TABLE 9.-Observed and expected deaths from lung Cancer
      in nonsmoking women with smoking husbands

ObseWZd   Expected   Difference    Ratio     X'

Japan (Hirayamal
U.S. IGarfinkell
Greece
(Trichopoulos et al.)

142       85.8     +56.2     + 65.5%   36.81  S+gdutnt
88       75.3     -12.7     + 16.9%    2.14  Not signifxant
29       12.1     + 16.9    + 139.7%   23 60 Significant

Total              259      1732     i 85.8     + 49.5%   42.50 Slymticant


SOURCE Hirayama 1211

limitations in data and study design do not allow a judgment on
causality at this time.

Summary

1. Mainstream and sidestream cigarette smoke contain similar
chemical constituents. (Mainstream smoke is smoke that the
smoker inhales directly during puffing. Sidestream smoke is
smoke emitted from a smoldering cigarette into the ambient
air.) These constituents include known carcinogens, some of
which are present in higher concentrations in sidestream
smoke than they are in mainstream smoke. Passive or involun-
tary smoking differs from voluntary cigarette smoking with
respect to the concentration of smoke components inhaled, the
duration and frequency of smoke exposure, and the pattern of
inhalation.

2. In two epidemiologic studies, an increased risk of lung cancer
in nonsmoking wives of smoking husbands was found. In these
studies, the nonsmoking wife's risk of lung cancer increased in
relation to the extent of the husband's smoking. In a third
study, the risk of lung cancer among nonsmoking wives of
smoking husbands was also increased, but the difference was
not statistically significant.

3. Although the currently available evidence is not sufficient to
conclude that passive or involuntary smoking causes lung
cancer in nonsmokers, the evidence does raise concern about a
possible serious public health problem.

251

377-3:o 0 - 82 - 18


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254


PART V. CESSATION OF SMOKING

255


PREVENTION IN ADULTHOOD: SELF-
MOTIVATED QUITTING

Introduction

It has been observed that 95 percent of those who have quit
smoking have done so without the aid of an organized smoking
cessation program (33). Furthermore, most current smokers indicate
a preference for quitting with a procedure they may use on their own
and a disinclination to enter an organized, comprehensive program.
In one survey of male smokers belonging to a prepaid medical group
in California, respondents were asked to indicate in which of 10
approaches to smoking cessation they would be willing to participate
(32). In order of popularity, subjects chose instructions (69 percent
"yes" or "maybe" responses), medicine (66 percent), television
programs (64 percent), and a book (53 percent). Group discussions (36
percent) and public health clinics (36 percent) were least popular. On
average, the procedures that could be carried out totally alone (the
book or television programs) received "yes" or "maybe" responses
from 58 percent of those surveyed; those requiring the continuing,
active involvement of others received "yes" or "maybe" responses
from only 39 percent.

The preferences of smokers and the unaided efforts of most who
have quit point clearly to the desirability of effective self-help
programs in smoking cessation. Such programs would appeal to
many who are unlikely to be reached by organized cessation clinics.
Furthermore', self-help programs are more easily disseminated than
are organized cessation clinics. With an estimated 50 million adult
smokers in this country and an average of 30 participants in an
organized clinic, 1.67 million clinics would be needed to treat all of
the adult smokers. This staggering estimate dramatizes the desir-
ability of a self-help approach.

Additional encouragement of self-help approaches arises from
observations that comprehensive or complex interventions may be
less effective in long-term behavior change than less comprehensive
interventions. As noted by Franks and Wilson (9, p. 361), "`more' is
not inevitably better-it could even be counterproductive." Several
smoking cessation research reports have indicated that programs
using a combination of treatments are less effective than the
individual components of which the programs are comprised (e.g.,
17,18). On the other hand, researchers cannot yet designate what
cessation techniques are most helpful for what individual, so that
offering a smoker a comprehensive package from which she or he
may self-select may still be preferable to offering only single
techniques.

The following sections review self-help approaches to smoking
cessation and the attempts to identify motivational factors or

257


personal characteristics that predict success with self-help ap-
proaches. As used in this text, the term "self-help" refers to an
individual's or group of individuals' efforts to quit smoking without
the continuing assistance of professionals, trained leaders, or organi-
zations (except for materials and occasional consultation). By this
definition, programs that minimize therapist involvement but in-
clude group meetings or classes organized by people other than the
members themselves are not considered as self-help procedures.
They are discussed in the next section of this Part of the Report,
which reviews long-term maintenance of smoking cessation.

Programs that involve mass media approaches, programs with no
person-to-person contact with trained leaders or professionals, and
programs with merely a single informational contact are included in
this discussion. Oftentimes, single informational contacts provide
only an instigation to cessation or a very specific, limited aid in
cessation. Essentially, the individual is left to his or her own devices
in quitting. As such, then, these interventions may be understood as
self-help programs, in that they instigate efforts to quit that are
otherwise unaided.

Review of Self-Help Approaches

In reviews of manuals for smoking cessation published prior to
1978, little success was reported when such manuals were used
without guidance or appreciable input from a clinician or group
leader (12, 13). The one exception was a study conducted in West
Germany in which subjects used on their own a behavioral treat-
ment manual, directions for behavioral contracting, or a combina-
tion of the two. These led to a 50 percent abstinence rate at a 15-
month followup, with no differences among the treatments (20, as
cited by 12). This report provides some optimism regarding the
potential impact of self-help approaches.

In their compayison of several manuals for smoking cessation to be
used either with or without therapist contact, Glasgow et al. (14)
compared the books of Danaher and Lichtenstein (6) and Pomerleau
and Pomerleau (27) with the "I Quit Kit" of the American Cancer
Society (2). All subjects paid a $15 deposit (returnable). Half of the
subjects were given the materials with no other contact and were
told that the program would be most effective if used on their own.
The remaining 50 percent of the subjects, who were told that
working with a therapist would facilitate use of the materials, met in
small groups (four to six subjects) with a therapist for eight sessions.
At the conclusion of treatment, the subjects' self-reports of absti-
nence indicated that the two books were more effective when used
with a therapist than when used alone. In contrast, the "I Quit Kit"
tended to be slightly more effective when used alone than with a

258


therapist. Analysis of abstinence data based on carbon monoxide
levels showed a parallel trend.

At a 6-month followup, those using the books still tended to do
better in the therapist-administered program, whereas those with
the "I Quit Kit" tended to do slightly better when using it alone.
These trends were statistically significant when based on self-report
data and of borderline significance (p < 0.10) for abstinence
determined by carbon monoxide testing. Self-reported abstinence
rates at the 6-month followup ranged from 0 percent with the
therapist-administered "I Quit Kit" and the self-administered use of
the Pomerleau and Pomerleau book to 24 percent in the therapist-
administered use of the Pomerleau and Pomerleau book. For all
those who used materials without therapist administration, the self-
report data indicated a 7 percent abstinence rate (3 of 41 subjects) at
6-month followup.

These data of Glasgow et al. (14) are sobering regarding the
potential of self-help approaches. However, several considerations
should be kept in mind. Because some subjects were to be in
therapist-administered treatments, solicitations placed little empha-
sis on the possibility of self-help procedures. The deposit and the
failure to emphasize self-help in solicitations may have kept individ-
uals eager for a self-help program from being encouraged to join.
Furthermore, subjects were rather heavy smokers, reporting a
pretreatment mean of 32 cigarettes smoked per day and an average
smoking history of 19 years. Thus, selection factors may have
lessened the impact of the procedures employed.

Subjects reported the extent to which they actually read the
treatment manuals and the percent of five critical activities they
actually completed. Therapist-administration led to higher rates of
completion of the books, whereas subjects in both programs with the
"I Quit Kit" read approximately equal amounts of their materials.
For percent of activities completed, therapist-administration was
found related to compliance with all three manuals. Subjects
working with therapists reported completion of 66 percent of the
activities suggested, but those working alone reported completion of
only 41 percent. These measures of adherence were correlated with
self-report of number of cigarettes smoked per day at posttreatment
(r = -0.42 and -0.43 for material read and activities completed,
respectively) and followup (r = -0.42 and -0.24). These findings are
unusual in the behavioral medicine literature, as correlations
between outcome and reports or observations of adherence to specific
treatment recommendations have not often been noted. The indices
of adherence were somewhat broad-extent of book read and percent
of critical activities completed. As such, they may have been as much
a behavioral measure of motivation as of the impact of any single
program element. Their correlations with outcome may reflect the

259


importance of participant effort rather than of actual nu,mber of
pages read or activities carried out.

Minimal Interventions

In addition to procedures used by individuals without assistance,
two classes of minimal interventions may also be considered within
the field of self-help: those including brief exhortation and advice on
quitting, and those with mass media or public education approaches.

The influence of simple advice to quit was found significantly
related to percentage reduction in smoking in a study reported by
Raw (28). Forty smokers attending a chest clinic were interviewed
just after seeing a physician and questioned as to whether or not the
physician had advised them to quit smoking. Half of them were also
provided with information regarding the risks of smoking and the
benefits of cessation. A higher percentage reduction in smoking at 3-
month followup was obtained among those subjects reporting
physicians' directions to quit (39 percent) compared with those not so
advised (17 percent). Thus, simple information or encouragement (or,
perhaps, remembering such) may be instrumental in changing
smoking behavior among some people. Since reductions in smoking
rate may be short-lived and fluctuating, it is unfortunate that
cessation rates were not reported.

Several findings from this study shed light on the issue of
motivation. First, Raw found that greater percentage reduction at 3-
month followup occurred when the interviewer wore a white coat at
the time of his interview with patients, irrespective of whether he
was advising them to quit. Thus, the authoritativeness of the whole
procedure seems to mediate its impact. A questionnaire measure of
subjects' motivation to quit at the time they arrived at the chest
clinic was correlated with percentage reduction (r = 0.43). The
attempt to motivate quitting through information on the health
risks of smoking and benefits of quitting was ineffective, leading only
to a 20 percent reduction in smoking at the 3-month followup in
comparison with a 36 percent. reduction among those not receiving
the instructions intended to be motivating. This difference was not
significant.

A more controlled version of a physician-effected minimal inter-
vention trial was conducted in the offices of 28 general practitioners,
involving 2,138 cigarette smoking patients (31). Self-reports of
smoking status were collected via mailed anonymous questionnaires
identified by numerical code. Patients received one of four treat-
ments: group 1, none (non-intervention controls); group 2, question-
naire-only controls; group 3, physician-advice to quit smoking; and
group 4, physician-advice to quit smoking, an informational leaflet,
and a warning that a followup would be performed. The advice to

260


quit was delivered during 1 to 2 minutes of the visit in the
physician's own style. At l-month followup, a greater percentage of
patients reported attempting to quit smoking in the two physician-
advice groups than in the remaining two groups. Patients in group 4
demonstrated a higher rate of trying to quit (17.2 percent) compared
with the combined control groups, and a slightly higher rate of
quitting (7.5 percent versus 3 percent). However, the percentage of
patients attempting to quit that actually succeeded was not signifi-
cantly different among the four groups. Thus, physician advice, with
or without the leaflet, had no effect upon the success rate of those
attempting to stop. The increased motivation to quit was strongest in
the first month after the visit to the physician, persisted through the
3-month followup, and was enhanced in the leaflet plus followup
warning condition. A measure of the intervention's effectiveness was
taken to be the percentage of patients in each group who had stopped
smoking within 1 month of the physician visit, and who were still
abstinent at l-year foilowup. Those percentages were: group 1, 0.3
percent; group 2, 1.6 percent; group 3, 3.3 percent; and group 4, 5.1
percent (p < 0.001). Furthermore, physician advice resulted in a
signficantly lower relapse rate 1 year later among those who had
quit at 1 month. There was no differential benefit derived from the
leaflets over the longer term.
This study indicates the potential for truly minimal (e.g., 1 to 2
minute) interventions by physicians. The authors point out that the
collective efforts of all general practitioners (in the United Kingdom)
working in this manner would produce more ex-smokers annually
than would intensive smoking cessation clinics which, although
obtaining much higher success rates than the 5 percent reported
here, reach far fewer smokers and incur far greater costs.
Another study of a relatively minimal intervention that included
screening and advice to quit smoking carried out in a medical setting
was reported by Rose and Hamilton (29). Following screening those
at high cardiorespiratory risk, those men at risk who also smoked
were assigned either to "normal care" or to the intervention. The
general practitioners of those in "normal care" received a full report
of the screening. The men assigned to the intervention were invited
bY letter to an appointment with a physician to review their
screening and the high risk posed for them by smoking. The 15-
minute appointments included a review of the benefits of cessation
as well as the risks of smoking. Subjects were scheduled for a second
appointment the following week, by which time they were to decide
if they wished to quit. They were given two booklets reviewing why
and how to stop, but were told the decision was up to them.
At the second interview, decisions were reviewed, the importance
Of quitting rather than cutting down was emphasized, and the men
Ivere given a card for recording daily consumption, to be returned by

261


mail after 3 weeks. Further I5-minute sessions were scheduled 10
weeks and 6 months later with continued contact by record card and
personal letter as needed. Thus, this intervention included more
contact between physician and patient than probably meets the self-
help criterion. However, the subjects were given little direct aid in
quitting other than advice, two brief manuals, and a possibly highly
motivating interaction with a physician.
Followup was conducted by clinic staff, and a questionnaire was
completed in person or returned by mail. No objective validation of
subjects' self-reports was made. The authors encouraged truthful
reporting through the use of "impersonal" and "standardized"
followup procedures to "avoid pressure to . . . deny or underestimate
continued smoking" (29, p. 2771. However, such an austere climate
may heighten the tendency to disclose desirable outcomes, and
thereby encourage over-reporting of abstinence. Response rates 1
year after the screening were 81 percent for the intervention group
and 86 percent for the "normal care" subjects. Of these, 39 and 9
percent, respectively, reported no cigarette consumption. Three
years after the screening, response rates were 64 and 70 percent and
abstinence rates were 35.5 and 14.5 percent in the intervention and
the "normal care" groups.
With regard to predictors of abstinence, smoking less than 20
cigarettes per day, non-inhaling, use of filter tips, and previous
attempts to stop, increased chances of success. On the other hand,
marital status of "other than married," and neuroticism as mea-
sured by the Eysenck Personality Inventory, decreased probability of
success.
While not clearly within the category of self-help approaches, the
interventions reported by Raw (28), Russell et al. (31), and by Rose
and Hamilton (29) indicate the potential impact of brief contacts
with physicians. Such contact is apparently enhanced by its timing
as part of a visit to a chest clinic, as in Raw's study, to a general
practitioner, as in the study of Russell et al., or as part of response
and followup to screening for individuals at high risk, as in that of
Rose and Hamilton. Similar findings are reported for myocardial
infarction patients following minimal physician intervention (5, 19).
Public media approaches to smoking cessation have begun to
achieve some popularity in recent years. Perhaps that receiving the
greatest publicity is "The Great American Smokeout" sponsored
each year by the American Cancer Society (ACS). A Gallup Poll
survey based on personal interviews with a representative national
sample of 1,551 men and women, 18 years of age and older, was
sponsored by the ACS to evaluate the 1980 Great American
Smokeout (2). The interviewing for the study was conducted 1 to 10
days after the Smokeout. The findings indicated a high degree of
visibility for the program, as 83 percent of those interviewed knew of


it. Approximately 30 percent of smokers interviewed participated in
the program-g.2 percent reported refraining totally from smoking
and an additional 21.2 percent reported cutting down on that day.
Demographic analyses showed a more pronounced impact of the
Smokeout in terms of rate of participation among women, younger
people, and better educated people, compared with men, medium-
aged and older people, and the less well educated. Finally, the
success of the program, as judged by level of familiarity with and
active participation in the 1980 Smokeout, was equal to or greater
than that occurring in the 1978 and 1979 programs.

The use of television in smoking cessation has been explored by
several investigators. One format involved carrying out a smoking
cessation program as part of a nightly news program. Each weekday
evening, for 3 weeks, the regular science reporter devoted 2 minutes
to the program. .The program included habit-breaking and self-
motivating procedures and several ways to prepare for a quit date,
including gradual withdrawal. Viewers were also urged to quit
before the quit date if they felt able to do so. Announcements the
week prior to the program's start encouraged viewers to participate
and to send a post card to the station if they were willing to be
included in the evaluation of the program. Out of about 5,000 post
cards received, a sample of 300 was drawn for followup. One month
after the final broadcast, 8 percent of the sample reported abstinence
(7). This sampling procedure probably included a selection bias for
highly motivated individuals; however, it should be noted that
subjects sent in their post cards prior to the start of the program,
before they knew how much they would like the program, or
whether they would succeed in it.

Working with the same televised cessation program, Dubren (8)
explored the impact of taped telephone messages to encourage
maintained abstinence. Following a broadcast invitation, 200 view-
ers sent in cards indicating they had quit for at least 1 day; of these,
64 were assigned to treatment or control groups. The treatment
group received a telephone number to call, but the controls received
no further attention except for followup. Run each weekday for 4
weeks, the 3-minute telephone messages were changed daily. Sub-
jects were encouraged to call the telephone number to help them-
selves remain abstinent throughout this period. Among those offered
the telephone messages, 65.5 percent reported not smoking at the
end of the 4-week period. In contrast, only 34.4 percent of the control
group reported abstinence. Seventyeight percent of those offered the
telephone messages reported calling at least once. Twenty-four
percent reported calling for all 20 of the recorded messages. The
mean number of calls among those who called at least once was 10.6.
The validity of these reports is suggested by the fact that the monitor
on the telephone answering machine recorded 256 calls received and

263


the subjects reported having made 245. The abstinence rates among
this group are impressive. However, it should be recalled that the
group was selected from among those who had quit for 1 day and who
took the initiative of sending in a post card to report their success.
For logistic reasons, the subject population was limited to those
residing within New York City, but only 67 cards were received from
this area. Thus, these results do not necessarily provide an accurate
indication of outcome to be expected in a more general population of
smokers.

Best (3) also reported on a television version of a smoking cessation
clinic consisting of six half-hour shows broadcast weekly. The
program content was developed from self-management components
of a clinic program also developed by Best and his colleagues (4). The
shows emphasized problem solving with behavioral self-management
approaches. Other procedures included self-monitoring, encourage-
ment of a buddy system, and modeling (each show included a
simulated interview with a participant). A quit date was set for the
day on which the fourth show was to be televised, but participants
were given an alternative of gradual withdrawal between shows
three and five.

A "companion self-help guide" was offered to all who wrote or
called the station. The 1,403 smokers who did so were followed for
program evaluation. Followup response rates varied from 64 to 87
percent due to unrelated events (e.g., a phone workers' strike).
Among those responding, abstinence rates were 11.5 percent at the
end of the series and 14.7 and 17.8 percent 3 and 6 months later. This
suggests a "sleeper effect" of increased abstinence over time.

Best reports costs of the program to have been $8,500, apparently
excluding promotion and cost of air time. This averages $48 per
abstinent case at 6-month followup, higher than several others
reviewed here, perhaps because of the limited population of the
setting-Bellingham, Washington.

Also explored in Best's study were predictors of successful
outcome. Pretreatment smoking rate was less (23.5 per day) among
those who were abstinent 6 months later than among those who
were not (27.2 per day). Several other predictors of outcome were
previous attempts to quit unaided, reduced rate of smoking during
the program but prior to quit-day, and subjects' perceived likelihood
of success. All these may be viewed as measures of motivation. This,
too, is consistent with the previous studies reviewed above. Subjects'
ratings of the extent to which they actually used the procedures
advocated in the program were also related to abstinence at 6
months. Again, such ratings are ambiguous as to whether they
reflect the subjects' motivation or the specific effects of program
components.

264


The importance of motivation is suggested by one final aspect of
Best's program. It achieved an abstinence rate about twice that
gained by the program reported by Dubren (7). Selection factors may
account for this. Dubren's program was run weeknights on the news
broadcast. Considerably greater commitment was required by Best's
program, as it was run between 7:00 and 7:30 on Saturday evenings.
Thus, it may have achieved a higher abstinence rate due to a higher
motivation level of its participants.
The viability of media as a vehicle for smoking cessation program-
ming is suggested by overall success of two well-known programs for
coronary risk reduction, the Stanford Heart Disease Prevention
Program and the North Karelia Project in Finland. Only the Finnish
project reports population shifts in smoking, obtained from assessing
different random samples over time. Both of these programs include
mass media encouragement of smoking cessation along with other
procedures for heart disease risk reduction. For example, as part of
the Stanford project, residents of one town receiving only mass
media intervention showed an 8 percent abstinence rate at a
followup 3 years after the initiation of the community program. A
control community showed an abstinence rate of only 3 percent.
Smokers at high risk for coronary heart disease were offered
counseling for smoking cessation in a third community. The overall
abstinence rate was 24 percent within this community (24). The
abstinence rate among those offered the group treatment was
between 32 and 50 percent at the S-year followup, depending on
whether those smoking at the start but not available at followup are
counted or not counted as smokers (23). This study admirably puts
into perspective the contribution of a media approach relative to no
treatment and to intensive treatment.
The focus of the North Karelia study was to explore the impact of
a televised smoking cessation clinic (21). An actual clinic with a
group of participants and a leader was videotaped and televised
nationally. The airing of the 10 sessions was timed so that the final
session would show the group members at actual Smonth followup,
discussing their experiences. Within the Province of North Karelia,
smokers were encouraged to watih the programs in groups. About
200 leaders volunteered to form the groups, which the authors
calculated to be only about 1 leader for every 300 to 400 smokers
within the Province. National surveys conducted before and 1 month
after the program indicated decreases in the percentage of persons
reporting smoking during the month prior to the second survey, from
45 to 43.2 percent among males and from 25.7 to 24 percent among
females. However, these trends were not statistically significant.
About 7 percent of the national sample watched at least four of the
seven sessions. Only 10 percent of those who watched reported
viewing the program in a supportive group setting.


This program was also evaluated by comparing the results in
North Karelia with those in a neighboring province. These results
were confined to data based on males, 30 to 64 years old. Intensive
publicity efforts within North Karelia resulted in 9 percent of this
sample viewing four or more of the seven programs in comparison
with 4.8 percent of the sample in the neighboring province. For both
samples, 27 percent of those who watched at least four programs and
attempted to stop smoking reported abstinence at a 6-month
followup. Although 2.3 percent of North Karelia smokers reported
abstinence at the 6-month followup in comparison to 1.3 percent in
the control province, this difference was not significant.

Thirteen months after the airing of the shows, a national survey
was repeated and indicated a maintained abstinence rate of about 1
percent of those smoking at the original airing. Furthermore, shows
were repeated 3 months prior to this final national survey. Approxi-
mately another 1 percent reported abstinence from this second
airing of the shows. Thus, the two broadcasts of the program led to
approximately 2 percent of smokers nationwide remaining abstinent
for 3 months to 1 year. The authors estimated that this constitutes
10,000 to 30,000 individuals, an appreciable number, especially when
the health and economic costs of diseases related to smoking are
considered. The authors further estimated that production of the
seven sessions cost only $8,000. These figures indicate a cost per
abstinent smoker of less than $1.00.

Predictors of Outcome

As mentioned previously, a number of studies have attempted to
identify personality patterns that typify the smoker. No underlying
personality pattern responsible for smoking has been found and,
therefore, no pattern-specific treatments have been developed. A
somewhat more productive strategy has explored those characteris-
tics related to success in specific cessation programs. Social support
factors have been found to encourage success in maintenance of
cessation (15, 22,341 while a history of "negative affect" smoking (26)
has been found to reduce maintenance success. (See the section in
this Part of the Report on maintenance of smoking cessation.)

More directly pertinent to self-help approaches was a study of
those who had successfully reduced smoking without assistance (25).
Subjects were university students who had smoked 20 or more
cigarettes per day for a minimum of 6 months. To be counted as
successful, they had to have reduced their consumption at least 50
percent for at least 4 months; half of the 24 successful subjects were
abstinent. Data were also gathered from 24 unsuccessful smokers.
All subjects were identified retrospectively. Thus, the decision to quit


or cut down and the manner in which this was accomplished were
not influenced by the survey.
Successful individuals reported greater use of self-reward and
problem-solving or self-management procedures than did the unsuc-
cessful persons. However, they did not report frequent use of self-
monitoring procedures, a nearly universal component of behavioral
self-control programs. Finally, 40 percent of the successful subjects
reported use of techniques to control cues related to smoking. This
study indicates that self-reward and active problem-solving strate-
gies may be worth emphasizing both in self-help and in more
organized approaches to smoking cessation. The importance of self-
reward is also suggested by Rozensky and Bellack (30) in studies of
self-rewarding tendencies for those who had quit smoking or lost
weight.
Friedman et al. (II) also surveyed several behavioral, social, and
psychological characteristics of Kaiser Permanente subscribers who
had or who had not quit smoking. Smoking histories, number of
cigarettes smoked per day, and reported depth of inhalation indicat-
ed less intense smoking at the time of the examination among those
who remained quitters than on the part of those who persisted in
smoking. The quitters reported somewhat less alcohol consumption
than persistent smokers among whites and among black males. The
percentage of subjects reporting consumption of more than six cups
of coffee per day at the time of the index examination was also lower
among quitters than among persistent smokers `for all subjects.
Among whites but not among blacks, a greater portion of quitters
had completed at least some college.

hplications

For a decade, those studying smoking cessation have felt little
encouragement from the relatively poor long-term outcome of
intensive smoking cessation clinics. With few exceptions, results
have stayed quite close to the 20 to 30 percent abstinence figures
described by Hunt and Matarazzo (16). More optimism is spurred by
the present assessments of self-help and mass media approaches and
of brief interventions by health professionals. Such approaches have
the potential to reach large numbers of smokers who find them
attractive. Abstinence rates ranging from 5 to 40 percent have been
obtained in selected but nevertheless large audiences (3, 14, 29). In
entire populations, such approaches may encourage 2 percent of
smokers to quit in a year's time (21). Their impacts may be enhanced
by "sleeper effects" in which increasing numbers of persons exposed
to them continue to quit as time passes (3). Largely unexplored is the
extent to which these approaches may be combined to enhance each
others' impacts (23).

267

37:-310 0 - 82 - 19


What determines the impact of self-help approaches? Those most
likely to quit on their own or with minimal media intervention seem
to be physically and psychologically healthier (IO), have milder
smoking habits, in terms of history and intensity of current smoking
(3, 10, 29), and may be generally more skillful in controlling their
own behavior, as measured by the use of self-reward and problem-
solving tendencies (25).

The other reliable predictor of outcome seems to be motivation, as
measured by participants' willingness to read manuals and to carry
out activities encouraged in them (14). If motivation to quit smoking
reflects incentives for long life, then the fact that measures of
motivation predict outcome suggest that quality of life is an
important factor.

A number of characteristics of the programs reviewed here may be
emphasized to promote higher levels of motivation and cessation of
smoking. Among these are modeling (3, 211, or pointing up the
positive consequences of cessation in an authoritative manner (29).
Several of the programs include buddy systems, but these apparently
have not been emphasized. Supportive self-help groups (21) may also'
add to an individual's willingness to follow through with a program.
All of these program elements may be combined with the range of
media sampled to develop improved packages.

Summary

1. Ninety-five percent of those who have quit smoking have done
so without the aid of an organized smoking cessation program,
and most current smokers indicate a preference for quitting
with a procedure they may use on their own, and a disinclina-
tion to enter an organized, comprehensive program.
2. Research evaluations of self-help aids have reported success
rates up to 50 percent cessation at extended followups (6 to 15
months). Most estimates, however, fall below this, around 5 to
20 percent.

3. Brief and simple advice to quit smoking delivered by a
physician has substantial potential for producing cessation in a
cost-effective manner.

4. Televised smoking cessation clinics result in variable rates of
abstinence at followup. The use of television and other mass
media are a cost-effective intervention because of their large
potential audiences.

5. Retrospective studies revealed greater use of self-reward and
active problem-solving strategies among those who quit or
reduced smoking on their own than among those who were
unsuccessful in quitting or reducing smoking.

268


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(23) MEYER, A.J., NASH, J.D., McALISTER, A.L., MACCOBY, N., FARQUHAR,
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(25) PERRI, M.G., RICHARDS, C.S., SCHULTHEIS, K.R. Behavioral self-control
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(27l POMERLEAU, O.F., POMERLEAU, C.S. Break the Smoking Habit. A
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(32) SCHWARTZ, J.L., DUBITZKY, M. Expressed willingness of smokers to try 10
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(33) U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE. The
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(34) WEST, D.W., GRAHAM, S.. SWANSON, M., WILKINSON, G. Five year
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270


PREVENTION IN ADULTHOOD:
MAINTENANCE OF CESSATION

Introduction

In their review, Hunt and Matarazzo (25) plotted the temporal
trend in relapse among smoking cessation clinic participants who
had quit at end of treatment. They demonstrated that the proportion
of participants remaining abstinent fell to about 25 percent 3 to 6
months later and remained fairly stable after that time, a trend
replicated by Evans and Lane (15). Even less optimistic were data
showing a long-term abstinence rate of 17.8 percent among 559
participants surveyed 5 years after attending smoking cessation
clinics (51). Hunt and Matarazzo also showed similar curves for
abstinence from heroin and alcohol use. With few exceptions (8, 24,
27, 33, 39, 491, studies published in recent years have failed to exceed
6-month abstinence rates of 30 percent. Therefore, improving the
ability to maintain nonsmoking status following successful cessation
would be a major advance in cessation technology.

Overview of Maintenance Procedures

Major reviews in recent years (3, 50) have emphasized the
importance of procedures directed specifically at maintenance. Such
procedures generally encourage maintenance directly by focusing on
events or problems that occur following cessation, rather than
encouraging maintenance indirectly by trying to develop more
effective cessation procedures or by scheduling "booster" sessions
that merely review cessation procedures. A number of approaches to
developing distinctive maintenance procedures have been reported
in recent years. Among these are reinforcement or incentive
procedures, self-management procedures, attempts to find the best
level of therapeutic contact, tailoring treatments to client character-
istics, identifying and treating antecedents of relapse, and social
support. Predictors of outcome have also been studied. Each will be
reviewed in turn.

Reinforcement of Maintenance

In general, changes in behavior will be better maintained if they
are supported by reinforcers that are relatively immediate and
positive (40). The incentives for smoking cessation that are naturally
occurring are negative and represent probabilities of delayed events
(i.e., disease incidence). The naturally occurring consequences of
cessation that are quick in developing, such as improved sense of
taste, less minor respiratory distress, and monetary savings may not
seem like large rewards. Unfortunately, the naturally occurring
aversive consequences develop quickly and are generally profound

271


and highly salient (45). Consequently, supplementing naturally
occurring reinforcers for cessation with programmed reinforcers
may help maintain abstinence through periods when incentives for
resumed smoking are strong.

Some research has shown beneficial effects of reinforcement on
nonsmoking. A monetary reward for adherence to a gradual
withdrawal scheme led to 50 percent abstinence levels in partici-
pants at 6-month followup, versus 24 percent in controls (52).
Subjects in the United Kingdom (36) made a deposit of 625, which
was returned at the rate of f;5 per week for each of the first 4 weeks
following cessation. For the second 4-week period, subjects made a
further 620 deposit, which was returned at the rate of fJ0 for each 2
weeks of abstinence. Subjects who smoked during the periods lost the
amount of money that would have been returned to them. Deposits
forfeited in this way were divided among those remaining abstinent.
At the end of this 2-month period, abstinence levels among partici-
pants approximated 75 percent, validated by urinary nicotine
analyses. Control subjects who did not participate in the reinforce-
ment procedure showed a 2-month abstinence level of 55 percent.
However, the difference between the two groups was no longer
apparent at g-month followup.  I
One way in which some have attempted to build reinforcement

into the real world is through programs in the workplace. Rosen and
Lichtenstein (42) reported a reinforcement program using a salary
bonus of $5 each month plus a Christmas bonus for employees who
did not smoke during working hours. A questionnaire evaluation of
12 participants who had smoked prior to the program revealed a
decline from an average of 33 cigarettes per day before the bonus
system to 9 cigarettes per day after. Four of these individuals
reported abstinence at the end of the program.

A number of anecdotal reports of smoking cessation and reinforce-
ment programs in the workplace have also appeared. Among the
procedures employed are reimbursement of the cessation clinic fee
for people who, maintain their abstinence until a target date,
substantial salary bonuses (some on the order of $l,OOO), making bets
against the "house" (i.e., the company) on one's chance of success,
and chances in a lottery for a fishing boat. Many of the programs
seem to have centered on a chief executive's enthusiastic efforts to
quit and, concurrently, to encourage other employees to do so (17).
Whether this sort of enthusiasm can be replicated in planned
programs is not clear.

The National Interagency Council on Smoking and Health recent-
ly surveyed several hundred major American companies regarding
their interests and current activities in smoking cessation programs
for employees. Programs were already offered by 14.7 percent of
these companies. Further details on approaches to smoking cessation

272


programs in the workplace are available in a conference report
published by the Council (353 and in papers by Danaher (13) and
Fisher et al. (I 7).

Another approach to reinforcement is self-reward. This was found
to be more common among those who were successful than among
those who were unsuccessful in attempts to quit smoking indepen-
dent of any organizational program (37).

Self-Management

Self-management packages may include procedures for relaxation
to cope with urges or the emotions likely to provoke craving,
procedures for contracting wit,h oneself regarding aversive conse-
quences for relapse and positive consequences for maintenance, and
"stimulus control" procedures in which cues for smoking are avoided
or eliminated. Lando (27) found 76 percent abstinence rates at 6-
months after cessation when a comprehensive program was added to
"laboratory smoking," which alone achieved 35 percent abstinence
rates.

Several studies have reported the impact of comprehensive self-
management on situational control procedures without aversive
components. Their results all report approximately 30 percent
abstinence at followup 6 months or more after cessation. These are
more striking, however, because of their validation by reports of
other group members (5), saliva thiocyanate (31), or urinary nicotine
G8).
A different assessment of the importance of self-management was
reported by Hackett and Horan (23). They studied self-management
procedures including making contracts for maintenance with peers
and family members, using relaxation skills, restructuring cogni-
[ions related to smoking and the desire for cigarettes, and thought
-topping. This last procedure (8) is designed to interrupt repetitive or
Lroubling thoughts, as a means for coping with urges. Their program
was used with and without "focussed smoking," in which partici-
Pants faced a wall, received suggestions as to the aversive quality of
smoking, and chain smoked for about 15 minutes for each of
approximately six sessions. Individuals smoked between 3 and 3.5
cigarettes on the average in each of these 15-minute sessions. Results
showed no improvement in maintenance with the addition of a self-
management package. Focused smoking with or without the compre-
`lensive program achieved abstinence rates of 40 percent from 6 to 9
months after cessation. It is important to note, however, that the
content of the self-control packages used by Lando and by Hackett
and Horan differed. Danaher (12) also failed to find any advantage of
including self-control training with rapid smoking or with a normal-
lY paced "placebo" alternative.

273


Therapist Contact

Another approach to maintenance has been increased or varied
modes of therapist contact. Schmahl et al. (44) found that subjects
called biweekly by a research assistant to check on progress
following cessation were more likely to relapse than were those
called only monthly. Similarly, Relinger and his colleagues (41)
found that increased therapeutic contact following cessation did not
improve outcomes. A similar finding was-reported by Lando (28),
exploring both extent of therapist contact and magnitude of treat-
ment. A two-stage treatment combined "laboratory smoking" and
the comprehensive maintenance procedures reported by Lando (27).
Subjects in a three-stage treatment received this combination plus a
pre-cessation phase including films, pamphlets, and discussion of the
risks of smoking. In an intensive contact program, subjects attended
13 or 15 treatment meetings, depending on whether they were in the
two- or three-stage treatment. Minimal contact subjects attended
only three or four sessions, again depending on whether they were in
the two- or three-stage treatment. A significant interaction was
found; subjects receiving the two-stage treatment did better in the
intensive contact program, but the subjects in the three-stage
treatment did better with less intensive contact. Lando (28) attrib-
uted his finding of relatively poor outcomes in the frequent therapist
contact, three-stage group to possible "information overload" or to
excessive complexity of treatment.

The finding that more contact may sometimes reduce treatment
benefits points up a failing in the behavioral medicine and health
education literatures. Reports often present only sketchy informa-
tion on the manner in which curricula are presented. For instance,
many devote little time to describing how meetings were run, what
media were or were not used to support interventions, whether
leaders used a didactic or a "self-discovery" approach to instructing
participants, etc. Additionally, the scheduling of meetings to coincide
with the natural progression of experiences prior to and after
cessation is rarely discussed. An admirable exception to this latter
point is a paper by Best (4).

Tailoring Treatments to Individual Characteristics

Treatment effects may be explored as interactions among treat-
ment type, client type, and circumstances.

Best (4) explored interactions between treatments and client
motivation and status on Rotter's (43) dimension of expectancy for
internal versus external locus of control. The internal versus
external (I-E) dimension was expected to interact with a "treatment
focus," either satiation through doubling normal smoking rate or
analyzing external cues for smoking. Satiation was expected to work
better for internals since it provided a means of reducing desires for

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cigarettes. Analyzing environmental cues for smoking, on the other
hand, was expected to be better for externals since they would tend
to be governed by such cues. The I-E variable was also expected to
interact with whether or not subjects were told to "punish" relapses
by smoking double their normal rate for 24 hours following any
relapse. Internals were expected to benefit more from punishment
since the punishment was self-managed and involved the satiation
procedure directed toward urges to smoke.

The level of motivation was measured by several scales, including
a semantic differential evaluation of smoking and subjects' estimates
of their motivation to quit, desire to smoke, and probability of
success. Several hypotheses were posed: (1) that motivation would
interact with the timing of an attitude change manipulation related
to the negative aspects of smoking; (2) that attempts to provoke
attitude change would be more effective after quitting than before
(before quitting, they might simply be met by client resistance); and
(31 that this would be more pronounced among subjects low in
motivation, since there would be greater difference between their
attitudes prior to quitting and the attitudes encouraged in the
change procedure. All subjects received individualized aversive
conditioning, using rapid smoking and concentrated cigarette smoke
in the treatment room.

Statistical analyses revealed significant interactions in the pre-
dicted directions between the treatment focus and the I-E variable
and between the timing of the attitude change manipulation and two
of the nine measures of motivation, the desire to smoke and the
estimated probability of success. No significant interaction was
found between the I-E measure and self-managed punishment
following relapses. Using the desire for cigarettes measure of
motivation and the I-E scale, subjects were coded as highly or not
highly motivated and as internal or external. Depending on such
status and the treatment received, they were then coded as matched
:or mismatched for treatment focus and for timing of attitude change.
.Imong those matched for each, 50 percent were abstinent 6 months
after treatment. Among those mismatched for each, 30 percent were
abstinent 6 months later, while 25 percent of those matched on one
and mismatched on the other variable were abstinent. Analyses of
:he percentage of pre-treatment levels still smoked at 6-month
-bllowup showed a significant difference between the matched-
natched (30.4 percent) and mismatched-mismatched (75.2 percent).
several problems limit this study. First, a control condition that did
rot manipulate the procedures with which subjects were matched or
nismatched in other conditions was not significantly less successful
han the Lest of the other conditions. Second, in order to demon-
itrate the clinical utility of tailoring by individual differences, one

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