subjects combined. Though an analysis of variance had revealed no significant difference between groups in terms of pre-treatment smoking frequency, inspection of the data indicated substantial differences (4.75 cigarettes per day) between self-management and SMSR groups’ pre-treatment smoking frequency. Because of these correlations and the large difference in pre-treatment smoking frequency between these two groups, a Group x Measurement Period analysis of covariance was performed on the smoking frequency data, with pre-treatment frequency as the covariate. Adjusted and unadjusted mean smoking frequencies at treatment termination and follow-up are presented in Table 1. The Measurement Period main effect failed to attain significance (F < l), as did the Group x Measurement Period Interaction (F = 2.92, d.f. = 2/22, p < 0.10). However, the Group main effect was highly significant (F = 13.05, d.f. = 2/23, p < 0.005). Group paired comparisons were analyzed via the Newman-Keuls test. At treatment termination, both SMT and SMSR means were significantly less than the NT mean (p < 0.01, both comparisons), while there was no significant difference between SMT and SMSR means (p < 0.05). At follow-up, there was no significant difference between SMSR and NT means (p < 0.10). However, there was a significant difference between SMT and NT means (p < 0.01) and between the SMT and SMSR means (p < 0.05). Changes in smoking frequency (unadjusted group means) from pre-treatment to follow-up within groups were analyzed via t-tests for correlated measures. The SMT mean at both treatment termination and follow-up was significantly less than at pre-treatment (p < 0.005 both comparisons). Also, the SMSR mean at both treatment termination and follow-up was significantly less than at pre-treatment (p < 0.005, both comparisons). There was no significant difference in the NT mean at either treatment termination or follow-up, relative to pre-treatment (p > 0.20 both comparisons). The non-significant Measurement Periods main effect indicated that there was no significant difference between treatment termination and follow-up means for any group. At treatment termination, no subjects had achieved abstinence. At follow-up, 2 NT subjects had achieved abstinence. Table 1. Originaland adjusted* mean number of cigarettes smoked at assessment periods Original Pre-treatment Adjusted Original 25.18 20.43 22.86
Self-management? Attention-placebo No treatment? * Pre-treatment
smoking
frequency
Post-treatment Adjusted Original 6.32 10.98 25.44
used as covariate.
5.15 12.16 25.42
Follow-up Adjusted Original 6.13 12.79 19.05
5.56 13.97 19.03
Self-management
treatment
of smoking
291
behavior
Figure 1 presents changes in unadjusted mean smoking frequency over time for each group in terms of percentage of base rate. By treatment termination, the SMT mean was 25.1% of base rate and 26.7% of base rate at follow-up. In contrast, the SMSR group mean was 53.7% of base rate at treatment termination and 62.6% of base rate at follow-up.
z : & a
o-0
Self-management
o
II 01234567
II
III
(Pretreatment) Time,
Fig. 1. Changes
treatment
to-
in unadjusted
I
(Termination) weeks
/,L+
(Follow-up)
mean smoking frequency over time for the three conditions in percentage base rate.
experimental
Mann-Whitney U-test of change scores between measurement periods revealed no significant therapist effects at either treatment termination or follow-up for either SMT or SMSR groups. As the sexes were similarly distributed among the 3 groups (x2 < l), data were collapsed across groups to investigate sex differences in smoking frequency at each of the 3 measurement periods. Males’ mean daily smoking frequency was not significantly higher than that of females at pre-treatment (+ < l), treatment termination (+ = 1.092, d.f. = 25, p < 0.20), and follow-up (+ < 1). All t-tests were two-tailed. Questionnaire data
SMT subjects self-reports revealed no significant differences in mean “consistency of use” or mean “difficulty of use” among the self-management techniques (F -C 1, both comparisons). Mean “consistency of use” ranged from 54.11 (chaining) to 74.33 (environmental constraints). Mean “difficulty of use” ranged from 46.67 (chaining) to 65.56 (incompatible responses). Within subjects, mean “consistency of use” and mean “difficulty of use” were calculated by summing the scaled score consistency (difficulty) ratings and dividing by 5. Partialling out pre-treatment smoking frequency, the partial correlation between “consistency of use” and change in smoking frequency during treatment was +0.770 (p < 0.01) and that between “difficulty of use” and change in smoking frequency during treatment was -0.107 ( > 0.10). DISCUSSION
Results were evaluated in terms of two issues: (1) treatment gains achieved and (2) the maintenance of treatment gains during the follow-up interim. In terms of the first issue, SMT did not prove to be statistically more effective than SMSR in modifying smoking by treatment termination. However, at treatment termination, the SMT mean was 25.1% of base rate, whereas the SMSR mean was 53.7% of base rate. More importantly, SMT led to a significantly lower mean smoking frequency at follow-up than did SMSR. These data suggest that though SMT was not statistically more effective than SMSR in terms of treatment gains achieved at treatment termination, there was a substantial difference between the groups in terms of percentage
292
MICHAEL J. MCGRAW
and SHARON MARTINELLIHALL
changes in base rate. More importantly, SMT was more effective than SMSR in terms of treatment gains achieved at follow-up. In terms of the second issue, both SMT and SMSR groups maintained treatment gains relatively well during the follow-up interim. However, because of the SMT group’s substantially reduced percentage of base rate at both treatment termination and follow-up, the minimal relapse during follow-up is particularly encouraging, especially in light of recent reports that most relapses occur within the first 3 months after treatment (Hunt & Bespalec, 1973; Lichtenstein et al., 1973). The minimal and non-significant relapse for both SMT and SMSR suggests the importance of an “extended” treatment period. The present SMT results might be compared to those of Whitman (1969) who employed a similar follow-up interval. He reported a substantially higher mean percentage of base rate at follow-up (67%) than the present study and no significant difference between his self-management and information dissemination (loosely analogous to the present SMSR) groups. Close reading of Whitman’s (1969) study suggests that active treatment extended over only 4 weeks. The marked contrast between Whitman’s (1969) results and those of the present study support the supposition that a comprehensive treatment program of longer duration would be useful in smoking treatments. In terms of the most stringent criterion of effectiveness, percentage of abstinent subjects, neither SMT nor SMSR was effective. This lack of efficacy may in part be a function of the fact that it was left to subjects’ discretion to determine when, if ever, they would attempt to achieve abstinence. It may be useful to develop criteria which take clients’ desires into account, rather than relying solely on therapist goals. Finally, the non-significant differences between SMT techniques in terms of “consistency of use” and “difficulty of use” suggests that SMT gains are not largely a function of the use of any one technique. Difficulties inherent in most self-management smoking research are many. Two major ones include the questionable reliability/validity of the assessment procedures and the uncertainty as to whether subjects employ suggested techniques. The first problem might be dealt with via observer reliability checks. Such “checks” were not used in the present study as there was no a-priori reason to assume that observers’ reports would be any more reliable/valid than those of subjects themselves; especially if subjects were to report low, non-abstinent smoking rates. However, use of an objective assessment of smoking rate, such as recently suggested by Lando (1975), clearly would enhance the credibility of future research. SMT subjects’ questionnaire responses are related to the second problem above. The substantial and significant partial correlation between “consistency of use” and changes in smoking frequency enhances the credibility that SMT treatment gains were associated with subjects’ use of the SMT techniques. However, the self-report nature of the “consistency” data leaves the above partial correlation open to alternative explanations (e.g., cognitive dissonance reduction). REFERENCES
Anderson, R. L. Missing plot techniques. Biometric Bulletin, 1946, 2, 4147. Gutmann, M., & Marston, A. Problems of subjects’ motivation in a behavioral program for reduction of cigarette smoking. Psychological Reports, 1967, 20, 110771114. Hunt, W. A., & Bespalec, D. A. (1974) An evaluation of current methods of modifying smoking behavior. Journal of Clinical Psychology, 1974, 30, 431437. Lando, H. A. An objective check upon self-reported smoking levels: A preliminary report. Behaoior Therapy, 1975, 6. 547-549. Lichtenstein, E., Harris, D. E., Birchler, G. R., Wahl, J. M., & Schmahl, D. P. Comparison of rapid smoking, warm, smoky air, and attention placebo in the modification of smoking behavior. Journal of Consulting and Clinical Psychology, 1973, 40, 92-98. Marston, A. R., & McFall, R. M. Comparison of behavior modification approaches to smoking reduction. Journal of Consulting and Clinical Psychology, 1971, 36, 153-162. Ober, D. C. Modification of smoking behavior. Journal of Consulting and Clinical Psychology, 1968, 32, 543-549. Sachs, L. B., Bean, H., & Morrow, J. E. Comparison of smoking treatments, Behauior Therapy, 1970, 1, 4655472. Whitman, T. L. Modification of chronic smoking behavior: A comparison of three approaches. Behmiour Research and Therapy, 1969, 7, 257-263.
Vol. 1. pp
287-292
Pergamon
Press
1976.
Printed
in Great
Britain
SELF-MANAGEMENT TREATMENT SMOKING BEHAVIOR*
OF
MICHAELJ. MCGRATH~ and SHARONMARTINELLIHALLS University
of Wisconsin-Milwaukee
Abstract-Twenty nine habitual smokers were randomly assigned to one of three treatments: (1) self-management treatment (SMT), (2) self-monitoring plus social reinforcement (SMSR), and (3) no-treatment control (NT). An analysis of covariance of mean smoking frequency, with pretreatment smoking frequency as the covariate, revealed that at treatment termination (7 weeks) SMT and SMSR means were significantly lower than the NT mean and there was no significant difference between the former 2 groups. At follow-up, 80 days after treatment termination, the SMT mean was significantly lower than either of the other 2 group means and there was no significant difference between these latter 2 groups. Further analyses indicated that both SMT and SMSR groups had significantly reduced means at both treatment termination and follow-up, relative to pretreatment. Further, neither SMT nor SMSR groups revealed significant relapses over the follow-up interim. Self-report data revealed significant relapses over the follow-up interim. Self-report data revealed a substantial (0.77) and significant partial correlation between consistency of use of SMT techniques and treatment gains. Results were interpreted self-management treatment package and as suggesting: (1) the efficacy of a “comprehensive” (2) the potential importance of extended treatment durations.
Studies concerning self-management treatment of cigarette smoking (Gutmann & Marston, 1967; Marston & McFall, 1971; Ober, 1968; Sachs, Bean & Morrow, 1970; Whitman, 1969) reveal that such treatment leads to significant reductions in smoking frequency at treatment termination and a substantial relapse at follow-up. Of the studies employing self-management procedures, only Ober (1968) and Whitman (1969) provide comprehensive self-management treatment programs. However, both authors employed relatively short treatment durations (4 and 5 weeks, respectively). Perhaps, these short treatment durations do not allow subjects sufficient time to develop self-management behaviors which can be employed following treatment. The present study was intended to test the efficacy of a comprehensive treatment program of more extended duration. Such a program would provide a longer period in which to learn new behaviors and an instructional program providing a variety of techniques and opportunities to individualize those techniques. Self-management treatment (SMT) was compared with a self-monitoring plus social reinforcement (SMSR) control and a no-treatment control (NT). The SMSR was included to control for such factors as motivation, social reinforcement, structured participation, self-monitoring, and expectation of success. A 3 month follow-up was conducted. METHOD
Subjects
Subjects were recruited via questionnaires completed in undergraduate psychology classes. No inducements (e.g., course credits) for participating in treatment were offered. Twelve males and 17 females participated in the study. Mean smoking frequency for the group was 23.3 cigarettes per day; mean number of years smoking was 6.6 and mean age was 24.1 yr. Sixteen subjects previously had been able to abstain from smoking for periods ranging from: 1 week to 6 months (Median: 1 month). Within limitations imposed by individual differences in availability for treatment sessions, subjects were randomly assigned to either SMT (N = 10; 3 males, 7 females), * Based upon the senior author’s Master’s thesis, submitted to the Department of Psychology, University of Wisconsin, Milwaukee and supported by a grant from the University of Wisconsin-Milwaukee School to the junior author, and in part by NIDA grant No. DA4RG012. t Now at University of Texas, Austin, Texas. $ Now at the Langley Porter Neuropsychiatric Institute, University of California-SanFrancisco, cisco, California, 94143. Request for reprints should be sent to the junior author at this address. 287
Graduate
San Fran-
288
MICHAEL J. MCGRATH and SHARON MARTINELLIHALL
SMSR (N = 10; 5 males, 5 females) or NT (N = 9; 4 males, 5 females), and to 1 of 2 therapists within treatments. There were no significant differences between groups in terms of self-monitored mean daily smoking frequency, mean number of years smoked, or mean age (F < 1 for all analyses). Because of the small number of volunteers, it was necessary to accept subjects who did not wish to become abstinent. Eight such subjects, none of whom indicated a treatment termination goal of more than 5 daily cigarettes, were randomly distributed among the 3 groups such that 3 were assigned to SMT, 2 to SMSR, and 3 to NT. Therapists
A second year psychology graduate student and an advanced undergraduate psychology student served as therapists. Each therapist treated 5 subjects in each of the 2 treatment groups, with males and females divided proportionately between therapists. Sessions were tape-recorded and recordings were exchanged weekly between therapists to ensure similar presentation of material. Dependent variable
The dependent variable was daily smoking frequency based upon 7 consecutive days of self-monitored data. Subjects were provided with cards to be maintained with their cigarette pack. Prior to smoking a cigarette, subjects recorded a tally mark on the card next to the hour during which the cigarette was smoked. PROCEDURE
At orientation meetings, therapists introduced themselves as persons knowledgeable about smoking cessation techniques and noted that the treatment program would involve techniques of demonstrated utility. At these meetings anamnestic data, smoking behavior data, and treatment goals were assessed via questionnaires. No details as to the treatment techniques were given. Subjects were informed that a $12 deposit, refundable at the rate of $1 per treatment session attended was required for participation in treatment. The final portion of the deposit ($4) was to be refunded upon submission of follow-up data. It was emphasized that the refund of the deposit was contingent only upon the subject attending weekly treatment sessions and submitting data; not upon reduction or cessation of smoking frequency. Subjects were provided with sufficient self-monitoring cards to self-monitor their daily smoking frequency for the next 7 consecutive days. Subjects were to return with their deposits and self-monitoring data to a second meeting the following week. The second meeting was devoted simply to collecting the previous week’s self-monitoring data (which was to serve as baseline data) and subjects’ deposits. The first treatment session began 10 days after the second orientation meeting. In both SMT and SMSR treatments, 7 weekly 50 min treatment sessions were conducted. An eighth weekly meeting was devoted to collecting the previous week’s selfmonitoring data. Subjects in both treatments monitored their daily smoking rate throughout the 7 week treatment period. The need for accurate self-monitoring data was emphasized throughout the treatment program. Subjects returned completed monitoring packets and provided graphic data of their daily smoking frequency at each treatment session. If possible, individual meetings were arranged for subjects who were unable to attend a given treatment session. At treatment termination, SMT and SMSR subjects completed similar questionnaires concerning their assessment of the treatment program. The SMT protocol included questions concerning the “consistency” and “difficulty” with which each self-management technique (excluding social committment) was applied. Subjects estimated “consistency” on a scale of t&100 (0 = never, 50 = half of the time, 100 = always) and “difficulty” on a similar scale (0 = extremely difficult, 50 = moderately difficult, 100 = extremely easy).
Self-management
treatment
of smoking
behavior
289
Self-management treatment (SMT) During the first treatment meeting the SMT rationale was presented. It was noted that smoking could be considered a learned behavior and hence could be modified (“shaped”) by appropriate training. Because each individual’s smoking behavior involved idiosyncracies, each subject was ultimately to be responsible for molding the techniques to apply to his/her own behavior. Each subsequent treatment meeting was initiated by the therapist reviewing subjects’ graphic data, praising subjects for reduction in smoking frequency, and urging continued striving for reductions. During the first treatment meeting 2 specific techniques (social commitment, environmental restraints) were presented. During each of the next 4 meetings, all previous techniques (except social commitment) were briefly reviewed and a new technique (self-reinforcement, physical aids, incompatible responses, and chaining, respectively, each week) was presented. The final 2 meetings were spent reviewing all techniques except social commitment. At the conclusion of the treatment program subjects were urged to continue using the treatment techniques in the future. Selfmonitoring
plus social reinforcment (SMSR)
The first SMSR meeting was devoted primarily to providing a rationale for the treatment program. It was noted that though psychologists had provided smokers with a variety of smoking modification techniques all of those techniques had typically proven to be ineffective. Such inefficacy was attributed to the fact that the techniques had not been “personally relevant” to smokers’ idiosyncratic patterns of smoking. Further, it was noted that 2 prerequisities necessary for long term success were: individuals motivated to quit/reduce and the development of “personal self-control.” It was argued that since the subjects were clearly motivated, having already paid deposits, the purpose of the program was to provide subjects with the opportunity to practice and perfect the skill (s) of “personal self-control.” It was suggested that small group meetings provided a convenient and structured framework in which to develop their own “personally relevant” smoking modification techniques during the treatment program. They were instructed to begin immediately developing such “personally relevant” techniques. It was left to subjects’ discretion to determine when, if ever, they would attempt to achieve abstinence. Each meeting subsequent to the first was initiated by the therapist reviewing subjects’ graphic data, praising subjects for smoking frequency reductions and urging continued striving for reductions. The remainder of each session was devoted to discussing general questions concerning smoking. Therapists did not suggest specific smoking reduction techniques. If subjects cited specific techniques the therapist refrained from evaluating the techniques, though no effort was made purposely to divert discussion from such techniques. No-treatment control (NT) During the period between the second orientation and first treatment meeting NT subjects were told that, because of the large number of volunteers for the program, they could not be provided treatment. They were assured of later treatment and were told that they would be contacted again in approximately 8 weeks. Their deposits were refunded. Prior to the final week of the treatment program, therapists met with NT subjects, provided them with self-monitoring packets, and briefly reviewed the self-monitoring procedure. Subjects again self-monitored their smoking frequency for 7 consecutive days during the final week of the treatment program. Subsequent to collection of these data, subjects were informed that treatment would begin in approximately 3 months. Subjects were next contacted during follow-up. The NT subjects accepted treatment at this time. Follow-up During approximately
the twelfth week following treatment
termination
all subjects
290
MICHAEL J. MCGRATH and SHARON MART~NELLI HALL
again were provided with self-monitoring packets and instructions. monitored their smoking frequency for 7 consecutive days. Changes
in smoking frequency
Subjects again self-
RESULTS
Dependent measures consisted of the mean daily smoking frequency (1) during the week which concluded 10 days prior to the first treatment session (pre-treatment), (2) during the week following the seventh treatment session (treatment termination), and (3) during the week which began approximately 80 days following the seventh treatment session (follow-up). Only data relating to subjects who had attended at least 5 treatment sessions were analyzed. Both SMT and SMSR lost one subject during treatment. Hence, data analysis involved 9 subjects per group. During the follow-up week, 1 SMSR subject incurred injuries which prevented him from smoking. He estimated that he had been smoking 2&40 daily cigarettes prior to his injuries. Hence, his follow-up data were statistically estimated via procedures suggested by Anderson (1946). Correlation analyses revealed substantial product-moment correlations between pretreatment and treatment termination (r = 0.41) and between pre-treatment and follow-up smoking frequencies (r = 0.35) for SMT and SMSR subjects combined. Though an analysis of variance had revealed no significant difference between groups in terms of pre-treatment smoking frequency, inspection of the data indicated substantial differences (4.75 cigarettes per day) between self-management and SMSR groups’ pre-treatment smoking frequency. Because of these correlations and the large difference in pre-treatment smoking frequency between these two groups, a Group x Measurement Period analysis of covariance was performed on the smoking frequency data, with pre-treatment frequency as the covariate. Adjusted and unadjusted mean smoking frequencies at treatment termination and follow-up are presented in Table 1. The Measurement Period main effect failed to attain significance (F < l), as did the Group x Measurement Period Interaction (F = 2.92, d.f. = 2/22, p < 0.10). However, the Group main effect was highly significant (F = 13.05, d.f. = 2/23, p < 0.005). Group paired comparisons were analyzed via the Newman-Keuls test. At treatment termination, both SMT and SMSR means were significantly less than the NT mean (p < 0.01, both comparisons), while there was no significant difference between SMT and SMSR means (p < 0.05). At follow-up, there was no significant difference between SMSR and NT means (p < 0.10). However, there was a significant difference between SMT and NT means (p < 0.01) and between the SMT and SMSR means (p < 0.05). Changes in smoking frequency (unadjusted group means) from pre-treatment to follow-up within groups were analyzed via t-tests for correlated measures. The SMT mean at both treatment termination and follow-up was significantly less than at pre-treatment (p < 0.005 both comparisons). Also, the SMSR mean at both treatment termination and follow-up was significantly less than at pre-treatment (p < 0.005, both comparisons). There was no significant difference in the NT mean at either treatment termination or follow-up, relative to pre-treatment (p > 0.20 both comparisons). The non-significant Measurement Periods main effect indicated that there was no significant difference between treatment termination and follow-up means for any group. At treatment termination, no subjects had achieved abstinence. At follow-up, 2 NT subjects had achieved abstinence. Table 1. Originaland adjusted* mean number of cigarettes smoked at assessment periods Original Pre-treatment Adjusted Original 25.18 20.43 22.86
Self-management? Attention-placebo No treatment? * Pre-treatment
smoking
frequency
Post-treatment Adjusted Original 6.32 10.98 25.44
used as covariate.
5.15 12.16 25.42
Follow-up Adjusted Original 6.13 12.79 19.05
5.56 13.97 19.03
Self-management
treatment
of smoking
291
behavior
Figure 1 presents changes in unadjusted mean smoking frequency over time for each group in terms of percentage of base rate. By treatment termination, the SMT mean was 25.1% of base rate and 26.7% of base rate at follow-up. In contrast, the SMSR group mean was 53.7% of base rate at treatment termination and 62.6% of base rate at follow-up.
z : & a
o-0
Self-management
o
II 01234567
II
III
(Pretreatment) Time,
Fig. 1. Changes
treatment
to-
in unadjusted
I
(Termination) weeks
/,L+
(Follow-up)
mean smoking frequency over time for the three conditions in percentage base rate.
experimental
Mann-Whitney U-test of change scores between measurement periods revealed no significant therapist effects at either treatment termination or follow-up for either SMT or SMSR groups. As the sexes were similarly distributed among the 3 groups (x2 < l), data were collapsed across groups to investigate sex differences in smoking frequency at each of the 3 measurement periods. Males’ mean daily smoking frequency was not significantly higher than that of females at pre-treatment (+ < l), treatment termination (+ = 1.092, d.f. = 25, p < 0.20), and follow-up (+ < 1). All t-tests were two-tailed. Questionnaire data
SMT subjects self-reports revealed no significant differences in mean “consistency of use” or mean “difficulty of use” among the self-management techniques (F -C 1, both comparisons). Mean “consistency of use” ranged from 54.11 (chaining) to 74.33 (environmental constraints). Mean “difficulty of use” ranged from 46.67 (chaining) to 65.56 (incompatible responses). Within subjects, mean “consistency of use” and mean “difficulty of use” were calculated by summing the scaled score consistency (difficulty) ratings and dividing by 5. Partialling out pre-treatment smoking frequency, the partial correlation between “consistency of use” and change in smoking frequency during treatment was +0.770 (p < 0.01) and that between “difficulty of use” and change in smoking frequency during treatment was -0.107 ( > 0.10). DISCUSSION
Results were evaluated in terms of two issues: (1) treatment gains achieved and (2) the maintenance of treatment gains during the follow-up interim. In terms of the first issue, SMT did not prove to be statistically more effective than SMSR in modifying smoking by treatment termination. However, at treatment termination, the SMT mean was 25.1% of base rate, whereas the SMSR mean was 53.7% of base rate. More importantly, SMT led to a significantly lower mean smoking frequency at follow-up than did SMSR. These data suggest that though SMT was not statistically more effective than SMSR in terms of treatment gains achieved at treatment termination, there was a substantial difference between the groups in terms of percentage
292
MICHAEL J. MCGRAW
and SHARON MARTINELLIHALL
changes in base rate. More importantly, SMT was more effective than SMSR in terms of treatment gains achieved at follow-up. In terms of the second issue, both SMT and SMSR groups maintained treatment gains relatively well during the follow-up interim. However, because of the SMT group’s substantially reduced percentage of base rate at both treatment termination and follow-up, the minimal relapse during follow-up is particularly encouraging, especially in light of recent reports that most relapses occur within the first 3 months after treatment (Hunt & Bespalec, 1973; Lichtenstein et al., 1973). The minimal and non-significant relapse for both SMT and SMSR suggests the importance of an “extended” treatment period. The present SMT results might be compared to those of Whitman (1969) who employed a similar follow-up interval. He reported a substantially higher mean percentage of base rate at follow-up (67%) than the present study and no significant difference between his self-management and information dissemination (loosely analogous to the present SMSR) groups. Close reading of Whitman’s (1969) study suggests that active treatment extended over only 4 weeks. The marked contrast between Whitman’s (1969) results and those of the present study support the supposition that a comprehensive treatment program of longer duration would be useful in smoking treatments. In terms of the most stringent criterion of effectiveness, percentage of abstinent subjects, neither SMT nor SMSR was effective. This lack of efficacy may in part be a function of the fact that it was left to subjects’ discretion to determine when, if ever, they would attempt to achieve abstinence. It may be useful to develop criteria which take clients’ desires into account, rather than relying solely on therapist goals. Finally, the non-significant differences between SMT techniques in terms of “consistency of use” and “difficulty of use” suggests that SMT gains are not largely a function of the use of any one technique. Difficulties inherent in most self-management smoking research are many. Two major ones include the questionable reliability/validity of the assessment procedures and the uncertainty as to whether subjects employ suggested techniques. The first problem might be dealt with via observer reliability checks. Such “checks” were not used in the present study as there was no a-priori reason to assume that observers’ reports would be any more reliable/valid than those of subjects themselves; especially if subjects were to report low, non-abstinent smoking rates. However, use of an objective assessment of smoking rate, such as recently suggested by Lando (1975), clearly would enhance the credibility of future research. SMT subjects’ questionnaire responses are related to the second problem above. The substantial and significant partial correlation between “consistency of use” and changes in smoking frequency enhances the credibility that SMT treatment gains were associated with subjects’ use of the SMT techniques. However, the self-report nature of the “consistency” data leaves the above partial correlation open to alternative explanations (e.g., cognitive dissonance reduction). REFERENCES
Anderson, R. L. Missing plot techniques. Biometric Bulletin, 1946, 2, 4147. Gutmann, M., & Marston, A. Problems of subjects’ motivation in a behavioral program for reduction of cigarette smoking. Psychological Reports, 1967, 20, 110771114. Hunt, W. A., & Bespalec, D. A. (1974) An evaluation of current methods of modifying smoking behavior. Journal of Clinical Psychology, 1974, 30, 431437. Lando, H. A. An objective check upon self-reported smoking levels: A preliminary report. Behaoior Therapy, 1975, 6. 547-549. Lichtenstein, E., Harris, D. E., Birchler, G. R., Wahl, J. M., & Schmahl, D. P. Comparison of rapid smoking, warm, smoky air, and attention placebo in the modification of smoking behavior. Journal of Consulting and Clinical Psychology, 1973, 40, 92-98. Marston, A. R., & McFall, R. M. Comparison of behavior modification approaches to smoking reduction. Journal of Consulting and Clinical Psychology, 1971, 36, 153-162. Ober, D. C. Modification of smoking behavior. Journal of Consulting and Clinical Psychology, 1968, 32, 543-549. Sachs, L. B., Bean, H., & Morrow, J. E. Comparison of smoking treatments, Behauior Therapy, 1970, 1, 4655472. Whitman, T. L. Modification of chronic smoking behavior: A comparison of three approaches. Behmiour Research and Therapy, 1969, 7, 257-263.