The rapid-smoking technique: Therapeutic effectiveness

Briiui. RP\ & Tlrrrop,. Vol 19. pp. 3X9 10 397. 19x2 Printed I” Great Bnlam All rlFhtS reserved

Copyrqht

001)s.7967~81/0503119-09102.00/0 0 1981 Pergamon Press Ltd

THE RAPID-SMOKING TECHNIQUE: THERAPEUTIC EFFECTIVENESS* A.

DESMOND

POOLE,R. W. SANSON-FISWER and G. ALLEN GERMAN

Department of Psychiatry and Behaviourat Science, University of Western Austraha, The Queen Elizabeth II Medical Centre, Nedlands. Western Australia 6009 (Recrioed 26 January 1981)

Summary-The study examined the effectiveness of the rapid-smoking technique in terms of two measures of outcome-post-treatment abstinence rate and reduction in smoking achieved by non-abstinent subjects. A total of 75 volunteers (40 men and 35 women) participated in treatment and were randomly allocated to one of four conditions-rapid-smoking alone; rapid-smoking and relaxation training; rapid-smoking, relaxation and contingency contracting; or contingent rapid-smoking. No significant differences between treatment conditions were obtained. For the total sample, abstinence was achieved by 64% of the subjects immediately post-treatment but the probability of remaining abstinent 12 months later was only 0.33. Immediately post-treatment the non-abstinent subjects reduced their rate of cigarette consumption to 34.2% (SD = 29.3) of baseline smoking but by 12 months average consumption had increased to 82.4% (SD = 28.3) of baseline. It is concluded that rapid-smoking gives rise to substantial short-term changes in smoking behaviour but these effects are not sustained.

INTRODUCTION Rapid-smoking, i.e. smoking while inhaling normally but at a rate of one inhalation every 6 set until reaching satiation. has been widely employed as an aversive technique to control smoking behaviour and it appears to be an effective treatment procedure (Bernstein and McAlister, 1976: Danaher, 1977a; Hunt and Bespalec, 1974; Lichtenstein and Danaher. 1976). For example, both Lichtenstein et af. (1973) and Schmahl et al. (1972) reported that 60% of their subjects, treated with the rapid-smoking technique, were still abstinent 6 months following treatment. Such findings are impressive given that Hunt and Bespalec (1974). reviewing the literature on smoking control programmes, concluded that only approximately one-third of persons who stopped smoking following treatment continued to be abstinent. Furthermore. McFall and Hammen (1971), using non-specific treatment procedures found that only 20% of their subjects, who were abstinent at the end of treatment, were still abstinent after 6 months. It appears, therefore, that rapidsmoking is therapeutically effective and in marked contrast to the generally poor outcome of other stop-smoking programmes. However. attempts to replicate the findings of Lichtenstein and his colleagues have not always produced comparable outcomes, although substantial reductions in smoking do occur following the use of rapid smoking (Danaher, 1977a; Kopel, 1975; Lando, 1975; Poole and Stumbles, 1979; Relinger et al., 1977; Sutherland et al., 1975). Yates (1975) has, however, pointed out that the effective components within the Lichtenstein et al. (1973) procedure have not been elucidated so that the poorer results may, in part, be due to the failure to replicate precisely the techniques employed, In addition, he has argued that the overall poor results obtained by behavioural techniques in the modification of smoking are due to an inadequate understanding of why people smoke, and that greater attention should be focused on seeking to determine the aetiology of smoking behaviour. While some attempts have been made to equate treatment procedures and subject characteristics (Best. 1975; Best and Steffy, 1975) research into the modification of smoking behaviour largely continues to adopt an empirical and technological approach. As Elliott and Denney (1978) have argued, such a strategy may be justified on the grounds * Requests for reprints should be addressed to The Secretary, Department of Psychiatry and Behavioural Science, University of Western Australia, Queen Elizabeth II Medical Centre. Nedlands, Western Australia 6009. 389

390

A. DESMOND POOLE et al.

that it is desirable first to produce an effective treatment and only then proceed to seek to determine the effective components within the treatment package. Consistent with this approach, treatment programmes for the control of smoking are increasingly moving away from the single variable approach of earlier research and are placing increasing emphasis on the use of multi-component treatment packages (Danaher, 1977b; Delahunt and Curran, 1976; Elliott and Denney, 1978; Lando, 1977). The present study, therefore, sought to evaluate further the effectiveness of the rapidsmoking technique in the control of smoking and to examine whether the inclusion of additional components into the treatment package enhanced therapeutic effectiveness.

METHOD

Subjects

The sample consisted of 75 smokers (40 men and 35 women) under the age of 50 yr who. in response to media advertizing, volunteered to take part in a smoking-control programme involving rapid-smoking. All subjects were required to undergo a medical examination prior to being accepted into the programme and, with the exception of the 40 yr age restriction, all of Dawley and Dillenkoffer’s (1975) criteria for the use of rapidsmoking were met by each participant. Some characteristics of the subjects are summarized in Table 1. Intake procedure

Prior to commencing the treatment programme persons who had indicated their interest in participating attended an introductory group meeting. During this meeting the rapid-smoking procedure was described and demonstrated, the need to undergo medical screening was explained and the medical examinations were organized. Each subject was also informed that they were required to pay a deposit of $25, of which $15 would be refunded at the completion of treatment and the balance when all the required follow-up data had been returned. Subjects were provided with data sheets on which to record daily cigarette consumption over a period of seven consecutive days. They also completed the Eysenck Personality Inventory (Eysenck and Eysenck. 1964) and Rotter’s (1966) Locus of Control Scale, together with a questionnaire to describe their smoking history and to assess their motivation to stop smoking and their expectation of success in doing so. All subjects who met the medical criteria, paid the deposit and completed the baseline recording of cigarette consumption were included in the study. Treatment procedures

Once the criteria for inclusion had been fulfilled participants were randomly allocated to one of four treatment programmes. Subjects in the first three conditions met in groups of 3-4 persons for the rapid-smoking treatment sessions while in the fourth condition

Table

1. Characteristics of (n = 75)

the

sample

Sex

Males Females Age X SD Years smoking X SD Daily baseline consumption X SD

35 40 32.2 7.8 14.4 8.0 28.4 9.3

Rapid-smokingtechnique:therapeuticeffectiveness

391

treatment was carried out on an individual basis. All sessions were conducted in a socially supportive treatment context. The four treatment groups were as follows: 1. Rapid-smoking (n = 19). Subjects underwent a series of rapid-smoking sessions following an initial session during which the use of rapid-smoking as an aversive procedure was explained in detail, together with information on its effectiveness based on the published literature. The importance of not smoking between treatment sessions once rapid-smoking trials had commenced was emphasized at both this and all subsequent sessions. Each subsequent session consisted of rapid-smoking trials together with general discussions about problems in not smoking between sessions and encouragement for inter-session abstinence. 2. Rapid-smoking and relaxntion (n = 21). Subjects allocated to this condition underwent an initial session similar to that for Group 1. However, thereafter they had a further two sessions during which each individual’s smoking behaviour was analysed in detail, self-control strategies for coping with smoking urges were presented and methods for implementing these procedures in order to reduce the frequency of smoking were provided. In particular the use of relaxation as a means of controlling the urge to smoke was emphasized, and training in muscular relaxation was commenced. Subsequent sessions involved rapid smoking similar to that for Group 1, with the importance of inter-session abstinence again being emphasized throughout. In addition each session incorporated further discussion regarding the implementation of self-control procedures and commenced with additional relaxation training. 3. Rapid-s~king, relaxation and conringency contracting (n = 18). Subjects in this group received the same treatment package as employed with Group 2. However, in addition, at the initial session each subject was required to nominate a ‘significant other’, e.g. spouse, workmate etc., with whom they had frequent contact and who was willing to be involved in treatment. Each subject, together with their nominated significant other, met on one occasion with the therapist who informed the confederate of the nature of the programme, the importance of inter-session abstinence and of the value of external control procedures in assisting smokers in controlling the urge to smoke. During this meeting contingency contracts were drawn up between each subject and his or her partner which were designed to reinforce the participants for not smoking. Arrangements were also made for contacting the partner to ensure that the contract was being adhered to. In each of these conditions the first three rapid-smoking sessions were held on consecutive days, session 4 followed a l-day interval, session 5 after a further two days and session 6 took place 4-5 days following the fifth session. Thereafter sessions were held at least 7 days apart. All participants were required to attend the initial six rapid-smoking sessions. However, the total number of sessions completed by individual subjects was determined by their ability to refrain from smoking for 7 days following a rapid-smoking session, or until they had completed 12 rapid-smoking sessions if the abstinence criterion was not achieved. at which point treatment was terminated and the follow-up period commenced. 4. Ca~r~ngen~ Cupid-smoking (n = 17). Subjects in this condition met individually with the therapist. Apart from being on an individual basis the initial session was similar to that for the other groups. They were again informed that, once rapid-smoking was commenced. inter-session abstinence was essential for treatment to be effective and were asked to nominate an informant, with whom they had frequent contact, who might be contacted to confirm their subjective reports of smoking behaviour. Following the initial session they were required to attend three rapid-smoking sessions over a &day period. However, if they, or their informants, reported that they had smoked between sessions Ihey were required to commence again the sequence of three sessions. Once a subject had completed three consecutive sessions with inter-session abstinence the treatment programme was considered to be complete but they were transferred to a maintenance period of up to 9 weeks. During this phase subjects, and their informants, were contacted once per week. on random days, and if either reported any smoking since the previous

392

A. DESMONDPOOLEet al.

contact the subject was required to undergo a further booster rapid-smoking session. Subjects in this condition, then, underwent a minimum of three rapid-smoking sessions, if they did not smoke between these sessions and were abstinent throughout the maintenance period, the total number of rapid-smoking sessions completed by individual participants again being determined by abstinence. However, as with the other conditions, if the abstinence criterion was not achieved they also underwent a maximum of 12 rapidsmoking sessions. For all participants the actual rapid-smoking procedure was similar to that described by Lichtenstein et al. (1973). Subjects were required to smoke their preferred brand of cigarettes, inhaling every 6 set while concentrating on the unpleasant effects, and to continue smoking in this manner until unable to tolerate a further inhalation. After a 5 min rest interval they were required to undergo a second identical trial and, following a further rest interval, were encouraged, but not required, to complete a third trial. Consequently each rapid-smoking session consisted of at least two smoking trials but the total number of sessions undertaken differed across individuals, being determined by their ability to refrain from smoking for 7 days following a rapid-smoking session.

Subjects were followed-up week following completion of treatment and at 1.2, 3, 6 and 12 months thereafter. Consequently, subjects in Group 4 (contingent rapid-smoking) were in the maintenance phase at the I-week follow-up with a number still on maintenance at the l- and 2-month follow-up points. The performance of Group 4 subjects is, therefore, contaminated by the intervention procedures at these points in time. On each follow-up occasion subjects were required to record their smoking for a 7-day period. RESULTS

The data were initially analysed to determine whether the variations in treatment procedures were differentially effective in terms of post-treatment abstinence and reductions in smoking. However, prior to examining treatment effectiveness a number of comparisons were made between the members of the four groups. A Chi-squared test revealed no significant differences in the numbers of male and female subjects in each group. Analyses of variance indicated that the groups were comparable in terms of age, years of smoking, number of previous attempts to stop and daily recorded consumption of cigarettes during the baseline period. In addition, there were no pre-treatment differences between the groups in their self-assessments of motivation to stop smoking or in their expectation of becoming abstinent following treatment, nor were there any significant differences in terms of their scores on the Eysenck Personality Inventory or the Locus of Control Scale. Relationships between subject characteristics and abstinence following rapid-smoking treatment are discussed elsewhere (Poole et al., 1980). Examination of treatment process variables indicated that there were no significant differences between the groups in either the number of rapid-smoking sessions completed or the number of trials per session during treatment. The groups were also comparable in terms of the rated unpleasantness of rapid-smoking. Abstinence following treatment Since the stated aim of treatment was to assist participants in stopping smoking the outcome data were first analysed in terms of the numbers of subjects within each condition who were abstinent at each of the follow-up occasions. These results are summarized in Table 2. Analyses by means of Chi-squared tests failed to reveal any significant differences between the four treatment conditions at any of the follow-up points. However, as can be seen, a number of subjects were lost to follow-up at 12 months which might, therefore, have resulted in underestimation of abstinence on that occasion. In fact, inspection of the

Rapid-smoking Table

2. Numbers

technique:

of subjects

within

therapeutic

each treatment at follow-up

condition

Follow-up

1 (n = 19) n 0, 1”

2(n = 21) ” “/,

3(n = 181

1 1 2 3 6 12

10 6 6 6 5 4

12 8 7 8 6 5

12 9 10 6 6 4

week month months months months months

*TV= 16; bn = 20:‘n

52.6 31.6 31.6 31.6 26.3 25.V

57.1 38.1 33.3 38.1 28.6 25.0b

n

393

effectiveness

“/:. 66.7 50.0 55.6 33.3 33.3 22.2

who were abstinent

4(n = 17)

n

%

14 12 11 7 3 2

82.4 70.6 64.7 41.2 17.6 14.3’

X2 4.0352 6.3467 6.0041 0.4545 1.1565 0.6734

= 14.

data obtained at 6 months from each of the missing subjects indicated that they all reported smoking at that point in time. Consequently the failure to obtain data from all subjects at 12 months appears unlikely to have affected the reported abstinence rates. It appears, therefore, that the variations in treatment regimes did not produce different rates of post-treatment abstinence. The failure to obtain any significant differences at 1 week and at the l- and 2-month follow-up is, perhaps, surprising, given that subjects in group 4 (contingent rapid-smoking) were still taking part in the maintenance phase of booster sessions during this period. In fact, on each of these follow-up occasions the rate of abstinence is higher in Group 4 than in any of the other three groups but in no case does the difference achieve statistical significance. The tendency for abstinence to be higher in Group 4 during the maintenance period might be due to those subjects not reporting smoking which would have resulted in them undergoing booster rapid-smoking sessions. However, such an explanation seems unlikely given that the reports obtained from the informants consistently verified the self-reports of abstinence. It does appear, therefore, that the maintenprocedure tended to facilitate non-smoking during the period that it was employed. What is also apparent, from the data presented in Table 2, is that following the withdrawal of the maintenance procedure the rate of abstinence in Group 4 rapidly declined and is lower than for the other 3 groups by the 6-month follow-up. The failure of the maintenance procedure to produce higher rates of longer term abstinence is, in fact, consistent with previous research indicating that booster sessions of rapid-smoking do not enhance treatment effectiveness (Kopel, 1975). Overall the present results indicate that the incorporation of self-control, relaxation and contingency contract in a stop-smoking treatment package involving rapid-smoking does not significantly increase post-treatment abstinence when compared to rapid-smoking alone. Smoking rate following treatment While the primary aim of the present treatment procedures was to seek to establish abstinence among the participants it may also be considered desirable to assist persons to reduce their level of cigarette consumption. Consequently a further, albeit less stringent, measure of therapeutic effectiveness may be considered, namely reduction in daily consumption of cigarettes following participation in treatment. Many investigators have, therefore. reported on outcome in terms of the percentage of cigarettes smoked during baseline which are still being smoked at follow-up. However, in most instances such data are reported for all subjects, within each treatment condition, even where significant differences are obtained between groups in terms of the numbers of abstinent subjects achieving abstinence. The presence of differing numbers of abstinent subjects across treatment conditions will, therefore, contaminate the analysis of percentage baseline smoking rates producing apparent differences in smoking rates which are solely attributable to the differences in abstinence. In addition, the presence of substantial numbers of abstinent subjects. i.e. persons smoking 0% of baseline, is likely to violate assumptions BRTIL)i~-n

394

A. DESMONDPOOLEet al Table 3. Percentage of baseline daily cigarette consumption by non-abstinent each treatment condition at follow-up

subjects within

Groups 1

2

4

3

Follow-up

x

SD

z?

SD

x

SD

2

SD

1 week 1 month 2 months 3 months 6 months 12 months

30.8 69.5 70.6 72.4 63.3 79.8

34.2 21.8 21.2 22.7 27.5 21.5

37.1 43.1 46.6 55.3 74.1 69.2

32.5 38.5 34.9 33.0 28.3 40.1

21.5 56.1 65.7 60.0 64.9 78.8

16.3 28.6 25.4 25.5 32.8 23.3

11.5 28.5 36.7 51.1 57.8 71.7

12.7 28.1 28.3 24.4 27.9 29.1

F(3.23) = F(3.36) = F(3. 37) = F(3.44) = F(3.51) = F(3.49) =

0.650 2.589 2.627 1.300 0.735 0.383

underlying the use of the parametric statistical procedures which are commonly employed to analyse such data (Poole and Dunn, 1980). In the present instance there were, in fact, no significant differences between the treatment conditions in terms of the numbers of subjects achieving abstinence at follow-up. However, in examining post-treatment smoking rates all subjects who achieved abstinence on any follow-up occasion were excluded. For the remaining non-abstinent subjects separate analyses of variance were performed on the percentage of baseline smoking data across the four treatment conditions at each follow-up. The results are summarized in Table 3. From these data it can be seen that there are no significant differences between the treatment conditions in terms of the percentage of baseline consumption by the nonabstinent members of the groups. However, once again the differences just fail to reach significance at the I- and 2-month follow-ups, when the members of Group 4 were still in the maintenance phase of their treatment programme. During this period the occurrence of booster rapid-smoking sessions contingent upon smoking appears to suppress the rate of reported smoking among the non-abstinent members of the contingent rapid-smoking group. However, by 3 months, when the maintenance phase had terminated for all participants in Group 4, the rate of smoking by the non-abstinent members of all four groups is strikingly similar, again lending support to earlier findings of the lack of effectiveness of booster sessions, and the lack of benefit of multi-component treatment packages compared to the application of rapid-smoking on its own. Changes

in smoking during follow-up

Examination of the data presented in Table 2 indicates that, within each treatment condition, the rate of abstinence declines over the 12-month follow-up period. A similar decline in the effectiveness of the interventions in controlling the rate of post-treatment smoking is apparent from the data presented in Table 3. However, since the previous analyses indicated that, both in terms of abstinence rates and reduction in smoking, there were no significant differences between the treatment conditions at any point during follow-up the data for the four groups were combined. The data were then analysed to examine changes in smoking during the period of follow-up.

Table 4. Abstinence rates in the total sample (n = 75) throughout the 12-month follow-up period

No. abstinent Y&Abstinent Probability of still being abstinent if abstinent 1 week after end of treatment d n = 68; b assuming non-contactable

Follow-up 2 months 3 months

1 week

1 month

48 64.0

35 46.7

34 45.3

0.73

0.71

subjects were smoking.

6 months

12 months

27 36.0

20 26.7

16 21.3b

0.56

0.42

0.33b

Rapid-smoking Table

5. Percentage

Percentage

baseline

of baseline

daily

x SD

technique:

therapeutic

cigarette consumption by non-abstinent sample at each follow-up

1 week

1 month

34.2 29.3

65.9 29.4

395

effectiveness subjects

Follow-up 2 months 3 months 61.2 26.5

10.4 29.7

(n = 19) in the total

6 months 74.0 28.2

12 months 82.4 28.3

Table 4 presents the data for abstinence in the total sample over the entire follow-up period. A Cochran Q-Test (Siegel, 1956) performed on the numbers of subjects who were abstinent or non-abstinent at each follow-up point, with subjects for whom complete data were not available being excluded, was found to be highly significant (x2 = 75.42; df = 5; P c 0.0001). Such a finding clearly indicates the diminishing effectiveness of the treatment procedures in maintaining abstinence over time. As may be seen in Table 4 the probability of a person who was abstinent 1 week after treatment still being abstinent at the end of the 12 months of follow-up is only 0.33. The foregoing analysis was concerned only with abstinence rates and post-treatment patterns of cigarette consumption were ignored. However, amongst those subjects who did not achieve abstinence at any point following treatment, and who were available for the full 12-month follow-up, the data presented in Table 5 clearly indicate that, while there is an initial marked reduction in smoking rate, daily consumption of cigarettes increases significantly over the 12-month period (F (5,90) = 13.12; P < 0.0001). As was the case for post-treatment abstinence, therefore, there is also diminishing therapeutic effectiveness in terms of smoking reduction amongst the non-abstinent subjects. DISCUSSION

AND

CONCLUSIONS

McFall and Hammen (1971) commenting upon the generally unsuccessful attempts to develop effective smoking control procedures, concluded that when the results of various interventions are compared there is considerable consistency in outcome, leading them to hypothesize that reported changes in smoking rates might be attributable to non-specific treatment factors common to all procedures. In a study designed to assess the effects of only such non-specific factors McFall and Hammen (1971) achieved end-of-treatment abstinence rates of 27.8’/& with 5% remaining abstinent after 6 months. These results are comparable to the outcomes achieved using specific treatment procedures which McFall and Hammen (1971) summarize as ranging from 7 to 40% (mean = 26%) at the end of treatment, and from 9 to 17% (mean = 13%) at, most commonly, O-month follow-up. However, more recent research employing the rapid-smoking technique, either alone or in combination with additional treatment procedures, has generally produced substantially higher abstinence. For example, Lichtenstein et al. (1973) achieved an abstinence rate of 60%, 6 months following treatment using rapid smoking. Best (1975) examining the effectiveness of package procedures tailored to subject characteristics achieved an overall 6-month abstinence rate of 31.5%, with the rate being 50% when treatment was matched to the characteristics of the subjects. Additional promising results following package treatment programmes involving some form of rapid smoking include: Delahunt and Curran (1976)-55.6% abstinence at 6 months; Lando (1977)-76% after 6 months, and Elliott and Denney (1978)-45x also at 6 months. In each of these instances the package procedures were superior to single variable interventions, and although not achieving comparable results to those reported by Lichtenstein et al. (1973) were superior to many independent investigations of the use of rapid-smoking (see: Danaher, 1977a). However, the apparent advantage of incorporating rapid-smoking into a package approach is brought into question by the findings of Danaher (1977b) who, at 13 weeks following treatment. found rapid-smoking alone more effective (35.7% abstinence) than its use in combination with various self-control procedures (21.4% abstinence). The present study also failed to obtain evidence consistent with enhanced therapeutic effectiveness of the package approach to treatment in that there were no significant

396

A. DESMOND

POOLE er al.

differences, in either post-treatment abstinence or smoking reduction, between the rapidsmoking only and the multiple component conditions. Furthermore, the results did not replicate the high rates of post-treatment abstinence reported by Lichtenstein and his colleagues (Lichtenstein et al., 1973; Schmahl et al., 1972) but are comparable to the findings of other investigators who have independently assessed the effectiveness of rapidsmoking (see: Danaher, 1977a). The overall abstinence rates obtained in the present study--64% post-treatment and 26.7% at 6 months-are significantly better than the 27.8% post-treatment and 5% at 6-month abstinence rates obtained by McFall and Hammen (1971) using non-specific intervention. As such the present study confirms earlier findings that rapid-smoking does have specific effects in the control of smoking. However, the finding that if abstinence is achieved immediately post-treatment the probability of a person remaining abstinent at 12 months is only 0.33 (see: Table 3) is consistent with Hunt and Bespalec’s (1974) conclusion that only one-third of persons who stopped smoking at the end of treatment are able to maintain abstinence over time. Consequently there is need for further research to determine methods of improving long-term effectiveness. The present study has also demonstrated that rapid-smoking is of diminishing effectiveness in terms of sustaining smoking reduction amongst the non-abstinent participants. McFall and Hammen (1971) have pointed out the existence of, what they term, a ‘floor effect’, i.e. the tendency of subjects, although failing to achieve abstinence, to reduce their daily smoking rates following treatment to 10 or less cigarettes per day. In their study 80.8% of non-abstinent subjects were, in fact, smoking 10 or less cigarettesper day (McFall and Hammen, 1971). In the present study 13 of the 19 non-abstinent subjects (68.4%) achieved a comparable rate of cigarette consumption 1 week after treatment. However, at the 12 month follow-up only 2 out of the 19 (10.5%) were smoking 10 or fewer cigarettes per day. The probability of maintaining a daily smoking rate of 10 or less cigarettes per day for 12 months following treatment is, therefore, only 0.15, which is lower than the probability of maintaining abstinence if that criterion is initially achieved. The present research has again confirmed that although rapid-smoking gives rise, in the short term, to reasonably high levels of abstinence and substantial reductions in smoking levels, long-term outcome is comparable to results commonly achieved by smoking control programmes whether they involve the use of rapid-smoking or not. It may be concluded, therefore, that while the rapid-smoking technique is a useful strategy for inducing short-term control of smoking, further research is required to enhance its effectiveness and ensure the maintenance of the effects. Danaher (1977a) has already made a number of specific recommendations as to how treatment, employing rapid-smoking, might be improved in order to achieve these aims. It is further recommended that more consideration should be given to the fact that smoking control programmes may give rise to two discrete outcomes, namely abstinence or reduction in smoking (Poole and Dunn, 1980). It is suggested that conceptualizing outcome in this way may enhance understanding of possible relationships between subject characteristics and treatment outcome. Acknowledgrments-This research was supported by a grant from the Australian Tobacco Research ation. The assistance of Jenny Harker, Trish Johnson and Les Harris, who conducted the treatment and John Dunn. who provided statistical advice. is gratefully acknowledged.

Foundsessions,

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