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Smoking cessation: Long-term irrelevance of mode of treatment
1. Bdwv.
Ther.
& Exp.
Psychlar
Vol.
7 pp. 93-95.
Pc~smon
Press, 1976. Rinted
in Gmt
Britaia
SMOKING CESSATION : LONG-TERM IRRELEVANCE OF MODE OF TREATMENT STEPHEN B. LEVENBBRG* Umversity of Alabama in Birmingham MERVYN K. WAGNER University of South Carolina Summary-After determining whether or not individuals smoked in response to anxiety, rapid smoking, systematic desensitization and relaxation treatments were administered to anxious and nonanxious smokers. At the end of treatment all treatments were effective with rapid smoking slightly superior. The experienced therapist obtained better results, but at follow-up both treatment and therapistexperience effects had largely dissipated. with its return contingent on clinic attendance and submission of follow-up data. Explaining that the experimenter was interested in collecting data on smokers’ personalities, subjects were asked to complete an “Interpersonal Stability Questionnaire”, a sham instrument. Next, subjects completed a “Taste Questionniare” on five brands of cigarettes in a IO min period, during which smoking behavior (number of puffs) was surreptitiously recorded by videotape. Subjects were told to smoke as much as needed to fill out the Test Questionnaires and that the experimenter would be simultaneously scoring the Interpersonal Stability Questionnaire to plan the beat smoking treatment. In the following 30-min period. the subjects completed an “Anxiety Smoking Situations Questionnaire” (later used for the systematic desensitixation group) and a “Questionnaire on Respiratory Symptoms” (used to screen medically unfit subjects from the rapid smoking group).t An anxiety arousal procedure modified from Abramson and Wunderlich (1972) was then administered, enabling the total sample pool to be divided into “anxiety smokers” and “non-anxiety smokers”. Bogus negative feedback was communicated to all subjects regarding the Interpersonal Stability Questionnaire results. They were told they had not done well, that the scores indicated a proneness to experience serious personal difficulties, and ihat it might be important to talk about these possible difficulties after finishing the other tests. Immediately following this presumed anxiety arousal, the subjects completed a second, identical taste test, during which the number of puffs was again surreptitiously recorded. A careful thorough debriefing was then completed, explaining that the deception was necessary in order that he actually be made to feel anxious.
LANG term effects of experimental efforts to modify cigarette smoking behavior have been minima1 (Hunt and Matarazxo, 1973). Studies have typically focused on devising and refining particular treatment strategies, ignoring factors in subjects and procedures relevant to maintenance of cessation. The present investigation was an initial attempt to study the utility of invoking individual differences to account for outcome variation by attempting to separate smokers who smoked in response to anxiety from those whose smoking behavior was independent of anxiety. In the former (the “anxiety smokers”), it was assumed that the most appropriate treatment would be to neutralize the anxiety responsible for the smoking behavior. The “non-anxiety smokers”, it was assumed, would be treated most appropriately by an aversion approach. Following Koenig and Masters (1965) and Marston and McFall (1971), the study also compared the impact of an inexperienced therapist with that of an experienced one. METHOD Prc-treatment
procedures
By means of advertisements, 54 subjects (mean age 39 yr; 28 males, 26 females; mean number of cigarettes smoked per day = 35; mean length of smoking habit = 20 yr) were recruited. Before the preliminary session, the subjects recorded their smoking rates for three days on tally cards provided by the experimenter. At the preliminary session, the subjects were interviewed and tested individually. Smoking rate was assessed twice during this session, each time following a 3B-min period of cigarette deprivation. After signing an Informed Consent Form, a 820 refundable deposit was collected
*Requests for reprints should be sent to Stephen B. Lcvenberg, University Center, Box 314 University Station, Birmingham, Alabama 35294. tSs in the rapid smoking group were also screened with an EKG test. 93
of Alabama
in Birmingham
Medical
94
STEPHEN
B. LEVENBERG
Those subjects whose scores on the second taste test fell above a regression line of best fit represented the anxiety smokers while those below constituted the nonanxiety smokers. The three treatment groups were composed in a double-blind fashion of roughly equal numbers of anxiety smokers and non-anxiety smokers. Treatment procedures Each nine-member group met for 40 min sessions, three evenings each week for 3 weeks. During the tirst session all groups received and discussed identical anti-smoking literature, a treatment-specific rationale based on leaming principles, and a suggested identical graduated withdrawal schedule. The rapid-smoking procedure (Schmahl et al., 1972; Lichtenstein et al.. 1973), involved having all subjects light up and inhale together to a recorded voice which said “smoke” every 6 set until they felt unable to tolerate another inhalation. They crushed out the cigarettes one by one until all subjects had completed the trial, whereupon the group repeated the procedure. The systematic desensitization group was first trained in relaxation techniques, followed by a flexibly applied hierarchy of anxiety situations including visualizations of increasingly longer cigarette deprivation, a few generally accepted smoking situations and any idiosyncratic items from the above-mentioned questionnaire. The relaxation control group (Wagner and Bragg, 1970) received relaxation training along with discussions regarding the health consequences of cigarette smoking. Half of the subjects (selected at random) were treated by the senior author, an experienced behavior modifier. The other half were treated by a USPHS Officer with no training or experience other than 3 hr of discussions with the experimenter, followed by his observing the latter lead two sessions in each treatment group. Mean smoking rates were the dependent measure. Four month follow-up data were obtained by mail. Per cent of pre-treatment smoking rate was employed for data analysis in the follow-up period.
RESULTS Seventy-five per cent of the subjects reported that they ‘fully believed’ they had been told the truth during the deception procedure, and 85 per cent stated they felt some degree of ‘anxiety’. Nevertheless, the procedure may have been in&Iiciently threatening. Four subjects dropped out of the clinic and a fifth failed to report follow-up data. The data from the remaining fifty subjects were analyzed by the least squares general linear regression approach to analysis of variance (Overall and Klett, 1972). Figure I shows the immediate and long-term effects for all groups. After treatment, 36 per cent of all subjects were totally abstinent. The mean reduction in smoking rate from pre-treatment levels was 76 per cent. The ANOVA was significant for the main effect of time (P < 0.01) indicating that the clinic effected meaningful reductions in smoking rates. Also significant was the main effect for treatments (P < 0.05), and posr hoc Scheffe analyses indicated significant differences between the rapid
and MERVYN 2
40r
8 JO-
f g
20-
2’
SD
.
b.
‘a
. J,/,
l
2 $
K. WAGNER
l
Rcl
.
RS
/
.
IO-
‘
PRE-TREATMENT
.
I MMEOIATELY POST-TREATMENT
FOUR MONTHS POST-TREATMENT
TIME
FIG. I. smoking and systematic desensitization groups (P < 0.05). The post-treatment abstinence rates of 56. 25. and 25 per cent for rapid smoking, systematic desenshiza~ tion and relaxation control groups (respectively) also reflected the somewhat superior effects of the rapid smoking condition. The therapist x time interaction attained significance (P < 0.01) indicating that even though the experienced therapist appears to have had, by chance, more heavy smokers in his groups, he obtained better results immediately post-treatment. Seventy-nine per cent of the abstinent subjects had been treated by the experienced therapist. “Appropriately treated subjects” were anxiety smokers treated with systematic desensitization and non-anxiety smokers treated with rapid smoking. Conversely, inappropriately treated subjects were anxiety smokers treated with rapid smoking and non-anxiety smokers treated with systematic desensitization. A non-significant anxiety x treatment interaction (F = 1’18) indicates that the appropriateness-of-treatment hypothesis was not supported. The hypothesis did receive some support from the immediate post-treatment abstinence rates of 58 and 29 per cent for appropriately and inappropriately treated subjects. Whereas 36 per cent of all subjects were abstinent at the conclusion of treatment, only 12 per cent remained abstinent at the end of the 4-month follow-up period. This decrease was significant at the 0.01 level. Figure 1 shows that the significant treatment effect noted during the clinics failed to prevail during follow-up. Therapist differences and the appropriateness-oftreatment hypotheses vvere also not supported during this period. Four-month abstinence rates were 11 and 14 per cent for appropriately and inappropriately treated subjects, respectively.
DISCUSSION The overall outcome of this study was similar to that found in most previous investigations; a marked reduction in smoking during treatment followed by a pervasive relapse at follow-up. The 11 per cent abstinence rate
SMOKING
CESSATION : LONG-TERM
IRRELEVANCE
at follow-up was strikingly different from the 53 per cent at 6-month follow-up reported by Schmahl et al. (1972) and Lichtenstein et al. (1973). The mediocre effects of the systematic desensitization treatment of cigarette smoking have been previously reported (Wagner and Bragg, 1970) but it should be noted that our treatment was group oriented and did not decondition specific anxietyresponse habits. Lichtenstein and Keutzer (1969) have called for more emphasis on clinically effective treatment procedures in smoking control research. Their conclusion (Lichtenstein et al., 1973) that rapid smoking had been shown lo be an ‘effective treatment’ now appears premature. The results of this investigation suggest that an effective treatment has yet to be found, and certainly much more work is needed on maintenance variables. REFERENCES ABRAMS~NE. E. and WIJNDERLICHR. A. (1972) Anxiety,
fear and eating: a test of the psychosomatic concept of obesity, J. abnorm. Psychol. 79, 317-321. HUNT W. A. and MATARAZZOJ. D. (1973) Three years later: recent developments in the experimental modification of smoking behavior, J. abnorm. Psychol. 81, 107-114.
KOENIG K.
OF MODE OF TREATMENT
95
P. and MUTES J. (1965) Experimental treatment of habitual smoking, Behow. Res. & Therapy 3,235-243. LI~NSTEIN E. and KEUTZER C. S. (1969) Experimental investigation of diverse techniques to modify smoking: a follow-up report, Behuv. Res. & Therapy 7, 139-141. LICHTENSTEINE., ~RRIS D. E., BIRCHLERG. R., WAHL J. M. and SCHMAHLD. P. (1973) Comparison of rapid smoking, warm, smoky air, and attention placebo in modification of smoking behavior, J. con. & clin. Psychol. 40,92-98. MARSTONA. R. and MCFALL R. M. (1971) Comparison of behavior modification approaches to smoking reduction, J. con. t clin. Psychol. 36, 153-162. OVERALL J. E. and KLEIN C. J. (1972) Applied Multivuriute A?&&. McGraw-Hill, New York. SCHMAHLD. i., .LICHIZNUEIN -E. and HARRIS D. E. (1972) Successful treatment of habitual smokers with war&, smoky air and rapid smoking, J. con. & clin. Psychol. 38, 105-112. WAGNER M. K. and BIUGG R. A. (1970) Comparing behavior modification approaches to habit decrement -smoking, J. con. & clin. Psycho/. 34.258-263.
Ther.
& Exp.
Psychlar
Vol.
7 pp. 93-95.
Pc~smon
Press, 1976. Rinted
in Gmt
Britaia
SMOKING CESSATION : LONG-TERM IRRELEVANCE OF MODE OF TREATMENT STEPHEN B. LEVENBBRG* Umversity of Alabama in Birmingham MERVYN K. WAGNER University of South Carolina Summary-After determining whether or not individuals smoked in response to anxiety, rapid smoking, systematic desensitization and relaxation treatments were administered to anxious and nonanxious smokers. At the end of treatment all treatments were effective with rapid smoking slightly superior. The experienced therapist obtained better results, but at follow-up both treatment and therapistexperience effects had largely dissipated. with its return contingent on clinic attendance and submission of follow-up data. Explaining that the experimenter was interested in collecting data on smokers’ personalities, subjects were asked to complete an “Interpersonal Stability Questionnaire”, a sham instrument. Next, subjects completed a “Taste Questionniare” on five brands of cigarettes in a IO min period, during which smoking behavior (number of puffs) was surreptitiously recorded by videotape. Subjects were told to smoke as much as needed to fill out the Test Questionnaires and that the experimenter would be simultaneously scoring the Interpersonal Stability Questionnaire to plan the beat smoking treatment. In the following 30-min period. the subjects completed an “Anxiety Smoking Situations Questionnaire” (later used for the systematic desensitixation group) and a “Questionnaire on Respiratory Symptoms” (used to screen medically unfit subjects from the rapid smoking group).t An anxiety arousal procedure modified from Abramson and Wunderlich (1972) was then administered, enabling the total sample pool to be divided into “anxiety smokers” and “non-anxiety smokers”. Bogus negative feedback was communicated to all subjects regarding the Interpersonal Stability Questionnaire results. They were told they had not done well, that the scores indicated a proneness to experience serious personal difficulties, and ihat it might be important to talk about these possible difficulties after finishing the other tests. Immediately following this presumed anxiety arousal, the subjects completed a second, identical taste test, during which the number of puffs was again surreptitiously recorded. A careful thorough debriefing was then completed, explaining that the deception was necessary in order that he actually be made to feel anxious.
LANG term effects of experimental efforts to modify cigarette smoking behavior have been minima1 (Hunt and Matarazxo, 1973). Studies have typically focused on devising and refining particular treatment strategies, ignoring factors in subjects and procedures relevant to maintenance of cessation. The present investigation was an initial attempt to study the utility of invoking individual differences to account for outcome variation by attempting to separate smokers who smoked in response to anxiety from those whose smoking behavior was independent of anxiety. In the former (the “anxiety smokers”), it was assumed that the most appropriate treatment would be to neutralize the anxiety responsible for the smoking behavior. The “non-anxiety smokers”, it was assumed, would be treated most appropriately by an aversion approach. Following Koenig and Masters (1965) and Marston and McFall (1971), the study also compared the impact of an inexperienced therapist with that of an experienced one. METHOD Prc-treatment
procedures
By means of advertisements, 54 subjects (mean age 39 yr; 28 males, 26 females; mean number of cigarettes smoked per day = 35; mean length of smoking habit = 20 yr) were recruited. Before the preliminary session, the subjects recorded their smoking rates for three days on tally cards provided by the experimenter. At the preliminary session, the subjects were interviewed and tested individually. Smoking rate was assessed twice during this session, each time following a 3B-min period of cigarette deprivation. After signing an Informed Consent Form, a 820 refundable deposit was collected
*Requests for reprints should be sent to Stephen B. Lcvenberg, University Center, Box 314 University Station, Birmingham, Alabama 35294. tSs in the rapid smoking group were also screened with an EKG test. 93
of Alabama
in Birmingham
Medical
94
STEPHEN
B. LEVENBERG
Those subjects whose scores on the second taste test fell above a regression line of best fit represented the anxiety smokers while those below constituted the nonanxiety smokers. The three treatment groups were composed in a double-blind fashion of roughly equal numbers of anxiety smokers and non-anxiety smokers. Treatment procedures Each nine-member group met for 40 min sessions, three evenings each week for 3 weeks. During the tirst session all groups received and discussed identical anti-smoking literature, a treatment-specific rationale based on leaming principles, and a suggested identical graduated withdrawal schedule. The rapid-smoking procedure (Schmahl et al., 1972; Lichtenstein et al.. 1973), involved having all subjects light up and inhale together to a recorded voice which said “smoke” every 6 set until they felt unable to tolerate another inhalation. They crushed out the cigarettes one by one until all subjects had completed the trial, whereupon the group repeated the procedure. The systematic desensitization group was first trained in relaxation techniques, followed by a flexibly applied hierarchy of anxiety situations including visualizations of increasingly longer cigarette deprivation, a few generally accepted smoking situations and any idiosyncratic items from the above-mentioned questionnaire. The relaxation control group (Wagner and Bragg, 1970) received relaxation training along with discussions regarding the health consequences of cigarette smoking. Half of the subjects (selected at random) were treated by the senior author, an experienced behavior modifier. The other half were treated by a USPHS Officer with no training or experience other than 3 hr of discussions with the experimenter, followed by his observing the latter lead two sessions in each treatment group. Mean smoking rates were the dependent measure. Four month follow-up data were obtained by mail. Per cent of pre-treatment smoking rate was employed for data analysis in the follow-up period.
RESULTS Seventy-five per cent of the subjects reported that they ‘fully believed’ they had been told the truth during the deception procedure, and 85 per cent stated they felt some degree of ‘anxiety’. Nevertheless, the procedure may have been in&Iiciently threatening. Four subjects dropped out of the clinic and a fifth failed to report follow-up data. The data from the remaining fifty subjects were analyzed by the least squares general linear regression approach to analysis of variance (Overall and Klett, 1972). Figure I shows the immediate and long-term effects for all groups. After treatment, 36 per cent of all subjects were totally abstinent. The mean reduction in smoking rate from pre-treatment levels was 76 per cent. The ANOVA was significant for the main effect of time (P < 0.01) indicating that the clinic effected meaningful reductions in smoking rates. Also significant was the main effect for treatments (P < 0.05), and posr hoc Scheffe analyses indicated significant differences between the rapid
and MERVYN 2
40r
8 JO-
f g
20-
2’
SD
.
b.
‘a
. J,/,
l
2 $
K. WAGNER
l
Rcl
.
RS
/
.
IO-
‘
PRE-TREATMENT
.
I MMEOIATELY POST-TREATMENT
FOUR MONTHS POST-TREATMENT
TIME
FIG. I. smoking and systematic desensitization groups (P < 0.05). The post-treatment abstinence rates of 56. 25. and 25 per cent for rapid smoking, systematic desenshiza~ tion and relaxation control groups (respectively) also reflected the somewhat superior effects of the rapid smoking condition. The therapist x time interaction attained significance (P < 0.01) indicating that even though the experienced therapist appears to have had, by chance, more heavy smokers in his groups, he obtained better results immediately post-treatment. Seventy-nine per cent of the abstinent subjects had been treated by the experienced therapist. “Appropriately treated subjects” were anxiety smokers treated with systematic desensitization and non-anxiety smokers treated with rapid smoking. Conversely, inappropriately treated subjects were anxiety smokers treated with rapid smoking and non-anxiety smokers treated with systematic desensitization. A non-significant anxiety x treatment interaction (F = 1’18) indicates that the appropriateness-of-treatment hypothesis was not supported. The hypothesis did receive some support from the immediate post-treatment abstinence rates of 58 and 29 per cent for appropriately and inappropriately treated subjects. Whereas 36 per cent of all subjects were abstinent at the conclusion of treatment, only 12 per cent remained abstinent at the end of the 4-month follow-up period. This decrease was significant at the 0.01 level. Figure 1 shows that the significant treatment effect noted during the clinics failed to prevail during follow-up. Therapist differences and the appropriateness-oftreatment hypotheses vvere also not supported during this period. Four-month abstinence rates were 11 and 14 per cent for appropriately and inappropriately treated subjects, respectively.
DISCUSSION The overall outcome of this study was similar to that found in most previous investigations; a marked reduction in smoking during treatment followed by a pervasive relapse at follow-up. The 11 per cent abstinence rate
SMOKING
CESSATION : LONG-TERM
IRRELEVANCE
at follow-up was strikingly different from the 53 per cent at 6-month follow-up reported by Schmahl et al. (1972) and Lichtenstein et al. (1973). The mediocre effects of the systematic desensitization treatment of cigarette smoking have been previously reported (Wagner and Bragg, 1970) but it should be noted that our treatment was group oriented and did not decondition specific anxietyresponse habits. Lichtenstein and Keutzer (1969) have called for more emphasis on clinically effective treatment procedures in smoking control research. Their conclusion (Lichtenstein et al., 1973) that rapid smoking had been shown lo be an ‘effective treatment’ now appears premature. The results of this investigation suggest that an effective treatment has yet to be found, and certainly much more work is needed on maintenance variables. REFERENCES ABRAMS~NE. E. and WIJNDERLICHR. A. (1972) Anxiety,
fear and eating: a test of the psychosomatic concept of obesity, J. abnorm. Psychol. 79, 317-321. HUNT W. A. and MATARAZZOJ. D. (1973) Three years later: recent developments in the experimental modification of smoking behavior, J. abnorm. Psychol. 81, 107-114.
KOENIG K.
OF MODE OF TREATMENT
95
P. and MUTES J. (1965) Experimental treatment of habitual smoking, Behow. Res. & Therapy 3,235-243. LI~NSTEIN E. and KEUTZER C. S. (1969) Experimental investigation of diverse techniques to modify smoking: a follow-up report, Behuv. Res. & Therapy 7, 139-141. LICHTENSTEINE., ~RRIS D. E., BIRCHLERG. R., WAHL J. M. and SCHMAHLD. P. (1973) Comparison of rapid smoking, warm, smoky air, and attention placebo in modification of smoking behavior, J. con. & clin. Psychol. 40,92-98. MARSTONA. R. and MCFALL R. M. (1971) Comparison of behavior modification approaches to smoking reduction, J. con. t clin. Psychol. 36, 153-162. OVERALL J. E. and KLEIN C. J. (1972) Applied Multivuriute A?&&. McGraw-Hill, New York. SCHMAHLD. i., .LICHIZNUEIN -E. and HARRIS D. E. (1972) Successful treatment of habitual smokers with war&, smoky air and rapid smoking, J. con. & clin. Psychol. 38, 105-112. WAGNER M. K. and BIUGG R. A. (1970) Comparing behavior modification approaches to habit decrement -smoking, J. con. & clin. Psycho/. 34.258-263.