Addictive Behaviors, Vol. 5, pp. 353-358, 1980 0306-4603/80/040353-06$02.00/O Printed in the USA. All rights reserved. Copyright 0 1980 Pergamon Press Ltd.

AVERSIVE SMOKING USING PRINTED INSTRUCTIONS AND AUDIOTAPE ADJUNCTS

BRIAN G. DANAHER* School of Public Health

University of California, Los Angeles

ROBERT W. JEFFERY School of Public Health University of Minnesota

RAUL ZIMMERMAN and ELIOT NELSON School of Medicine Stanford University

Abstract-Two promising comprehensive smoking cessation programs emphasizing aversive smoking and self-management were tested using a moditied format with reduced supervision. The aver&e smoking procedures-rapid smoking (RS) or regular-paced aversive smoking (RPAS)-were presented via audiotaped instructions practiced entirely in clients’ homes as were the instructions for deep muscular relaxation. Meetings with the consultant were designed for discussion of problems and progress with the homepractice guided by audiotape and a printed workbook. Results of the 6-week program showed significant benefits at termination by both programs (RS=56.3% abstinence and RPAS=71.4% abstinence) with some recovery of baseline at the &month follow-up (Rs=37.5% abstinence and RPAS=28.6% abstinence). A netreatment comparison group was found to be smoking significantly more cigarettes at a time correspond- ing to termination (0% abstinent) but unexplained quitting in this group resulted in a nonsig- nificant difference at the follow-up (11.8%). Implications for community-based public health programs were explored.

An impressive variety of research has examined the effectiveness of smoking cessation programs (Lichtenstein & Danaher, 1976; Pechacek, 1979; Schwartz, 1978). One class of treatment procedures that has shown considerable promise involves the use of aversive smoking within a comprehensive package of behavioral skills. A number of reports (e.g., Danaher, 1977; Hackett & Horan, 1979; Hall er al., 1979) have found that rapid smoking and/or the less stressful regular-paced aversive smoking encourages high levels of abstinence at termination and satis- factory long-term nonsmoking levels.

To date, research on aversive smoking has usually approximated the “standard treatment format” which calls for a flexible number of meetings with a consultant combined with a schedule of daily contact during the early phase of treatment followed by less intensive involve- ment. In addition, this version usually includes office-based exposure to the aversive smoking procedure. Other parameters of the standard format have been described elsewhere (Danaher, 1977).

Community-based public health programs are becoming increasingly interested in offering smoking cessation classes but problems may be encountered when translating procedures from the clinic research setting to community classes (cf. Best ef al., 1977). Two potential problems involve adequate staff training and less intense interaction of participants with program person- nel. Thus, practical constraints of community settings demanded a departure from the usual version of aversive smoking.

*Requests for reprints should be sent to Brian G. Danaher, Ph.D., Division of Behavioral Sciences and Health Education, UCLA School of Public Health, Los Angeles, CA 90024.

353

354 BRIAN G. DANAHER et al.

The present research examined the effectiveness of modified versions of the rapid smoking and regular-paced aversive smoking procedures. In keeping with the practical emphasis, weekly meetings were used rather than a flexible number of more frequent interactions. Those meet- ings that were scheduled were occupied with discussion of problems and progress with a variety of homework tasks. Home practice of key treatment skills was directly largely through the use of a printed workbook and a set of audiotaped instructions.

METHOD

Participant recruitment Advertisements were placed in local newspapers which described a smoking cessation pro-

gram intended for persons who smoked at least one pack of cigarettes dally. In excess of 75 callers responded and were randomly assigned to one of the two aversive smoking conditions or a notreatment comparison group. Written permission from personal physicians was a pre- requisite for participation in both aversive smoking conditions. Other elements of appropriate screening were also employed (cf. Danaher, 1977).

Two potential participants-one in each experimental condition-failed to obtain physician approval and were therefore excluded. Six other participants withdrew during the initial phase of the program while a seventh individual withdrew before the mid-way point. Attrition was shared evenly by the two experimental conditions. The final sample was comprised of 16 persons ln the rapid smoking condition, 14 persons in the regular-paced aversive smoking condition, and 17 persons in the no-treatment comparison group.

Procedure Participants in the aversive smoking conditions were seen individually by one of four trained

consultants over the course of the six-week program. Weekly meetings were limited to a period of 30 minutes. All meetings were held in the General Medical Clinic at Stanford University Hospital during hours when these facilities were not otherwise ln use. A detailed workbook was

provided which outlined daily homework activities along with special data collection papers. Audiotapes were also developed which corresponded to the relaxation and aversive smoking tasks contained in the workbook. In no case were relaxation or aversive smoking procedures demonstrated ln the scheduled meetings-the entire burden of presenting these complex pro-

cedures fell to the audiotape adjuncts and logs contained in the workbook.’ The overall smoking program followed a three-phase sequence of Preparation (monitoring

smoking patterns, practice of deep muscular relaxation), Quitting (personal contracting and aversive smoking) and Maintenance (stimulus control procedures, self-reward, changing self-

statements, etc.). A more exhaustive description of the methods employed can be found in Danaher & Lichtenstein (1978).

Persons assigned to the no-treatment comparison condition were informed that they would not be able to participate in the research project and were given a listing of alternative resources ln the community for smoking cessation. Questionnaires were not administered at baseline nor was there any further contact with these individuals until a time corresponding chronologically to the g-month follow-up.

RESULTS

Key demographic characteristics were available for participants assigned to the aversive smoking conditions. These data are presented along with process results in Table 1. Inspection of the tabulated data reveals that no meaningful differences in the treated samples on demo graphic indices obtained. Baseline smoking data substantiates that the recruitment plan suc- cessfully involved only chronic heavy smokers.

Participants also completed the Health Locus of Control Scale or HLC (Wallston et al., 1976) the mean results of which are also presented in Table 2. It is interesting to note that the results were skewed to the “internal” direction-even more than the preliminary normative HLC data presented ln Wallston et al. (1976). Over 90% of these participants reported having at

Aversive smoking 355

Table 1. Demographic and process data for aversive smoking conditions

Regular-paced Rapid smoking aversive smoking F

Age 37.1 37.5 .02 No. cigarettes smoked per day in baseline 28.8 27.6 .20 Yearssmoking 17.8 21.0 1.61 Expectancy rati@ 5.47 5.29 .16 Motivation ratinga 5.67 5.64 .OO Satisfaction rati@ 6.18 6.00 .24 Health locus of controlC 29.31 29.36 -00

Aversion ratinga No. negative behaviors checked/t&lb

5.97 4.73 17.84* 9.38 6.07 32.14*

aBased on a 7-point scale: 1 = “not at all,” 4 = “moderately,” and 7 = “extremely.” bValues indicate number of behaviors checked out of a possible 18. CMaximum score = 66; higher score indicates “‘externality.” *P < .OOl.

least some college education, 27% had sought prior help to stop smoking, and 33% were experiencing health problems at the time of their participation.

Process measures were collected and key items are listed in Table 1. The two aversive smoking groups were found to be equivalent and quite positive in their ratings of expected success in the program, motivation for quitting, and initial satisfaction with the treatment regimen. Of particular importance was the general finding that the rapid smoking experience was significantly more unpleasant than the regular-paced aversive smoking experience measured both by ratings of unpleasantness and also by the number of negative behaviors checked on a negative sensation checklist.

Cigarette smoking behavior-the central dependent variable-was assessed at three points in time for the two experimental conditions (baseline, termination and at the 8-month follow-up) and at two times for the no-treatment comparison condition (a retrospective report of smoking status at times corresponding to termination in addition to an unannounced follow-up assess- ment). These smoking data are presented in Table 2 using three perspectives: (a) abstinence levels, (b) percent baseline smoking, and (c) mean smoking rate (Number of cigarettes smoked per day).

Table 2. Outcome smoking data

Statistica

% abstinent at termination I(-month follow-up

_-

Rapid smoking (N=16)

56.3 37.5

Condition Regular-paced

Aversive smoking W14)

71.4 28.6

No-treatment comparison

(N=17)

o.oo* 11.8

% baseline smoking at termination 14.8 (28.1)

&month follow-up 47.6 ( 4.5)

Mean smoking rate at termination (1:::)

&month followpup 15.2 (18.0)

aSta.ndard deviations displayed in within parentheses. *Significant at P < .OOl level.

10.4 NA (18.0) 54.9 NA

( 4.6)

( :::, 24.4*

16.0 (262f) (13.7) (11:7)

356 BRIAN G. DANAHER et al.

Outcome performance was collapsed across consultant as this factor was found to be a

nonsignificant source of variance. A repeated measures (baseline, termination, follow-up) analysis of variance computed using

the smoking rate data from the two aversive smoking conditions revealed a significant change in smoking performance over time (F=64.11, 2/56, K.001) but no significant between-group effects either from baseline to termination(F=0.2, l/28, P--.65) or termination to follow-up (p1.29, l/28, e.27). Further foundation for the observation that there were no between differences between the aversive conditions emerged in an analysis of percent baseline smoking

performance at termination (~0.5 1, df=28, P-.6 1) and at follow-up (r-0.44, df=28, fi.67). Additional analysis of the smoking rate data-this time including the no-treatment compari-

son condition-shows a statistically significant difference at termination (Fz20.78, 2/46, K.001) which can be attributed to differences between the combined aversive smoking groups and the comparison condition. Similar analyses conducted on follow-up data uncovered no other significant differences (+1.24,2/46, F.30).

Reports of abstinence were compared using Chi-square analyses. At termination, both aversive smoking groups displayed marked levels of abstinence which, when compared to the nonexistent abstinence reported in the no-treatment comparison condition, yielded a sta- tistically significant difference (X2=19.97, df=2, P<.OOl). All remaining possible comparisons of abstinence data failed to uncover any additional group differences. It is important to note, however, that at follow-up the combined abstinence of the experimental conditions was 2.8 times greater than that found in the no-treatment condition.

Validation of Self-reports At follow-up, reports of smoking or nonsmoking were validated using plasma thiocyanate

and expired air carbon monoxide measures. These evaluations were conducted on 38 individuals (81% of the total sample). The chemical measures were significantly correlated with self- reported smoking rate at follow-up: for thiocyanate (r5.53, df=36, P<.Ol) and for carbon monoxide (r=.77, df=36, P<.OOl). Assuming that self-report represented “true smoking status”

and the 8 ppm CO and 100 & mole thiocyanate thresholds were employed as suggested in the literature (Vogt et al., 1977, 1979) the thiocyanate measure was found to have a false positive level of 3.6% and a negligible false negative ratio whereas carbon monoxide showed a 10.3% false positive level and a 11.1% false negative ratio. In no case (N=ll) was self-reported ab- stinence contradicted by both tests.

Predictors of Outcome Pearson product-moment correlations were computed for a large number of demographic

and treatment variables but no statistically significant prognostic indicators of follow-up per- formance were identified.

DISCUSSION

The long-term results of the present investigation were not as impressive as had been hoped but they fall within the range of outcomes reported for aversive smoking procedures (cf. Danaher, 1977). One problem when using fixed schedules and standard numbers of aversive smoking trials is that abstinence at termination is not achieved by as many participants and thus the eventual outcome performance is diminished. Innovative methods for providing a sense of closer contact with the ongoing performance of participants may be required in order to encourage more uniform abstinence by the point of termination.

Several other findings deserve additional comment. First, one possible consequence of emphasizing a self-directed program for smoking control may be the emergence of elevated levels of participant attrition. While the attrition noted in the present study is not unique (cf. Rest et al., 1977; Best et al, 1978), it does merit careful consideration. Some participants may discover that they would prefer having the opportunity for greater sharing of personal experi- ence in a group setting others may improve their follow-through when they receive the prompt- ing effects of daily meetings. The recruitment or promotion message for any given smoking

Aversive smoking 357

cessation program may have to become much more explicit about the type and degree of personal contact that can be expected. In this way, participants would be better able to select programs that are consonant with their personal expectations and agenda.

A second issue involves the failure of the present research to find any clinical utility for the Health Locus of Control (HLC) Scale. The notion that programs can be tailored in a priori fashion to the idiosyncratic trait or state characteristics of a given participant has received intensive discussion (e.g., Pomerleau et af., 1978) but consistent and helpful predictors have not emerged. The utility of the HLC for smoking remains an open empirical question (Glasgow,

1978). The protocols used in the present research were designed so as to make programs for

smoking control more available to health professionals in the community. The availability of polished treatment workbooks and adjunctive autiotapes reduces the need for a highly-skilled consultant within the context of a concentrated, highly-supervised treatment program- elements which make promising programs seem too expensive and thereby impractical (cf. Green et al., 1978). Packaged programs can therefore encourage more widespread application of smoking control programs-reaching out beyond the university research setting and into the workplace (Danaher, 1980; Fielding, 1979) to high-risk individuals (Ellis, 1978) and to physician offices (Lichtenstein & Danaher, 1978). A public health perspective encourages the dissemination of promising health behavior change programs while taking care to modify ele- ments to fit new situations and encouraging effective follow-through. It is likely that “small media” like workbooks and tapes (Schramm, 1977) will play key roles in this emerging arena for applied research.

Acknowledgement-This project was supported in part by National Institutes of Health Research Service Award (#S T32 HL 07034-03) from the Heart, Lung and Blood Institute and American Cancer Society Institutional Grant (#2 HLK 613).

REFERENCES

Best, J.A., Bass, F. & Owen, L.E. Mode of service delivery in a smoking cessation program for public health. Canadian Journal of Public Health, 1911,68,469473.

Best, J.A., Gwen, L.E. & Trentadue, L. Comparison of satiation and rapid smoking in self-managed smoking cessation. Addictive Behaviors, 1978, 3, 71-18.

Danaher, B.G. Smoking cessation programs in occupational settings.PublicHsalth Reports, 1980,95,149-157. Danaher, B.G. Research on rapid smoking: Interim summary and recommendations. Addictive Behaviors,

1977, 2, 151-166. Danaher, B.G. & Lichtenstein, E. Become an Ex-smoker. Englewood Cliffs, N.J.: Prentice-HaB, 1978. Ellis, B.H., Jr. How to reach and convince asbestos workers to give up smoking. In J.L. Schwam (Ed.),

Promss in Smoking Cessation. vu. 160-182. New York: American Cancer Society, 1978. Field&, J.E. Reventke medicine -and the bottom line. JOM: Journal of Occupational Medicine, 1978, 21,

79-88. Glasgow, R.E. Effects of self-control manual, rapid smoking, and the amount of therapist contact on smoking

reduction Journal of Consulting and Clinical Psychology, 1978,46, 1439-1447. Green, L.W., Rimer, B. & Bertera, R. How cost-effective are smoking cessation methods? In J.L. Schwartz

(Ed.),Progress in smoking cessation, pp. 91-104. New York: American Cancer Society, 1978. Hackett, G. & Horan, J.J. Partial component analysis of a comprehensive smoking program. Addictive

Behaviors, 1979,4,259-262. Hall, R.G., Sachs, D.P.L. & Hall, S.M. Medical risk and therapeutic effectiveness of rapid smoking. Behavior

Thempy, 1979,10,249-259. Lichtenstein, E. & Danaher, B.G. Modification of smoking behavior: A critical analysis of theory, research

and practice. In M. Hersen, R.M. Eisler & P.M. Miller (Eds.), Progress in Behavior Modification, Vol. 3, pp. 79-132. New York: Academic Press, 1976.

Lichtenstein, E. & Danaher, B.G. What can the physician do to assist the patient to stop smoking? In R.E. Brashear & M.L. Rhodes (Eds.), Chronic Lung Disease: Clinical Treatment and Management, pp. 227-241. St. Louis: Mosby, 1978.

Pechacek, T.F. Modification of smoking behavior. In Smoking and Health: A Report of the Surgeon Geneml. Washinaton, D.C.: U.S. Department of Health, Education and Welfare, 1979. DHEW Publication No. (PHS) ?9-50066. -

Pomerleau, O., Adkins, D. & Pertschuk, M. Predictors of outcome and recidivism in smoking cessation treatment. Addictive Behaviors, 1978, 3,65-70.

Schramm, W. BigMedkz, Little Media: Tools and Technologies for Instruction. Beverly Hills, CA: Sage, 1977. Schwartz, J.L. Review and Evaluation of Smoking Control Methods: The United States and Cams&,

1969-I 9 77. Atlanta: U.S. Department of Health, Education and Welfare (Bureau of Health Education, Center for Disease Control), 1978. DHEW Publication No. (CDC) 79-3869.

358 BRIAN G. DANAHER et al.

Vogt, T.M., Selvin, S. & Hulley, S.B. Comparison of biochemical and questionnaire estimates of tobacco exposure. Preventive Medicine, 1979,8,23-33.

Vogt, T.M. Seivin, S., Widdowson, G. & Hulley, S.B. Expired air carbon monoxide and serum thiocyanate as objective measures of cigarette exposure. American Journal of Public Health, 1977,67, 545-549.

Wallston, B.S., Wallston, K.A., Kaplan, G.D. & Maides, S.A. Development and validation of the Health Locus of Control (HLC) Scale. Journal of Consulting and Clinical Psychology, 1976,44,580-585.

FOOTNOTE

’ More polished versions of the audiotapes used in the reported research (relaxation, regular-paced aversive smoking and rapid smoking) can be obtained from BMA Audio Cassettes, 200 Park Avenue South, New York, NY 10003. The title of the tapes is. “Comprehensive Smoking Cessation Program” by Danaher and Lichtenstein.