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Cognitive and behavioural strategies in the maintenance of smoking cessation Bloch, Maurice 1977

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COGNITIVE AND BEHAVIOURAL STRATEGIES IN THE MAINTENANCE OF SMOKING CESSATION by MAURICE BLOCH B.A., B.Comm., 1969, B.A.(Hons), 1974, University of Cape Town A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES (Department of Psychology) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA June, 1977 <g> Maurice Bloch, 1977 In p resent ing t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the requirements fo r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I f u r t h e r agree tha t permiss ion fo r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s e n t a t i v e s . It i s understood that copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l ga in s h a l l not be a l lowed without my w r i t t e n p e r m i s s i o n . Department of P S~?OtfOl^O Gr7 The U n i v e r s i t y of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date X%rJ (klCsUST. 1°*"*'7 i ABSTRACT Si x t y - f i v e subjects were randomly assigned to one of f i v e condi-tions — combined, cognitive, behavioural, oversmoking control and minimal treatment control. Subjects i n the f i r s t four (treatment) conditions underwent a core procedure, oversmoking, designed to help them quit smoking. These subjects then received either a cognitive, behavioural, combination or no treatment package designed to enhance the d u r a b i l i t y of change i n smoking behaviour achieved with the core procedure. Subjects i n the minimal treatment condition were informed at a single session about treatment procedures (excluding oversmoking) and encouraged to implement a programme on their own. A comprehensive package (combined) proved more effective than the simple package (cognitive or behavioural), which i n turn did not d i f f e r from each other i n maintaining reduced rates of smoking. However, subjects who received maintenance packages did not do s i g n i f i c a n t l y better than those who underwent the oversmoking only. Subjects i n treatment maintained s i g n i f i c a n t l y lower rates of smoking than subjects i n the minimal treatment control. The study provides a basis for the further development of maintenance strategies. The need to investigate the process of change, maintenance, and their interaction i s discussed. TABLE OF CONTENTS Abstract L i s t of Tables L i s t of Figures Acknowledgement Introduction Method Results Discussion Footnotes References Appendices A: Preliminary and posttreatment questionnaires, rating scales and consent forms B: Handouts and rating scales given to subjects during the course of the c l i n i c C: Data analyses D: Means and standard deviations for variables descriptive of the course of treatment i i i LIST OF TABLES METHOD Page Table 1. Summary of subject survival and mortality between i n i t i a l contact and end of treat-ment 15 RESULTS Table 1. Means for pre and posttreatment-cigarettes per day, percentage of pretreatment smoking rate and percentage abstinence 30 Table 2. Repeated measures analyses of variance on operant, posttreatment and follow-up smoking rates over time — four treatment conditions 31 Table 3. Repeated measures analyses of variance for pretreatment,. posttreatment and follow-up estimated smoking rates over time — f i v e conditions 33 Table 4. Analyses of variance for posttreatment and follow-up smoking rates over time as related to cognitive and behavioural modes of treat-ment *:36 Table 5. Summary table of multiple comparisons between conditions for differences i n mean abstinence rates over follow-ups •37 Table 6. Percent reduction at three month follow-up as a function of baseline rate - treatment conditions 45. Table 7. Repeated measures analysis of variance by operant grouping over time 46 i v LIST OF FIGURES Page Figure 1. Posttreatment and follow-up smoking rates over time: A l l conditions 34 Figure 2. Posttreatment and follow-up abstinence rates over time: A l l conditions 35 Figure 3. Posttreatment and follow-up smoking rates over time: Combined versus cognitive and behavioural conditions 39 Figure 4. Posttreatment and follow-up smoking rates' over time: Maintenance conditions versus oversmoking co n t r o l 4 1 Figure 5. Follow-up smoking rates over time: Treatment versus minimal treatment 42 V ACKNOWLEDGEMENTS Dr. J. A l l a n Best whose s k i l l f u l supervision, deep interest and steadfast support proved indispensable to the development of th i s research. Dr. Ralph Hakstian and Dr. Lynn Alden for their contributions as members of the author's dissertation committee. Lois Owen and Vivienne Weinronk for their respective roles i n coordinating data c o l l e c t i o n , scheduling of subjects,, record keeping, coding and the milenia of other details which arise i n a research project of th i s nature. The research was supported by a grant to Dr. J. All a n Best from the Non-Medical Use of Drugs Directorate, Health and Welfare Canada (No. 1212-9-42-1). 1 INTRODUCTION The c a u s a l r e l a t i o n s h i p be tween c i g a r e t t e smok ing and a v a r i e t y o f d i s e a s e s has been w e l l documented (Canada Commi s s i on o f I n q u i r y i n t o t h e Non M e d i c a l Use o f D rug s , 1973; NMUD, 1976; USPHS, 1976; WHO, 1975). P u b l i c knowledge o f t h e h a r m f u l e f f e c t s o f smok ing has n o t r e s u l t e d i n any s i g n i f i c a n t d e c l i n e i n t h e number o f smokers ( G a l l u p , 1974; NMUD, 1974 ) . The US Su rgeon G e n e r a l ' s r e p o r t (1964) became a l a ndma rk i n t h e h i s t o r y o f smok ing r e s e a r c h . The r e p o r t d rew t h e a t t e n t i o n o f b o t h h e a l t h p r o f e s s i o n a l s and t h e p u b l i c t o t h e p r o b l e m s o f c i g a r e t t e smok ing . I t gave a f r e s h i m p e t u s t o t h e s e a r c h f o r ways o f h e l p i n g p e o p l e c o n t r o l o r q u i t smok ing . A d r a m a t i c i n c r e a s e i n r e s e a r c h f o l l o w e d and a v a r i e t y o f t h e r a p e u t i c t e c h n i q u e s were b r o u g h t t o b e a r upon t h e p r o b l e m . These have i n c l u d e d t h e i n d i r e c t a p p r o a c h e s o f l e g i s l a t i o n , e d u c a t i o n and a d -v e r t i s i n g and t h e more d i r e c t i n t e r v e n t i o n s r a n g i n g f r o m p s y c h o a n a l y s i s , h y p n o s i s and d rug s t h r o u g h g roup t h e r a p y and a w i d e r ange o f b e h a v i o u r m o d i f i c a t i o n t h e r a p i e s encompas s i ng b o t h r e s p o n d e n t and o p e r a n t c o n d i -t i o n i n g t e c h n i q u e s . By 1970 t h e r e was l i t t l e t o show i n r e t u r n f o r a l l t h e r e s e a r c h i n v e s t m e n t . Rev i ews o f t h e l i t e r a t u r e ( B e r n s t e i n , 1969; K e u t z e r , L i c h t e n s t e i n and Mees, 1968; L i c h t e n s t e i n and K e u t z e r , 1971; M c F a l l and Hammen, 1971; S c h w a r t z , 1969) were unan imous abou t t h e i n a b i l i t y o f any p r o c e d u r e t o p r o d u c e l o n g t e r m smok ing c e s s a t i o n . The t y p i c a l p a t t e r n o f r e s u l t s i n a smok ing r e s e a r c h s t u d y has been a s i g n i f i c a n t immed i a t e r e d u c t i o n i n smok ing f o l l o w e d by a n e g a t i v e l y a c c e l e r a t i n g r e l a p s e c u r v e . 2 McFall and Hammen (1971), i n a summary of 11 prominent studies, found a mean 13% (with a range of between 9% and 17%) of the o r i g i n a l sample of subjects abstinent at s i x months after treatment. Hunt and Bespalec (1974) i n a summary of abstinence data i n 89 studies found that an average of 30% of subjects abstinent at termination were s t i l l abstinent si x months l a t e r . Bernstein (1969) attributed the state of a f f a i r s at that time to the use of unsatisfactory research methodology i n the area and to the persual of a l i n e of research which persisted with questions about the i n i t i a l change of behaviour instead of exploring the factors which con-tributed to the maintenance of nonsmoking behaviour. The next generation of reviews (Lichtenstein and Danaher, 1976; Bernstein and McAlister, 1976) described a s t i l l bleak picture but was more optimistic about the d i r e c t i o n which research was now taking. Lichtenstein and his colleagues at Oregon had succeeded i n de-veloping an aversive procedure, rapid smoking, which has proved to be an e f f i c i e n t and effective technique. They have reported 36% to 100% i n i t i a l abstinence and 41% to 64% abstinence at between 3 and 6 months follow up when rapid smoking has been administered i n a warm, s o c i a l l y supportive,laboratory environment (Harris and Lichtenstein, 1971; Lichtenstein, Harris, B i r c h l e r , Wahl and Schmahl, 1973; Kopel, 1974; Schmahl, Lichtenstein and Harris, 1972; Weinrobe and Lichtenstein, 1975). A second reason for optimism i s the increasing recognition that factors contributing to both i n i t i a l abstinence and maintenance must be investigated. Recently a number of studies offering self-management treatment packages designed to deal with both change and maintenance 3 factors have emerged (e.g., Best, Owen and Trentadue, 1977; Chapman, Smith and Layden, 1971; Delahunt and Curran, 1976; Morrow, Sachs, Gmeinder and Burgess, 1973; Pomerleau and Ciccone, 1974). The aim of t h i s study i s to investigate the effectiveness of a set of procedures which together comprise a package programme for the treat-ment of smoking. The rationale for developing t h i s package i s based on (1) a consideration of the factors which maintain smoking behaviour, (2) empirical evidence from previous smoking cessation studies, and (3) conceptual consideration of the kind of intervention which i s needed to effect long term smoking reduction. Factors Which Maintain Smoking Behaviour . . We are s t i l l f a i r l y ignorant as to factors contributing to the main-tenance of smoking behaviour. Behavioural, a f f e c t i v e , cognitive, sen-sori-motor, s o c i a l and physical s t i m u l i have been included either singly \ or i n combination i n the conceptual models of researchers and theorists i n the area (Bernstein, 1969; Berecz, 1976; Best and Hakstian, 1977; Dunn, 1973; Glad, Tyre and Addesso, 1976; Russell, 1974;.Tonkins, 1966). These varying conceptualisations of smoking are not incompatible with the learning model of smoking which we adopt here. We believe that, because of our lack of understanding about which factors do con-tribute to the maintenance of smoking behaviour, we should not exclude any of them from our model of smoking. It i s consistent with the learning model to regard cigarette smoking as a conditioned response to s t i m u l i both from within and without; and include cognitive, environmental, a f f e c t i v e , s o c i a l , physical and sensori-4 motor s t i m u l i . There i s evidence that smoking i s both an overlearned response (Hunt and Matarazzo, 1970) as well as having instrumental value for .the smoker (Ferster, 1970; J a r v i k , 1973). Cigarette smoking i s maintained by a combination of respondent and operant con-ditioning (Bernstein, 1969). I t appears l i k e l y that to the extent that smoking has an operant value for individuals, reasons for smoking w i l l d i f f e r from one person to another. Different mixes of functional variables w i l l play more or less important roles i n maintaining an individual's smoking behaviour. For one ind i v i d u a l i t may be that cigarettes relieve boredom or tension. Another may believe that i t i s masculine to smoke. A t h i r d may smoke for a combination of a l l three reasons. A number of models of smoking have been developed which support the b e l i e f that smokers have different, reasons for smoking (Best and Hakstian, 1977; Ikard, Green and Horn, 1969; McKennell, 1970,.1973; Mausner and P i a t t , 1971; Tomkins, 1966, 1968). The success of s e l f -management programmes which have emphasised the use of functional a l -ternative coping responses provides indirect support for t h i s viewpoint (Best, Owen and Trentadue, 1977; Chapman, Smith and Layden, 1971; Danaher, 1976; Flaxman, 1974; McGrath and H a l l , 1976; Morrow, Sachs, Gmeinder and Burgess, 1973; Pomerleau and Ciccone, 1974). Best and Hakstian (1977) found that smoking tends to be r e l a t i v e l y s i t u a t i o n a l l y s p e c i f i c . This i s consistent with the behavioural view-point and i t s emphasis on the environment. Best and Hakstian (1977) point out that many behaviour modifiers have noted the increased s p e c i f i c i t y which smoking acquires as smokers reduce their daily rate 5 of consumption. Thus there appears to be d i f f e r e n t i a l importance placed upon cigarettes. The habit, s i t u a t i o n a l component being impor-tant i n a reducing phase while the f u n c t i o n a l i t y of smoking assumes importance once change has occurred and the smoker has quit. The Treatment of Smoking An effective psychological treatment must produce change of be-haviour, the generalization of that change and the enduring maintenance of the changed behaviour (Bandura, 1969). Maintenance may depend on factors e n t i r e l y d i s t i n c t from those which effect change and for t h i s reason should be considered separately from change. Operationally, change may be defined as the difference between pre and post treatment measures of the target behaviour, i . e . , i t i s the a l t e r a t i o n i n behaviour which occurs during treatment. Maintenance refers to the post treatment d u r a b i l i t y of that change. A serious shortcoming i n smoking modification research has been the f a i l u r e to recognize t h i s d i s t i n c t i o n between maintenance and change of behaviour. Most researchers have concentrated on achieving i n i t i a l abstinence without paying equal attention to developing techniques which would ensure the persistence of that change. Indeed, research has often f a i l e d to distinguish between techniques which appear best suited to change behaviour and those which are best suited to maintain that change. One view i s that the reduction or cessation of an ex-cessive target behaviour such as smoking may be achieved by a procedure which would immediately suppress that behaviour due to the potency of i t s impact (aversive procedures, contingency contracts). The maintenance 6 of change may be achieved by the acquisition of certain nonsmoking and sel f - c o n t r o l s k i l l s which the nonsmoker would include i n his permanent cognitive/behavioural repertoire. Most research i n the treatment of smoking has focused on i n i t i a l change without considering the issues of change and change maintenance either empirically or conceptually. This has resulted i n the empirical fact of the negatively accelerating recidivism curve observed on follow-up. On the conceptual l e v e l , we find that a large number of studies employ techniques which can be construed as either only change approp-r i a t e or only maintenance appropriate. In addition, some researchers have compared these d i f f e r e n t i a l l y appropriate techniques d i r e c t l y with each other. Change appropriate techniques lead to reduced smoking without regard for the need to provide the smoker with a set of s k i l l s which he can use to counter the overlearned habit and the instrumental value of smoking. These change techniques include aversive techniques as wel l as certain s e l f - c o n t r o l procedures. The main aversive techniques used have been e l e c t r i c shock and oversmoking procedures. A series of studies have f a i l e d to achieve s i g n i f i c a n t differences between experi-mental groups, treated by shocking the act of smoking, and control groups (Andrews, 1970; Conway, 1974; Levine, 1974; Powell and Azrin,, 1968; Russell, Armstrong and Patel, i n press; whitman, 1969). Both Steffy, Meichenbaum and Best (1970) and Berecz (1976) shocked cogni-tions about smoking rather than the act of smoking i t s e l f . They achieved greater reduction i n smoking i n the experimental groups than 7 i n the control groups. I t i s possible that by consistently shocking cognitions the cognitive set of the smoker i s being changed and this has a long tern effect. Wilson and Davison (1969) have argued that an aversive procedure which includes the same cues as the target behaviour i s l i k e l y to have an effect which i s more salient and generalized than the effect of a tech-nique which stems from a r t i f i c i a l sources. Thus i t i s not unexpected that the use of cigarette smoke has been shown to be the most ef f e c t i v e procedure for reducing smoking. Cigarette smoke i s used as an aversive procedure i n two main ways — f i r s t l y , where the subject i s required to smoke much more than he usually smokes (sat i a t i o n smoking) and, secondly, where the subject i s required to smoke cigarettes much faster than he usually smokes (rapid smoking). The early success achieved with s a t i a t i o n (Resnick, 1968) has not been replicated (Claiborn, Lewis , and Humble, 1972; McCallum, 1971; Marston and McFall, 197/1; Sushinsky, 1972). As mentioned e a r l i e r , rapid smoking has been de-monstrated to be the most consistently e f f e c t i v e procedure i n the treatment of smoking. The maintenance effect of rapid smoking may, l i k e the effect of shocking cognitions, be due to changing the i n -dividual's cognitive set. For example, the rapid smoking may provide the subject with the salient unpleasant experiences which Bandura (1969, p. 507) submits he can subsequently reinstate or rehearse cognitively i n order to counteract the smoking urges which occur posttreatment (Lichtenstein and Danaher, 1976). Self-control techniques, conceptually appropriate for producing change i n smoking behaviour, have not been very successful i n 8 producing ei ther i n i t i a l abstinence or an impressive reduction i n smoking rates. I t i s noteworthy that those studies which have included an abrupt qu i t t ing procedure ( E l l i o t and Tighe, 1968; Winett, 1973) did better than those which employed gradual qu i t t i ng procedures (Azrin and Powell , 1968; Upper and Meredith, 1971; Cla iborn , Lewis ~ and Humble, 1972; Levenson et a l . , 1971; Marston and McFa l l , 1971; Nolan, 1968; Guttman and Marston, 1967). Flaxman (1974) studied th i s question of rate of qu i t t ing and her resu l t s provide d i rec t support for th i s observation. The se l f control techniques used for change have included increasing the stimulus i n t e r v a l between smoking (Azrin and Powell , 1968; Upper and Meredith, 1971; Bernard and Efran, 1972; Shapiro et a l . , 1971); h i e ra rch ica l reduction (Pumroy and March, 1966; Guttman and Marston, 1967; Marston and McFa l l , 1971; Levenson et a l . , 1971); deposit systems (Tighe and E l l i o t , 1968; Winett, 1973) and s o c i a l contracts (Tighe and E l l i o t , 1968; Guttman and Marston, 1967; Nehemkis and Lich tens te in , 1971). Maintenance appropriate procedures serve to a l t e r the subject is cognit ive/behavioural repertoire i n such a way that the effects of the procedure are retained after treatment has ended. Studies which have r e l i e d on maintenance procedures only have included covert s ens i t i za t ion (Cautela, 1970; Gordon, 1972; Wisocki and Rooney, 1971), coverant cont ro l (Danaher and Lich tens te in , 1974; Hark, 1970); thought stopping (Wisocki and Rooney, 1971); contracting beyond treatment (Frederiksen, Peterson and Murphy, 1976) and a package of maintenance appropriate self-management techniques (McGrath and H a l l , 9 1976). The direct comparison of both change and maintenance appropriate procedures has resulted i n an apparent methodological confound. These included the comparison of shock with operant s e l f - c o n t r o l techniques (Ober, 1968); h i e r a r c h i c a l reduction with covert s e n s i t i z a t i o n (Sachs, Bean and Morrow, 1970); rapid smoking with coverant control (Johnson, 1968; Keutzer, 1968); rapid smoking with systematic desensitization ( K r e i t l e r , Shahar and K r e i t l e r , 1976); contingency management and contractual management with covert s e n s i t i z a t i o n (Lawson and May, 1970) and the effectiveness of lobeline, psychotherapy, covert s e n s i t i z a t i o n , rapid smoking and e l e c t r i c shock were a l l compared i n one study (Brengelman and Sedlmayr, 1975). The package treatment developed as a response to the increasing awareness that changes i n smoking behaviour are complexly determined. There has been a substantial increase i n the number of package programmes i n recent years. This increase has occurred despite the s a c r i f i c e of ex-perimental rigour which occurs when a variety of techniques are included i n a single treatment package. The package programmes have usually included both a change and a maintenance focus. However, they have not always taken into account the m u l t i f a c t o r i a l and i n d i v i d u a l nature of the smoking habit. Conse-quently they f a i l to provide a s u f f i c i e n t l y comprehensive variety of treatments to meet the reasons people have for smoking. These programmes f a l l short of being able to t a i l o r treatment f u l l y according to the individual's reasons for smoking. Some package programmes have included a change procedure with a 10 maintenance programme which does not consider the operant value of smoking. These include the use of shock with stimulus control, contin-gency management and covert reinforcement procedures (Conway, 19 74), stimulus control, role playing and covert punishment (Chapman, Smith and Layden, 1971); rapid smoking with self reinforcement or punishment and incompatible responses (Delahunt and Curran, 1976), s o c i a l contracting, imagery and s e l f - c o n t r o l hints (Lewittes and I s r a e l , 1975), stimulus ' control, role playing, alternative behaviour and rapid smoking on re-lapse (Morrow, Sachs, Gmeinder and Burgess, 1973), deposit system or s o c i a l support or continued rapid smoking (Gordon and Katz, 1977), de-posit system (Lando, 1976); s a t i a t i o n with public commitment, stimulus control, covert reinforcement and role playing (Pomerleau and Ciccone, 1974) ; hypnosis with alternative s e l f - c o n t r o l behaviours and monthly posttreatment sessions (Pederson, Scrimgeour and Lefcoe, 1975); a token economy with stimulus control, self-contracting, continued thera-p i s t contact and the prin c i p l e s of learning theory (Bdrnstein et a l . , 1975) ; abrupt quitt i n g with education, a buddy system and group discus-sion (Schlegel and Kunetsky, 1976); a self-contract to reduce smoking with continued self-monitoring or contingency contracting or instruc-tions to change (Miller and Gimpl, 1971). Sutherland, Amit, Golden and Roseberger (1975) combine rapid smoking with progressive relaxation to produce a package whose main-tenance component focuses on only one functional aspect of smoking while neglecting also the overlearned habit component of the behaviour. Some researchers have included i n the i r maintenance programme, components which address both the overlearned and functional aspects 11 of smoking. Pechacek (1976) uses a target date for qu i t t i n g with stress management train i n g as wel l as cognitive restructuring, stimulus control, self-reinforcement and problem solving t r a i n i n g ; Flaxman (1974) used a target date for qu i t t i n g with relaxation training as wel l as contin-gency management, stimulus control and thought stopping; Danaher (in press) combined rapid smoking with relaxation training as well as s t i -mulus control, self-reward and a cognitive ecology programme. F i n a l l y , i n this c l i n i c we have combined change techniques with a maintenance programme which addresses both the habit and functional components of the smoker's behaviour. A l l the smoker's reasons for smoking are analyzed and treatment i s t a i l o r e d according to each smoker's pattern of smoking. Thus Best, Owen and Trentadue (1977) combine sa-t i a t i o n and rapid smoking with s e l f - c o n t r o l s k i l l s as well as a set of functional alternative ways of coping with tension, affect and other reasons which people have for smoking. Best, Bass and Owen (in press) added a component of phone support to the previous study while Suedfeld and Best ( i n press) combined sensory deprivation and s a t i a t i o n with a similar comprehensive maintenance programme. Another desirable aspect of the package programme i s the emphasis i t places on the cafe t e r i a - s t y l e self-management programme. Davidson (1976) points out that the cafeteri a - s t y l e behavioural programme which trains a variety of s k i l l s i s l i k e l y to be effective because i t both increases s e l f - a t t r i b u t i o n and increases the freedom of choice for the c l i e n t and thereby reduces the l i k e l i h o o d of reactance. Delahunt and Curran (1976) hold that s e l f - c o n t r o l i s appropriate for a l t e r i n g the operant components of smoking behaviour. Self-control focuses on the 12 i n d i v i d u a l as the agent of change i n h i s own environment thereby en-suring generalization of behaviour (Lichtenstein and Danaher, 1976) and the i n d i v i d u a l w i l l be more able to include behaviours as needed i n the problem s i t u a t i o n s (Best, Owen and Trentadue, 1977). The present study includes the most important and successful components of smoking research to date — a package treatment including oversmoking and a c a f e t e r i a s t y l e self-management programme of main-tenance techniques. In the present study we investigate the compara-t i v e usefulness of package treatments which include behavioural tech-niques only, cognitive techniques only and the more comprehensive package which combines both the behavioural and cognitive packages. The i n c l u s i o n of cognitive modification procedures i n smoking modification research i s warranted for a number of reasons. F i r s t l y , the recent upsurge of i n t e r e s t i n cognitive behaviour modification research has led to the development of new procedures which deserve a p p l i c a t i o n i n smoking research programmes (Bandura, 1969; Kanfer and Goldstein, 1976; Mahoney, 1975; Mahoney and Thoresen, 1974; Meichenbaum, 1974; Thoresen and Mahoney, 1974). Secondly, c e n t r a l mediational processes are i n many respects the most i n f l u e n t i a l regulatory mechanisms (Bandura, 1969). T h i r d l y , to the extent that c e r t a i n aspects of smoking behaviour are cognitive i n themselves, they might best be remediated c o g n i t i v e l y . Fourthly, early intervention i n the cognitive/behavioural sequence of events leading to smoking might be more e f f e c t i v e with a cognitive technique. Thus Cautela (1970) suggests that the urge to smoke could be managed by using coverant c o n t r o l . 13 F i n a l l y , offering both behavioural and cognitive procedures has two aims. F i r s t l y , i t expands the comprehensiveness of the package by providing alternative ways of coping with a greater variety of factors which maintain smoking. Secondly, i t increases the v e r s a t i l i t y of the package by offering equivalent behavioural and cognitive tech-niques. The strategy of the present study was to begin with a core set of procedures shown to have a s i g n i f i c a n t impact i n i n i t i a t i n g immediate change and to then add different maintenance packages and to assess the d i f f e r e n t i a l effectiveness of these procedures on the d u r a b i l i t y of smoking change. Experimental Hypotheses (1) Subjects i n the combined behavioural/cognitive condition w i l l be smoking s i g n i f i c a n t l y less on treatment follow-ups than subjects i n the behavioural only and cognitive only conditions. (2) Subjects i n the behavioural only and cognitive only conditions w i l l not be smoking at s i g n i f i c a n t l y different levels on treatment follow-ups. (3) Subjects i n the maintenance conditions (combined, behavioural only, cognitive only) w i l l smoke at a s i g n i f i c e n t l y lower rate on trea t -ment follow-ups than subjects i n the no-maintenance condition (rapid smoking only). (4) Subjects i n the treatment conditions w i l l smoke at a s i g n i f i c a n t l y lower rate on treatment follow-ups than subjects i n the minimal treatment control. 14 METHOD Subj ects Subjects were recruited through advertisements i n a l o c a l d a i l y newspaper for a free smoking c l i n i c . They were randomly assigned to successive treatment conditions i n the order that they responded to the advertisement by phoning the c l i n i c ' s receptionist. At this time they were given an outline of the c l i n i c ' s approach and the basic procedures to be followed i n the programme; given a medical screening; informed that they would be required to provide a physician's consent i n order to participate i n the programme; informed that the programme was free but that each subject would be required to make a deposit which would be refunded when research data was received at the three month followup. One i n every f i v e respondents to the advertisement was . told that the programme was f u l l . They were, however, encouraged to attend a single session where the procedures which the c l i n i c used would be outlined to them. I t was suggested that on the basis of this single session, they could develop their own quit-smoking programme. These subjects became the minimal control group. Of the 129 respondents to the advertisement, 72 actually started the treatment programme and 65 subjects were included i n the f i n a l sample (see Table 1). Subjects were considered medically unsuitable either i f they reported a history indica t i v e of cardiovascular or serious broncho-pulmonary disease or i f their physicians refused con-sent for thei r p a r t i c i p a t i o n i n the c l i n i c . Physicians were sent an a r t i c l e (Lichtenstein and Glasgow, 1976) which describes current research Table 1 Summary of Subject Survival and Mortality Between I n i t i a l Contact and End of Treatment F i n a l Sample 65 ^Completed Treatment - Dropped from Study 1 *Dropped out during Treatment 6 Medically Unsuitable 14 1) C l i n i c Telephone Screening (11) 2) S's physician (3) Unable to find Suitable Time 4 Changed Mind - Called i n before Session 1 9 Failed to arrive at Treatment Session 1 27 *Other 3 Total number of Respondents 129 *See Footnote 1 16 on the effects of oversmoking (Appendix A). This treatment sample appeared to be a representative cross-section of the l o c a l community. The average age was 35.7 (S.D. = 9.8). They reported an average d a i l y smoking rate of 28.6 cigarettes (S.D. = 10.5). They had been smoking for an average of 17.9 years (S.D. = 8.6). Forty-two percent of the treatment sample was male and 58% female. Experimental Design Two treatment factors were f a c t o r i a l l y represented: two levels of cognitive procedures (cognitive versus no cognitive) and two levels of behavioural procedures (behavioural versus no behavioural). The design thus included a control condition i n which subjects received no maintenance treatment procedures ( i . e . , no cognitive or behavioural procedures). Behaviour changes i n t h i s group were attributable only to the core treatment procedures and not to any of the procedures which were designed to promote enduring change. As mentioned, a minimal treatment control was also included. Behaviour change i n t h i s group was attributable to the subject's motivation to change and his success i n self-implementation of the maintenance treatment procedures. There were a t o t a l of 65 subjects i n the f i v e c e l l s : combined (14), cognitive only (12); behavioural only (12); oversmoking only control (14), minimal treatment control (13). The only r e s t r i c t i o n placed upon random assignment of subjects to treatment conditions was that c l i e n t s coming to the c l i n i c together (married couples, work associates, friends, etc.) were assigned to the same treatment conditions. 2 This was necessary so that different 17 treatments across groups would not be e a s i l y contaminated. The experimental hypotheses were tested by planned orthogonal contrasts. The minimal treatment control was included only i n one contrast. The MSw term was then recalculated and analyses including the four in-treatment conditions were undertaken separately. Inter-action between the treatment conditions was tested by using the 2x2 f a c t o r i a l design. Intake Procedures A l l subjects attended an intake meeting i n the groups to which they were assigned. There were three groups per condition. Subjects were required to complete a battery of questionnaires (Appendix A). (1) Subjects completed a background information ques-tionnaire related to age, sex, marital status, education and occupation as well as information about the individual's smoking habits. (2) Two questionnaires, the Smoking Occasions and the Smoking Motivation questionnaires, were administered with the intention of making the sub-jects more aware of the d i f f e r e n t situations they smoked i n and their reasons for smoking. (3) Subjects completed two personality measures: the Wallston et a l . (1976) Health Locus of Control Scale (HLOC) and Snyder's (1974) Personal Reaction Inventory (PRI). (4) An imagery scale was constructed and administered to give subjects an opportunity to become more aware of self-engendered imagery. (5) Two scales were constructed to assess motivation for quitting — these include (a) a motivation thermometer, on which subjects indicated the strength of thei r motivation to quit smoking and (b) a desire thermometer on which 18 subjects indicated the strength of their desire to continue smoking. A l l subjects were given a learning theory rationale for the maintenance of the smoking habit and the treatment to be followed. Subjects i n the minimal treatment condition were given an overview of the c l i n i c ' s approach to treatment and a detailed guide and outline to the implementation of procedures (excluding oversmoking). These subjects attended only the "intake" session. They were given no written materials. The programme for the next four sessions was outlined for subjects i n the four treatment conditions. They were to l d that the i r date for qu i t t i n g smoking would be the day of the t h i r d session. I t was emphasized that they should focus on that target date. The cigarette t a l l y system was explained. The system required the recording of the time of day, the place, the a c t i v i t y i n which the subject was involved and the sub-ject's perceived reason for smoking each cigarette. Subjects were ex-p l i c i t l y instructed not to change their smoking habits u n t i l the next meeting i n one week's time. The importance of getting an accurate picture of their normal smoking was stressed. They were to l d to e n l i s t the help of a friend or r e l a t i v e who would act as a confederate and check the daily record at the end of each day (see Best, 1975; Ober, 1968; Steffy et a l . , 1970). Subjects were asked to provide the c l i n i c with the name and address of a confederate who could a s s i s t the subjects with t h e i r tallying.(Appendix A). A data deposit was explained. Subjects were asked to sign a "data deposit agreement" (Appendix A) and to make a data deposit of $25 payable to a l o c a l charitable organization. The deposit has proven 19 effective i n ensuring that subjects both complete the course of treat-ment and submit a l l necessary cigarette t a l l i e s and questionnaires (Best, 1975; Best and Steffy, 1971; Keutzer, 1968; Mees, 1966). The deposit was refunded a f t e r a three month c l i n i c follow up i f the subject had complied with a l l requests for information. The return of the deposit was not contingent upon any aspect of the subject's smoking habit per se. F i n a l l y subjects signed a research p a r t i c i p a t i o n consent form (Appendix A). Subjects took with them from the intake meeting a folder i n which to keep c l i n i c handouts; a 3"x5" wire-bound notebook for recor-ding the i r cigarette t a l l i e s ; a set of instructions explaining the t a l l y system i n d e t a i l , and a t a l l y summary sheet (Appendix B). Rationale Presented to Subjects As mentioned, subjects were given a theoretical model for the development of smoking and the approach to treatment. The model con-ceptualized the development of the smoking habit as the development of S-R bonds. The rationale then diff e r e d according to treatment condition. Subjects i n the oversmoking and combined conditions were to l d that these bonds were formed by the development of l i n k s be-tween either environmental situations or thoughts and the smoking response. Subjects i n the cognitive only condition were told that the bonds existed between thoughts and the smoking response. I t was ex-plained that t h i s was so as most behaviour i s at least cognitively mediated. Subjects i n the behavioural only condition were told that 20 the bonds developed between environmental situations and the smoking response. A l l subjects were told that quit t i n g involved the disruption or breaking of these bonds. Further, subjects i n the experimental condi-tions were to l d that to maintain abstinence they needed to replace the smoking behaviour with new behaviour. To do t h i s , they would need to learn non-smoking s k i l l s . Subjects i n the combined condition were told that their new s k i l l s could be either cognitive or behavioural. Subjects i n the cog-n i t i v e only and behavioural only conditions were t o l d , respectively, that only cognitive or only behavioural s k i l l s would be appropriate. General Treatment Procedures Following the intake meeting subjects were seen i n the same groups, at weekly i n t e r v a l s , on four further occasions. Thus the programme comprised a t o t a l of f i v e sessions. At the second session, the subjects' t a l l i e s were collected and thei r reasons for smoking discussed. Subjects were given a rationale for aversive conditioning. They were instructed i n the f i r s t of the oversmoking procedures, s a t i a t i o n . They were told that for the three days prior to the t h i r d session they were to smoke many more cigarettes than they usually smoked. They were to l d that the rule of thumb was to smoke at double the normal rate. I t was explained, however, that the goal was subjective discomfort rather than smoking a certain number of cigarettes. I t was emphasized that the procedure worked best i f carried out for a l l three days. Subjects were given handouts which 21 explained the s a t i a t i o n procedure, a s a t i a t i o n "symptom rating scale" and a " s a t i a t i o n quota and t a l l y system" blank (Appendix B). At the end of each evening subjects completed the symptom form, requiring severity judgements on a 5-point scale for each of 24 possible reactions. They then decided upon the number of cigarettes for the next day and allocated them on an hourly quota basis. A l l subjects were instructed to quit smoking "cold turkey" after the three days of s a t i a t i o n , the day of the t h i r d session. At the t h i r d session rapid smoking was described. The f i r s t rapid smoking session was held i n the c l i n i c at the t h i r d session. Handouts supple-mented the explanation and a "symptom rating scale" provided informa-t i o n about the subjects' experiences (Appendix B). The procedure on conditioning t r i a l s was as follows. The subject was to set himself up with a lighted candle, s u f f i c i e n t cigarettes placed close by on the table, an ashtray and a watch or clock with a second hand. The subject was instructed to inhale normally at s i x second i n t e r v a l s , l i g h t i n g fresh cigarettes as necessary. A t r i a l ended when the subject f e l t that he could not tolerate another inhalation. The subject would then crush out the ciagrette while covertly verbalizing the aversiveness of smoking. At the end of the t r i a l the subject recorded the number of cigarettes smoked to the nearest quarter. The subjects were per-mitted to drink water between t r i a l s . After two or three minutes for recuperation a second t r i a l commenced. And s i m i l a r l y a t h i r d t r i a l . Subjects were not obliged to complete three t r i a l s but rather to con-tinue u n t i l they had achieved a maximal aversive effect. At the end of each rapid smoking session subjects completed the symptom rating 22 scale. The procedure was s l i g h t l y varied at the f i r s t session — only two t r i a l s were held and the experimenter called out "puff" at s i x second in t e r v a l s . Subjects were t o l d , both when sat i a t i n g and rapid smoking, to focus on their physical experiences. I t was explained that t h i s would help build i n a memory component of cigarettes as unpleasant which would help them stay off cigarettes. A t o t a l of 7 rapid smoking sessions were scheduled, the l a s t s i x to be held at home. Sessions were i n i t i a l l y massed (days 1, 2, 3) and then gradually spaced out (days 5 and 7 and then days 10 and 13). The f i n a l rapid smoking session was held the day before the f i f t h session. Throughout the programme the experimenter maintained high l e v e l s of expectation of success and s o c i a l support, equally across a l l groups. Experimental Treatment Procedures From the second session u n t i l the end of the programme subjects i n the three experimental conditions concentrated on developing s k i l l s of non-smoking. The subjects i n the oversmoking control condition were encouraged to discuss the i r progress and problems at sessions. The therapist's role i n this group was non-directive. The subjects i n the experimental conditions developed s e l f - c o n t r o l s k i l l s as wel l as functional alternative behaviours to cope with the different reasons they might have for smoking. The se l f - c o n t r o l s k i l l s refer to these procedures which the subject applies i n order to change some aspect of his own behaviour (Lichtenstein and Danaher, 1976). Functional alternatives refer to behaviours which replace cigarettes 23 while purporting to serve the same perceived function for the subject as the cigarettes do. I t was emphasized that: (1) the programme was a self-management programme, (2) l i k e any other s k i l l "getting good" at being a nonsmoker required practice and (3) they should select those procedures which best suited their needs i n developing their programme. Behavioural Techniques A. Self-Control Procedures 1. Stimulus control techniques aim,to control behaviour by control-l i n g the s t i m u l i which e l i c i t the smoking response. These include the following: (a) Avoiding or leaving certain situations, strongly t i e d to smoking. For example, not going out drinking. (b) A l t e r i n g a routinized or r i t u a l i z e d pattern which includes smoking a cigarette. For example, drinking tea instead of coffee i n the livingroom instead of at the table (c) Removing the e l i c i t i n g s t i m u l i from the environ-ment. For example, disposing of a l l cigarettes and ashtrays i n the house. 2. Non-Functional alternative behaviours such as chewing gum or sipping water when speaking on the telephone. 3. A self-reward system involving the reward of non-smoking behaviour. The reward system was outlined to the subjects at the t h i r d session . and supplemented by a handout (Appendix B) which described the contin-gencies necessary for reward to be e f f e c t i v e . Subjects reward pro- . grammes were then discussed at l a t e r sessions. B. Functional Alternatives Whenever i t i s considered that a cigarette i s doing something for 24 the subject an attempt was made to control the urge to smoke by using a new response considered functionally equivalent to the cigarette under the circumstances. The following are some of the common techniques used: 1. Progressive relaxation using 16 muscle groups (Bernstein and B'orkbvec , 1973) was presented at the second session and supplemented with a handout (Appendix B). Subjects were told that to acquire effec-t i v e s k i l l s i n relaxation as an answer to tension they should practice the procedure twice d a i l y . Once acquired the relaxation could be used as a coping s k i l l i n situations (Goldfried and T r i e r , 1974). 2. Deep-breathing was suggested as a second good alternative res-ponse to tension. 3. A cold shower or brisk exercise are good responses where a wake-up stimulant i s needed. 4. Reading an exciting pocket novel, a crossword puzzle, planning the next day's business could serve as good responses when bored. 5. A short break from work helps maintain concentration on a job. 6. Find a new reward for reinforcement of a job completed. 7. When lonely or depressed, c a l l a friend or do some other a c t i v i t y which w i l l a l t e r the mood state. Cognitive Techniques A. Self-control procedures 1. Urge-management, an adaptation of coverant control (Danaher, 1974; Homme , 1965, 1966; Mahoney, 1970) i s designed to control the urge to smoke by consequating the urge with negative covert statements or 25 images about smoking. This i s followed by a covertly-verbalized decision not to smoke. This decision i s reinforced with covert positive associations with nonsmoking. Clients were asked-to generate their own l i s t s of positive and negative associations and to vary them i n applying the technique. The procedure was presented at the t h i r d session and supplemented with a handout (Appendix B). 2. The approach to s e l f - i n s t r u c t i o n a l training was adopted from Meichenbaum (1975). Subjects i n the cognitive conditions were instructed to record their self-statements about smoking. They did t h i s for three days after the second session i n addition to the self-monitoring described e a r l i e r . The following techniques were presented to help subjects control smoking through their self-statements. The explana-tion of procedures was supplemented by a handout (Appendix B ) . a. practising redefining certain situations as nonsmoking situations. For example, the subject might be instructed to practice repeating to himself that he does a number of things after dinner but he does not smoke. b. using coping imagery, especially where a d i f f i c u l t s i t u a t i o n could be anticipated. For example, the subject who anticipated smoking at a party may spend a few minutes before the party imagining himself i n the s i t u a t i o n he fears and thus seeing himself coping without a cigarette i n that si t u a t i o n . c. becoming more r a t i o n a l about smoking by thinking through a self-statement i n order to arrive at the i r r a t i o n a l i t y of i t s conclu-sion. For example, a subject who says that he cannot enjoy a party without smoking might arrive at the conclusion that the worst thing 26 that could happen i s that he would not enjoy the party. d. preparing to use s e l f - i n s t r u c t i o n d i r e c t l y i n certain situations. For example, a subject may rehearse the coping strategies he w i l l use i n the c r i t i c a l s i tuation. Once i n the si t u a t i o n he can instruct himself i n strategies for coping without smoking. e. practising thinking p o s i t i v e l y about q u i t t i n g . For exam-ple, a subject who i s repeatedly t e l l i n g himself that he w i l l not be able to succeed i n quitti n g can practice saying the opposite. f. thought stopping (Wolpe and Lazarus, 1966) to stop con-stant thoughts and ruminations about smoking. Subjects were instructed to covertly"shout""stop" and then to have planned thoughts upon which they could focus attention. 3. A Self-reward programme was presented i n the same way as the behavioural programme except that rewards involved only the use of imagery. B. Functional Alternatives Sim i l a r l y to the behavioural condition, whenever cigarettes are considered to be doing something for the smoker a new functional a l t e r -native behaviour must be substituted for smoking. The following pro-cedures were used. 1. A relaxation procedure using relaxing imagery was presented to subjects at the second session. They were given the same general i n -structions about relaxation as i n the behavioural condition, and a handout (Appendix B). 2. Functional imagery appropriate to different reasons for smoking were suggested. This involved using imagery which i s appropriately 27 relaxing, stimulating, rewarding, etc. Termination A l l subjects terminated treatment at the f i f t h session. At the end of t h i s session the subjects assessed treatment by rank-ordering the different treatment components and by rating average discomfort with respect to urges to smoke during treatment and their confidence i n maintaining abstinence (Appendix A). Dependent Variable The p r i n c i p a l dependent variables used were d a i l y rate of cigarette smoking and abstinence or non-abstinence from cigarettes. Followup scores reflected subjects' estimates of their smoking rate during the preceding week. Followup At .the f i n a l session subjects were given a postage paid card to return a week l a t e r . They reported their smoking for the week on the card. Subjects were told that they would be contacted for followup information. At one, two and three months they estimated current smoking. Data deposits were refunded when the three month followup questionnaire was mailed to the subjects. Overview of S t a t i s t i c a l Procedure 1. A 1-way Anovar was used to test for i n i t i a l differences between conditions. 2. A 2-way Anovar was calculated at each time point (posttreatment, one month, two months and three months). The MS terms from these 28 calculations were used i n the planned orthogonal contrasts involving the four treatment conditions. A one way Anovar with a l l f i v e conditions was calculated at one month, two months and three months. The MS terms from these c a l -w culations were used i n the planned orthogonal contrasts involving a l l f i v e conditions. Planned orthogonal contrasts were carried out to test the main hypotheses at each time point. A repeated measures Anovar was performed to test for interaction between the behavioural and cognitive conditions. An analysis of proportions procedure (Marascuilo, 1966) was used to assess the differences between conditions on abstinence rates at each time point. A repeated measures Anovar was performed on subjects grouped by operant smoking rate. A correlation matrix was computed on a number of demographic, personality, motivational and treatment process variables. 29 RESULTS Analyses of variance were performed to test for pretreatment d i f -ferences i n smoking rates between conditions and o v e r a l l change i n smoking rates between the pretreatment, posttreatment and follow-up time points. Mean and standard deviations are reported i n Table 1. I n i t i a l differences i n smoking rates were not s i g n i f i c a n t for either a l l f i v e conditions compared on preestimated smoking rates, j?(4,60) = 0.13, p_ > .75, or the four treatment groups compared on operant smoking rates, _F(3,48) = 0.25, p_ > .75 (Appendix C). Subjects i n the four treatment conditions reduced the i r smoking rates over the course of treatment (Table 2). From a recorded average of 23.38 cigarettes per day (SD = 8.9) during the operant ( f i r s t ) week of the programme, subjects reduced the i r d a i l y smoking to a mean of 5.71 cigarettes per day (SD = 9.17) at posttreatment. Scheffe post hoc multiple comparisons on these differences were s i g n i f i c a n t , J£(4,46) = 6.67, p_ < .001. At three month follow-up subjects had increased their smoking rates to an average of 15.56 cigarettes per day (SD = 14.35). Scheffe comparisons found t h i s to be s t i l l s i g n i f i c a n t l y less than pre-treatment smoking rates, _F(4,46) = 6.47, p_ < .001. However, the increase i n smoking rates from posttreatment to three months was also s i g n i f i c a n t , F(4,46) = 3.76, £ < .01. Furthermore, 21 of 52 or 40.38% of the subjects remained t o t a l l y abstinent during the posttreatment week. Seventeen of 52 or 32.69% of the subjects were abstinent at the three month follow-up. Reduction i n smoking rates for a l l f i v e conditions, based on pre-30 T A B L E M E A N S r o R PHI-: A N P P P P T T R E A W P E R C E N T A G E O E P R E T R E A T M E N T S M O K I N G N T - C1 (JARKTTET, P K K PAY, H A T E AMI) P E R C E N T A G E AhSTJNKNT S M O K I N G R A T E S P K E - E S T I M A T E I ) O P E R A N T ( r i l E T R E A T ' t E N T R E C O R D E D ) POSTHKATHENT & FOLLOWUP C1GS/UAY 1 week 1 month .2 months 3 months % PRI-J-EST I MATED 1 month 2 months 3 months 1 v/eok 1 month 2 months 3 months I A B S T I N E N T 1 woek 1 month 2 months 3 months COGNITIVE IIIIIIAV 1 OUHAL OVEK.''^  :oi; I no TREATMENT OVERALL com 'KOI, CONTROL MEAN 28. 2 9 2 6. 83 2 9 . 00 2 9 . 1 4 29.69 20.61 ( 9 . 46) '( 6. 55) . (15. 24) (11. V0) ( 9.56) (10.55) 23. 50 22. 71 2-'.. 98 22. 09 . . . 23.20 ( 7. 48) ( 5. 71) (14. 36) ( .7. 20) ( 8.90) 1. 74 6. 13 9. 46 6. 14 5.71 ( 5. 29) ( 9. 67) (12. 57) ( 7. 55) ( 9.17) 3. 52 13. 39 16. 1 3 15. 26 25.12 14. 52 ( 7. 72) (10. 13) (19. 35) (12. 69) (12.'2 8 ) (14.32) 4 . 53 . 16. 75 19. 50 18 . 48 24.15 16.47 ( 8 . 8 8 ) (10. 23) (20. 20) (16. 35) (12.12) (15.23) 8 . 11 16. 55 20. 4 5 17. 93 24.75 17.38 (11. 04) (12. 43) (20. 68) (13. 35) (12.75) (14.94) 12. 86 .51. 92 43. 87 53. 08 8 3.67 48.44 (28. 04) (41. 45) (44 . 98) (41. 22) (28.84) (42.93) 16. 64 62. 70 51. 53 61. 05 80.21 53.86 (30. 51) (35. 93) (4G-. <6) (45. 02) (27.00) (42.44) 32. 45 60. 44 54. 65 62 . 93 83.01 58 . 39 (42. 92) (40. 22) (49 . 56) (49. 17) (31.58) (45.06) 7. .71 24 . 05 37 . 10 31 .2). 24. 46 (21 . 55) (35. .76) (51. .28) (40 .01) (38.64) 17 . 59 57 . 57 49 .46 65 .01 46.94 (38 . 98) (42 .94) (53 . 8 1 ) (51 .62) (49.45) 21 .75 72 .19 58 . 50 7 0 .11 57.04 (11 . 31) (35 .89) (52 .73) (63 .21) (53.38) 43 . 51 . 70 .37 62 . 53 75 . 8 8 62.01 (59 .92) (42 .03) (58 .04) (54 .64) (53.75) 57 : 14 2 5 .00 50 . 00 28 . 57 --- 40. 38 71 . 40 10 .66 41 . 66 21 .42 7.69 32.31 (30.46) 71 . 40 8 .33 41 . 66 21 .42 7.69 30. 7 6 ( 36 . 54 ) 50 . 00 IC .66 41 . 06 2) .42 7.69 27. 69 (32.69) IN liRACKT. IT.. •* MKAW AUST INENCE RATI;.'; KXC/.UDI.K'i MINI MAT, TMIVrMKHT COI.'TftQl, 31 Table 2 Repeated Measures Analysis of Variance on Operant, Posttreatment and Follow-up Smoking Rates Over Time — Four Treatment Conditions Source df SS MS F p Treatment Conditions (A) 3 3513.784 1171.26 2.367 >.05 Subjects (A) 47 32353.32 494.75 Time (T) 4 8087.18 2021.79 29.67 <.001 A x T 12 1324.97 110.41 1.62 >.05 Subjects (A x T). 188 12811.89 68.14 32 estimated smoking rates also proved s i g n i f i c a n t at three month follow-up on the Scheffe comparisons, F(3, 61) = 5.49, p < .001 (Table 3). Repeated measures analysis of variance based on percentage operant smoking rates are reported i n Appendix C. 3 Evaluation of the Experimental Treatment E f f e c t s Experimental treatment e f f e c t s were evaluated by comparing mean smoking rates per day for subjects i n each condition (Figure 1). E f f e c t s were also evaluated by comparing abstinence rates between groups (Fig-ure 2). Smoking data were a v a i l a b l e for posttreatment^ and one, two and three month follow-up periods. Thus a time factor was included i n the analysis of variance calculated to assess the e f f e c t s of i n t e r a c t i o n between the cognitive and behavioural modes of treatment. As can be seen i n Table 4, neither i n t e r a c t i o n over time nor between modes of treatment was s i g n i f i c a n t . The s i g n i f i c a n t time factor r e f l e c t s relapse and increasing smoking rates following c l i n i c termination. The mean d a i l y rates were 5.71, 14.52, 16.47 and 17.38 for the posttreatment, one two and three month follow-up periods, r e s p e c t i v e l y . Abstinence rates were compared on a multiple comparison procedure based upon a X 2 analog of Scheffe's multiple comparison procedures (Marascuilo, 1966; Hakstian et a l . , 1976). The r e s u l t s are reported i n Table 5 and d i s -cussed below i n the section which r e l a t e s to the hypothesis being tested. The Comprehensive Maintenance versus Simple Maintenance Results support the hypothesis that subjects who received the combined maintenance package would reduce smoking more than subjects who received a simple cognitive or simple behavioural package only 33 Table 3 Repeated Measures Analysis of Variance for Pretreatment, Posttreatment and Follow-up Estimated Smoking Rates Over Time - Five Conditions Source df SS MS F p Conditions (A) 4 6028.88 1507.22 2.86 <.05 Subjects (A) 60 31615.63 526.93 Time (T) 3 7599.23 2533.07 47.73 <.001 A x T 12 1832.80 152.73 2.88 <.001 Subjects (A x T) 180 9551.75 53.07 20 - P cd « rt •H O S m & •H cd n rt CD 15 10 0 -A Minimal Treatment Control "A Cognitive Behavioural Oversmoking Control • Combined J_ Posttreatment 1 Month 2 Months 3 Months Figure 1. Posttreatment and Follow-up Smoking Rates over Time: A l l Conditions 100 CO. CD - P cd K CD O rt CD rt •H - P CO < CD cd CD O r-t CD 90 80 701 60 50i 40 30 20 101 0 Combined B e h a v i o u r a l _ ^_ _ _ x O v e r s m o k i n S C o n t r o l Cognitive X-. ^ M i n i m a l Treatment Con t r o l Figure P o s t t r e a t m e n t 1 Month 2 Months 3 Months 2. Posttreatment and Follow-up Abstinence Rates over Time: A l l Conditions 36 Table 4 Analysis of Variance for Posttreatment and Follow-up Smoking Rates Over Time as Related to Cognitive and Behavioural Modes of Treatment Source df SS MS F £ Cognitive (A) 1 2366.67 2366.67 4.97 <.05 Behavioural (B) 1 674.66 674.66 1.42 <.10 A x B 1 1312.64 1312.64 2. 76 <.05 Subjects (A x B) 47. 22372.31 476.01 Time (T) 3 3091.52 1030.51 14.96 <.00 A x T 3 166.8 55.6 0.81 <.25 B x T 3 218.43 72.81 1.06 <.25 A x B x T 3 39.7 13.23 0.19 <.50 Subjects (A x B x T) 141 9714.47 68.9 37 Table 5 * Summary Table of Multiple Comparisons Between Conditions for Differences i n Mean Abstinence Rates Over Follow-ups Contrast (¥)*** 95 Confidence l e v e l for Q Significance Group 1 vs 2 and 3 Combined** 1 month 2 months 3 months ,007 ,11 ,4882 1.685 1. 73 1.3082 p < .05 £ < .05 n. s. Group 1, 2 and 3 Combined vs Group 4 1 month : 2 months 3 months .51 ,58 .73 1.85 1.74 1.65 n. s. n. s. n. s. Group 2 vs Group 3 1 month 2 months 3 months 75 79 75 ..25 .11 .25 n. s. n. s. n. s. Groups 1, 2, 3 and 4 Combined vs Group 5 1 month 2 months 3 months ,012 ,03 ,2 2.36 2.27 2.16 p < .05 n. s. n. s. Group 1 = Combined; Group 2 = Cognitive only; Group 3 = Behavioural only; Group 4 = Oversmoking Control; Group 5 = Minimal Control. Chi squared for Posttreatment was nonsignificant, therefore no multiple comparisons. The f i r s t 3 sets of contrasts were done as i f the experiment included only four groups, the fourth with f i v e groups. 38 (Figure 3). Posttreatment planned orthogonal contrast showed a nonsignificant difference between the two sets of subjects, JT(1,47) = 3.99, £ < .05. However, at a l l three follow-up points, one month, Fl,48) = 6.60, £ < .01, two months, F(l,48) = 7.73, £ < .10, and three months, J?(l,48) = 4.44, £ < .05, differences were s i g n i f i -cant. The combined group had a s i g n i f i c a n t l y greater number of sub-jects abstinent at the one and two month follow-ups than the other two maintenance conditions. Differences were not s i g n i f i c a n t at posttreatment and three month follow-up (see Table 5). Mean rates of abstinence at the posttreatment, one month, two month and three month follow-up were 57.14%, 71.4%, 71.4% and 50% for the combined conditions and 37.5%, 29.16%, 24.99% and 29.16% for the simple main-tenance conditions. Cognitive only versus Behavioural only Results were consistent with the hypothesis that there would be no difference i n smoking rates between subjects who received a cognitive only maintenance package and subjects who received a behavioural only maintenance package (Figure 1). Differences were nonsignificant at posttreatment F(l,47) = 0.82, £ > .25, one month, F(l,48) = 0.27, £ > .50, two months, JF(1,48) = 0.21, £ > .50, and three months, F(l,48) = 0.43, £ > .50. Differences i n rates of abstinence were also not s i g n i f i c a n t at a l l time points (see Table 5). For mean rates of abstinence see Table 1. 25h 20r 0| ! , L P o s t t r e a t m e n t 1 M o n t h 2 Months 3 Months 'vo F i g u r e 3. P o s t t r e a t m e n t a n d F o l l o w - u p S m o k i n g R a t e s o v e r T i m e : Combined v e r s u s C o g n i t i v e and B e h a v i o u r a l C o n d i t i o n s . 40 Maintenance versus No Maintenance The hypothesis that subjects i n the conditions which include a maintenance package would reduce smoking at follow-ups more than sub-jects who received only the oversmoking, the core treatment procedure, was not supported (Figure 4) . Differences on the planned orthogonal contrasts did not achieve significance at posttreatment, F(l,47) = 0.02, £ > .75, one month, F(l,48) = 1.09, £ > .25, two months, F(l,48) = 1.15, £ > 0.25, and three months, F(l,48) = 0.40, £ > .5 .. Differences i n abstinence rates were not s i g n i f i c a n t at any of the follow-up points. Mean abstinence rates at posttreatment, one month, two months and three months were 44.7%, 44.72%, 42.09%, 36.83% for the subjects i n the maintenance conditions and 28.57%, 21.42%, 21.42%, and 21.42% for the oversmoking control subjects. Treatment versus Minimal Treatment The hypotheses that subjects who were i n conditions which included a f u l l length treatment programme (the four treatment groups) would reduce smoking more than subjects i n a minimal treatment condition, was supported (Figure 5). The planned contrasts were s i g n i f i c a n t at one month, F( 1,60) = 10.68, £ < .005 '., two months, F(l,60) = 4.56, £ < . 05 , and three months, F(l,60) = 4.1, £ < .05 • Differences i n abstinence rates were s i g n i f i c a n t at one month follow-up but not at two and three month follow-ups (see Table 5). Mean rates of abstinence at one month, two months and three months follow-up were 38.4%, 36.52% and 32.68% for the subjects i n the treat-ment conditions and 7.69% at a l l times for the subjects i n the minimal treatment conditions. 25 OJ I I : 1 1 — — Posttreatment 1 Month 2 Months 3 Months Figure 4. Posttreatment and Follow-up Smoking Rates over Time:. Maintenance Conditions versus Oversmoking Control 25 Mi n i m a l Treatment C o n t r o l 20 15 Treatment Groups 10h 0 Figure 5. JL 1 Month 2 Months 3 Months Follow-up Smoking Rates over Time: Treatment versus Minimal Treatment 43 Relationship between Treatment Condition and Oversmoking Treatment  Process Variables In order to consider whether differences i n subjects' behaviour and experience i n r e l a t i o n to the core treatment procedures might offer an alternative explanation for differences i n outcome, analyses of variance between treatment condition and the following variables were carried out: t o t a l sessions attended; mean number of cigarettes per day smoked during treatment; the mean number of cigarettes per day smoked during s a t i a t i o n ; the number of cigarettes smoked during s a t i a t i o n as a percentage of operant smoking rate; the mean t o t a l of s a t i a t i o n reac-tions experienced; the mean sa i t a t i o n discomfort; t o t a l number of rapid smoking sessions; the mean number of t r i a l s per session; the mean number of cigarettes smoked per t r i a l ; the mean t o t a l rapid smoking reactions experienced and mean rapid smoking discomfort. Of these variables only the number of cigarettes smoked during treatment was s i g n i f i c a n t l y different' i n the treatment conditions (F(3,48) = 3.01, p_ < .05). Mean smoking rates during treatment for each condition were:combined 1.5 cigarettes (SD = 2.76); cognitive 5.8 cigarettes (SD = 9.6); behavioural 4.7 cigarettes (SD = 4.45) and oversmoking control 10.4 cigarettes (SD = 11.13). Analysis of variance for number of cigarettes smoked during treatment i s reported i n Appendix C. Means and standard deviations for variables descriptive of the course of treatment are reported i n Appendix D. 44 Operant Grouping and Treatment Outcome The National Interagency.Council on Smoking and Health Report (1974) has recommended that the c o l l e c t i o n of data should adhere to the categories used i n recent n a t i o n a l surveys on smoking habits. We have summarized our treatment sample operant smoking rates (Table 6). Table 7 reports the r e s u l t s of a repeated measures analysis of variance over time for subjects grouped according to operant smoking rates. Operant groupings based on d a i l y smoking rates were: 5-14.9 (n=6); (15-24.9 (n=26); 25-34.9 (n=15) and over 35 (n=5). Differences be-tween groupings were not s i g n i f i c a n t , j?(3,46) = 1.57, p_ > .10. Relationship between Individual Differences, Course of Treatment and  Treatment Outcome A large number of scores were a v a i l a b l e for each subject i n addition to the outcome date. These scores f e l l into four classes: A. Demographic, Personality and Motivational — including age, sex, personality questionnaires, how motivated subjects were to q u i t , etc. B. Smoking P r o f i l e — smoking behaviour before, during and a f t e r treatment, reasons for smoking C. Description of the course of treatment — number of conditioning t r i a l s , perceived t r i a l s everity, number of sessions attended, etc. Means and standard deviations f o r treatment d e s c r i p t i o n v a r i a b l e s can be found i n Appendix C. Table 6 Percent Reduction at Three Month Follow-up as a Function of Baseline Rate - Treatment Conditions Percent Reduction from Baseline Baseline Percent Baseline N 100% 75-99% 50-74% 15-49% 14% Rate at Termination 5 " 1 4 2 96 (li g h t , „ v 6 66.6 16.7 0 0 16.7 , \ (sd-6.67.)smoker) 15-24 - , (moderate , A ,7, A Q , 26 22.5 3.8 7.6 11.5 53.8 . >. (sd=42.08) smoker) ^ (sd=40899) 15 40 0 0 20 40 smoker) 35+ :ve: smoker) (very heavy ( s ^ 3 5 ) 5 2 0 ° ° 2 0 6 ° Total Percentages shown r e f l e c t the proportion of subjects i n each category -c-46 Table 7 Repeated Measures Analysis of Variance by Operant Grouping Over Time Source df SS MS F p Operant (A) 3 32649.7 10883.2 1.57 >,10 Subjects (A) 46 319584.8 6847.5 Time (T) 3 34546.2 11515.5 12.27 <.'001 A x T 9 7202.8 800.3 0.85 >-5,0, Subjects (A x T) 138 129493.0 938.4 47 D. P o s t t r e a t m e n t q u e s t i o n n a i r e —- a s s e s s i n g t h e p e r c e i v e d i m p a c t o f t r e a t m e n t ( Append i x A ) . These, f o u r c a t e g o r i e s o f s c o r e s were c o r r e l a t e d w i t h t r e a t m e n t outcome (Append i x C ) . The c o r r e l a t i o n s were l o o k e d a t on a p o s t hoc b a s i s f o r p o s s i b l e r e l a t i o n s h i p s t h a t m i g h t w a r r a n t f u r t h e r i n v e s t i -g a t i o n . B o t h p r e - e s t i m a t e d and o p e r a n t smok ing r a t e s were p o s i t i v e l y c o r -r e l a t e d w i t h smok ing r a t e s on f o l l o w - u p . The c o r r e l a t i o n s were +0.486 , d f = 63 , £ < .001 a t one month ; +0.600 , d f = 63 , £ < .001 a t two month s ; and +0.526 , elf = 63 , £ < .001 a t t h r e e months w i t h p r e - e s t i m a t e d smok ing r a t e s . The c o r r e l a t i o n s were +0.533 , df_ = 50 , £ < .001 a t one month ; +0.574 , d f = 50 , £ < .001 a t two months and +0.555 , d f = 5 0 , £ < .001 a t t h r e e months w i t h t h e o p e r a n t smok ing r a t e . T h i s s u g g e s t s t h a t h e a v i e r smokers b e f o r e t r e a t m e n t w i l l smoke more c i g a r e t t e s a f t e r t r e a t m e n t . The number o f c i g a r e t t e s smoked d u r i n g t r e a t m e n t i s t h e o n l y p r o c e s s v a r i a b l e w h i c h a p p e a r s t o p r e d i c t outcome. C o r r e l a t i o n s were s i g n i f i c a n t a t p o s t t r e a t m e n t ( r = 0 . 602 , d f = 49, £ < . 0 0 5 ) , one month (r_ = 0 .5142 , d f = 50 , £ .< . 0 0 1 ) , two months ( r = 0 .4557 , d f = 50, £ < . 0 0 1 ) , and t h r e e months ( r = 0 . 442 , d f = 50 , £ < .001) f o l l o w - u p . A number o f p o s t t r e a t m e n t e v a l u a t i o n v a r i a b l e s c o r r e l a t e w i t h outcome. The re was a n e g a t i v e c o r r e l a t i o n be tween t h e s u b j e c t s e v a l u a -t i o n o f d i s c u s s i o n o f p r o b l e m s and t h e number o f c i g a r e t t e s smoked. I n o t h e r w o r d s , t h e l e s s r e l a t i v e v a l u e t h e s u b j e c t p l a c e d on d i s c u s s i o n t h e b e t t e r h i s outcome. C o r r e l a t i o n s were s i g n i f i c a n t a t p o s t t r e a t m e n t ( r = -0.255, d f = 49 , £ < .05 ), one month ( r = - 0 . 248 , d f = 50 , £ <.05 ) 48 and two months (r = -0.2355, df_ = 50, p_ < . 05 ) but not at three months. There was also a negative correlation between the subjects evalu-ation of the importance of relaxation as a therapeutic procedure and outcome. In other words, the less r e l a t i v e importance the subject placed on relaxation the better was his outcome. Correlations were si g n i f i c a n t at two months (_r = -0.344 , df_ = 24, £ < .05 j and three months (r = -0.3504, df = 24, £ < .05). Subjects' end of treatment evaluation of the d i f f i c u l t y they had i n q u i t t i n g was p o s i t i v e l y correlated with the number of cigarettes they smoked at posttreatment (_r = 0.398 , df_ = 49, £ < .005), one month (r = 0.358 ;, df = 50, £ < .005), two months (r = 0.3352, df = 50, £ < '.,1)1,), and three months (r = 0.455 , df = 30, £ < .001). F i n a l l y , the confidence subjects f e l t about staying off was nega-t i v e l y correlated with the number of cigarettes smoked after treatment. That i s , the less confident a subject f e l t the more cigarettes he smoked. Results were s i g n i f i c a n t at posttreatment (_r = -0.506 , <lf = 48, £ < .001) one month (r = -0.505, df = 49, £ < .001), two months (r_ = -0.5205, df = 49, £ < .001). In summary, a few smoking p r o f i l e , process and evaluation variables correlated with outcome. The higher a subject's pretreatment smoking rate and the more he smoked during treatment the more he smoked at follow-up. In evaluating the c l i n i c those subjects who placed higher value on the discussion and relaxation components of treatment had worse outcomes at follow-up than those who did not. Those subjects who reported greater d i f f i c u l t y i n quitti n g and had less confidence i n staying off smoked higher rates at follow-up. 49 DISCUSSION The c l i n i c had a substantial impact upon the smoking behaviour of subjects i n the treatment conditions. Subjects reduced smoking s i g n i -f i c a n t l y by 75.5% from 23.3 cigarettes a day pretreatment to 5.71 ciga-rettes per day at treatment termination. However, by three months follow-up, subjects were smoking at a mean of 62.8% of th e i r pretreat-ment l e v e l or a mean of 17.2 cigarettes per day, a s i g n i f i c a n t increase i n smoking rates since treatment termination. Abstinence was 40.4% posttreatment and 27.7% at three months follow-up. This compared favourably with the average 13% abstinence on follow-up for a sample of representative studies reported by McFall and Hammen (1971). Furthermore by three months follow-up only 31.5% of subjects abstinent at posttreatment had relapsed, compared with the approximately 75% of i n i t i a l successes that ultimately relapsed reported by Hunt and Bespalec (1974). Compared with some of the more recent studies using oversmoking our abstinence rates are somewhat poorer. Lichtenstein and his c o l -leagues have reported around 60% abstinence at six months (Lichtenstein et a l . , 1973; Schmahl et a l . , 1972). These comparisons are complicated by procedural differences. Lichtenstein's re suits were obtained i n the laboratory whereas ours i s e s s e n t i a l l y a take home procedure. Lichtenstein continued sessions of rapid smoking u n t i l subjects had reached a c r i t e r i o n l e v e l of abstinence and reported that they f e l t able to control th e i r urges. We, on the other hand, used a fixed number of sessions. The three month follow-up abstinence rate of 50% of our combined treatment 50 group i s closer to the Oregon results. The results i n th i s study supported the f i r s t two hypotheses, that a more comprehensive maintenance package would be more effec-t i v e than simple packages and that there would be no difference be-tween the cognitive and behavioural packages. The superiority of the combined treatment i s possibly due to i t s greater comprehensiveness compared with each of the simple packages. The combined package offers (1) equivalent procedures both i n the behavioural and cognitive modes, e.g., a subject may choose to relieve his boredom either by doing something exciting or thinking about something exc i t i n g ; (2) complementary procedures i n either the behavioural or the cog-n i t i v e mode, e.g., a subject may play with worry beads to keep his hands occupied and he may use thought-stopping to control constant ruminations about smoking. The fact that there was no s i g n i f i c a n t difference on follow-up between the three maintenance conditions and the oversmoking control suggests that the results should be i n t e r -preted with caution. In addition as only one therapist saw a l l sub-jects the p o s s i b i l i t y of therapist bias cannot be excluded as an alternative explanation for the superior performance of the subjects who received the comprehensive maintenance package. The status of the oversmoking only condition i n th i s study i s ambiguous. To the extent that the subjects i n th i s condition are a control for the maintenance procedures i t i s equivalent to Bernstein's (1969) "attention-placebo" control group which experiences equivalent 51 therapist involvement. However, subjects are actively involved i n treatment and therefore i t i s also an experimental condition. The minimal treatment control group i s similar to Bernstein's (1969) "effo r t control" group who are asked to quit on the i r own. But our control condition took this one step further. The c l i n i c ' s programme was described to the c l i e n t s who were encouraged to imple-ment i t . I t was thus both an e f f o r t and an informational control. The success of the treatment groups compared with t h i s more powerful con-t r o l group i s encouraging i n the r e l a t i v e context of t h i s experiment as a whole. As mentioned before and also apparent from the results of t h i s study, the problem of recidivism had not been solved, despite the recent improved trend. One reason for relapse may be that quitters do not continue to practise their s k i l l s of nonsmoking so that the new behaviours may become an established part of the response reper-t o i r e , powerful enough to consistently compete with the engrained smoking responses. They forget how to not smoke. I t i s l i k e l y that some c l i e n t s may relapse because they never adhere to the treatment regimen and therefore never acquire the s k i l l s of nonsmoking. I t i s apparent that o v e r a l l some treatment strategies are superior to others. However, a subgroup of individuals may be better suited to a different treatment. The clue to t h i s difference may be found i n the subjects' compliance with the treatment regimen (Best and Bloch, 1977). A second reason for recidivism may be due to the fact that relapse i s determined;?by a variety of factors. The scope o f - t h i s study had not per-mitted the examination of the wide variety of indi v i d u a l variables 52 which c l i e n t s bring with them to treatment. However, research findings on the relationship between demographic, personality and motivational variables and treatment outcome has been equivocal. Studies have found that some demographic variables do predict outcome (e.g., Delarue, 1973; Curtis, Simpson and Cole, 1976; Raw, 1976). But these relationships have often not been found and where they have the effect i s t y p i c a l l y small. Similarly s p e c i f i c t r a i t s have not been shown to consistently contribute to accurate prediction of outcome i n smoking research (Best, 1975; Best and Steffy, 1971; Lichtenstein et a l . , 1973; Marston and McFall, 1971). And again, while a number of studies have found that prediction i s enhanced by measuring two variables s p e c i f i c to the smoking habit, motivation to change or expectation of success (e.g., Best, Bloch and Owen, 1977. McFall and Hammen, 1971; Schlegel and Kunetsky, 1976) and pretreatment smoking rate (Best, Bloch and Owen, 1977; Delarue, 1973), a far larger number of studies have f a i l e d to find these relationships. A number of researchers have investigated the interaction between c l i e n t and treatment variables. Clients have benefited from assignment to treatment on the basis of both personality and motivational variables (Best, 1975; Best and Steffy, 1971). Client variables such as " l e v e l of commitment" (Hildebrandt and Feldman, 1976), a t t r i b u t i o n of response control (Conway, 1974) and l e v e l of anxiety (Pechacek, 1976) have been sug-gested to interact with treatment. Again the findings are not con-siste n t , nor are the effects large. This i s consistent with the broader l i t e r a t u r e on indi v i d u a l differences which finds weak rela-:. tionships between general t r a i t measures and response to s p e c i f i c 53 circumstances (Bowers, 1973; Mischel, 1968). So while on the one hand we recognize that smoking i s determined by a variety of factors, on the other hand the s p e c i f i c c o n t r o l l i n g variables appear to elude us. This brings us back at least part way to where we started from — to a consideration of variables i n the person's current smoking pattern. We need to investigate more thoroughly variables such as degree of addiction, depth of inhalation, situations i n which smoking occurs and the individual's reasons for smoking. We need to explore c l i e n t variables, pertinent to the current smoking habit, and the ways i n which they interact with treatment. A t h i r d contributing cause to recidivism may be found by ex-ploring more caref u l l y the processes of maintenance and change at their interface. There i s generally a dearth of process directed research i n the area of smoking and as a result there i s l i t t l e upon which to base speculation at t h i s stage. I t i s possible that main-tenance procedures f a i l when they are combined with an inadequate change procedure. Relapse may occur because the s k i l l s of nonsmoking do not have s u f f i c i e n t opportunity to establish themselves. One problem i n exploring t h i s question i s the conceptual d i f f i c u l t y of separating change from maintenance. Change could be operationalized as the absolute l e v e l of change which occurs between pre and post-treatment. The change which i s measured should relate not only to change i n rate of smoking but also to other relevant variables such as urge in t e n s i t y , v a r i a b i l i t y of urge and frequency of urge. Given knowledge of these variables we may f i n d a direct relationship be-tween change and the efficacy of maintenance — maintenance opera-54 t i o n a l i z e d as the slope of the relapse curve and relapse not only with respect to smoking rate but also to the parameters of the urge to smoke. We are suggesting that at l e a s t part of the mystery of relapse may be unravelled by more c a r e f u l consideration of what we mean by change and maintenance; by examination of the process variables which are involved i n each and by examining the i n t e r a c t i o n at the in t e r f a c e between q u i t t i n g smoking and learning the s k i l l s of nonsmoking. A fourth reason f o r re c i d i v i s m may be that we have neglected some good maintenance procedures i n favour of a self-management o r i e n t a -t i o n . Both contingency management procedures such as the deposit system employed by E l l i o t and Tighe (1968) and prolonged c l i n i c contact (Pomerlau and Ciccone, 1974) have been associated with e f f e c t i v e pro-grammes. However, self-management has a number of i n t r i n s i c advan-tages over approaches which r e l y on continued c l i n i c involvement. Once acquired nonsmoking s k i l l s are u n i v e r s a l l y a v a i l a b l e to the c l i e n t ; the c l i e n t i s more l i k e l y to a t t r i b u t e success to himself; and the superior cost effectiveness of self-management enhances i t s accep-t a b i l i t y f o r del i v e r y within a health system. In conclusion, the main contribution of t h i s study l i e s i n the fin d i n g that a comprehensive treatment package t a i l o r e d to the i n d i -vidual's reasons f o r smoking i s more e f f e c t i v e than le s s complex t r e a t -ment strategies. The value of incorporating cognitive procedures into treatment has been demonstrated. The r e s u l t s support the enthusiasm of c e r t a i n researchers about the p o t e n t i a l role of cognitive procedures i n the maintenance of nonsmoking (Berecz, 1974; Danaher, 1976). How-ever, our r e s u l t s suggest that cognitive techniques are e f f e c t i v e only 55 when added to a behavioural programme rather than on thei r own. I t i s apparent, however, that more research needs to be directed toward the maintenance of nonsmoking behaviour. Furthermore, researchers must begin to consider the nature of the complex processes and i n t e r -actions which occur when an indiv i d u a l stops smoking and learns to become a nonsmoker. 56 FOOTNOTES One subject who had completed treatment was dropped for purposes of data analysis. This subject had been very sporadic i n c l i n i c attendance and was unreliable i n recording information. Six sub-jects dropped out after having completed 1-3 sessions. Three of these expressed discouragement with their progress; one was trans-ferred to a different c i t y ; one was preparing for examinations and decided that i t was the wrong time to quit; one expressed d i s -s a t i s f a c t i o n with the structure of the programme. Three subjects decided not to j o i n the programme for idiosyncratic reasons: one was i d e a l o g i c a l l y opposed to oversmoking; one did not believe that the oversmoking would help and a t h i r d preferred not to j o i n the minimal treatment control condition. This assignment r e s t r i c t i o n occurred an average of twice per condi-tion. The range of occurrence across groups was one to three. These tables are included because the results of smoking studies have often been reported as a percentage of operant smoking rates rather than as cigarettes per day. No posttreatment data were collected for the minimal treatment control as there was no appropriate treatment termination time point for subjects i n t h i s condition. 57 R E F E R E N C E S A n d r e w s , D . A . A v e r s i v e t r e a t m e n t p r o c e d u r e s i n t h e m o d i f i c a t i o n o f s m o k i n g . - ( U n p u b l i s h e d d o c t o r a l d i s s e r t a t i o n , Q u e e n s U n i v e r s i t y , C a n a d a , 1970). A z r i n , H . H . , a n d P o w e l l , J . B e h a v i o r a l e n g i n e e r i n g : T h e r e d u c t i o n o f s m o k i n g b e h a v i o r b y a c o n d i t i o n i n g a p p a r a t u s a n d p r o c e d u r e . J o u r n a l  o f A p p l i e d B e h a v i o r A n a l y s i s , 1968, 1_,- 193-200. B a n d u r a , A . P r i n c i p l e s o f b e h a v i o r m o d i f i c a t i o n . New Y o r k : H o l t , R i n e h a r t & W i n s t o n , 1969. B e r e c z , J . M . 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World Health Organization. Smoking and i t s effects on health. (Tech-n i c a l Report Series 568). Geneva: WHO, 1975. 67 APPENDIX A Preliminary and Posttreatment Questionnaires, Rating Scales and Consent Forms 68 A - l Background Information Questionnaire INFORMATION SHEET 69 Date: 1. Name ( p r i n t ) 2, Address 3. Do you expect to be at the above address f o r the next twelve months? 4. Phone; Home Bus ines s 5. Ages 6. Sex; 7. M a r i t a l S t a t u s ; 8. How much e d u c a t i o n have you had? ( c i r c l e maximum l e v e l of s c h o o l i n g ) Elementary ] L 2 3 4 High School 1 L 2 3 4 Trade School ] L 2 3 4 Bus ines s Schoo l L 2+ U n i v e r s i t y L 2 3 4 Graduate School L 2 3+ 9. What i s your o c c u p a t i o n ? 10. How many c i g a r e t t e s do you smoke d a i l y ? 11. How long have you smoked? 12. What o ther k i n d s of tobacco do you use , i f any? 13. What p r o p o r t i o n of p u f f s per c i g a r e t t e do you u s u a l l y i n h a l e ? ( c i r c l e answer) 1 2 3 4 5 H a r d l y any Some About H a l f Most Almost A l l 14. How deep ly do you i n h a l e ? ( c i r c l e answer) 1 2 3 4 5 Very L i t t l e Some M o d e r a t e l y A l o t Very Deeply 15. About how many t imes have you made a f a i r l y s e r i o u s attempt to q u i t smoking e n t i r e l y ? 70 2 -~ 1 6 . H a v e y o u a n y m e d i c a l p r o b l e m s , p a r t i c u l a r l y h e a r t o r r e s p i r a t o r y p r o b l e m s ; w h i c h may be a g g r a v a t e d b y s m o k i n g ? P l e a s e S p e c i f y . H a v e y o u a n y o t h e r n o t e a b l e m e d i c a l p r o b l e m s ? P l e a s e S p e c i f y . 71 A-2 Awareness Engendering Questionnaire 72 Name: Date: SMOKING MOTIVATION QUESTIONNAIRE People smoke for a variety of reasons. Moreover, a person smokes some cigarettes for one reason and other cigarettes for a different reason. Below you w i l l find descriptions of possible reasons for smoking. Consider them as they apply to your smoking. 1. Sometimes the cigarette acts as a stimulant, that i s to make you more alert and attentive when you are performing a task such as driving a car or studying. In this same class you may smoke because you are bored or have nothing better to do. 2. Another reason why one may smoke is because the cigarette acts as a relaxant. You may be anxious or tense or upset and a cigarette would thus act to calm you down; i t would help you get control of the situation and yourself. 3. Another reason why people may smoke i s because they crave a cigarette. You may smoke a cigarette because you deeply want one. You may feel that your mouth i s dry, you can't concentrate, you feel you need nicotine. You are aware of the fact that you are not smoking and you l ight up a cigarette to remove the discomfort of not smoking. 4 . Another reason why people smoke i s because i t is the social ly desirable thing to do. You light-up a cigarette because others are smoking, or someone has offered you a cigarette and you do not wish to refuse. For example, you may be at a party or with someone else and the "suave'" thing to do is smoke. 5. Another reason why you may l ight up a cigarette is because of affect or mood state you are i n . You may l ight up a cigarette to cheer yourself up, or because you're melancholy, or aggravated. 6. Another reason why you may smoke is because of habit. You light-up a cigarette for no particular reason other than the fact you usually smoke a cigarette in this situation. For example, a cigarette may usually accompany a coffee break, or arriving at work, or with a drink. Be sure when you use this reason that the other reasons are not applicable. 73 - 2 -7. Another reason why people may smoke Is for the purpose of self-rewards. Sometimes you give yourself a c i g a r e t t e because of a job we l l done. You deserve some small treat f o r an accomplishment, so you take a c i g a r e t t e or a c i g a r e t t e "break". 8. F i n a l l y you may decide that the reason you smoke i s f o r some other reason than what we have covered. For e x a m p l e , you light-up a c i g a r e t t e because you don't w a n t t o eat, or because you have to do something with your hands, etc. Beside each of these reasons, as summarized below, place an estimate of the number of ci g a r e t t e s you smoke each day for that reason. Place an estimate (zero i s permissible) beside each of the reasons so that when the ci g a r e t t e s per reason are added up, the sum i s equal to your estimate of the average t o t a l , number of cigare t t e s smoked d a l l y . I f you do use the "other'' category, specify the reasons you have i n mind. Estimate the average t o t a l number of ci g a r e t t e s smoked d a i l y . Relaxant Stimulant Affect H a b i t Craving Reward D e s i r a b i l i t y Other SMOKING OCCASIONS QUESTIONNAIRE 74 P e o p l e smoke f o r a v a r i e t y of reasons i n many d i f f e r e n t s i t u a t i o n s . One way of d e s c r i b i n g your smoking p a t t e r n i s to l o o k at how s t r o n g your urge to smoke i s i n each c i r c u m s t a n c e . C o n s i d e r each of the f o l l o w i n g s i t u a t i o n s and r a t e the u s u a l s t r e n g t h of your urge to smoke i n t h a t s i t u a t i o n . Think of how s t r o n g your urge i s on the average when you smoke and use t h a t average urge as the b a s i s f o r your r a t i n g s . C i r c l e the s t r e n g t h which most c l o s e l y d e s c r i b e s your .wivgaaaissaa&i. s i t u a t i o n . 1. When you are f e e l i n g i r r i t a t e d 2. no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 more than v e r y average average s t r o n g 0 1 2 When you want to a v o i d d o i n g something or want to put something o f f f o r a w h i l e . no v e r y l e s s than more than v e r y c r a v i n g s l i g h t average average average s t r o n g - 3 - 2 -1 0 1 2 When you want to s i t back and enjoy a c i g a r e t t e . no v e r y l e s s than c r a v i n g s l i g h t average more than v e r y average average s t r o n g -3 -2 -1 0 When you want t o t a s t e a c i g a r e t t e , no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 When you f e e l a n x i o u s . no v e r y l e s s than c r a v i n g s l i g h t average average 1 more than v e r y average s t r o n g 1 more than v e r y average average s t r o n g s e v e r e 3 sev e r e 3 severe 3 severe 3 -3 -2 -1 se v e r e 3 6. When you f e e l r e a l l y happy. no v e r y l e s s than c r a v i n g s l i g h t average average more than average v e r y s t r o n g s e v e r e - 2 -75 When you h a v e a d r y m o u t h . 9. no v e r y l e s s t h a n more t h a n v e r y c r a v i n g s l i g h t a v e r a g e a v e r a g e a v e r a g e s t r o n g s e v e r e - 3 - 2 - 1 0 1 2 3 When you want s o m e t h i n g , t o do w i t h y o u r h a n d s . no v e r y l e s s t h a n more t h a n v e r y c r a v i n g s l i g h t a v e r a g e a v e r a g e a v e r a g e s t r o n g s e v e r e - 3 - 2 - 1 0 1 2 3 When you s i m p l y become aware o f t h e f a c t t h a t you a r e n o t s m o k i n g . no v e r y l e s s t h a n more t h a n v e r y c r a v i n g s l i g h t a v e r a g e a v e r a g e a v e r a g e s t r o n g s e v e r e - 3 - 2 - 1 0 1 1 0 . When you want t o r e w a r d y o u r s e l f f o r s o m e t h i n g y o u ' v e done o r t e l l y o u r s e l f t h a t you c a n h a v e a c i g a r e t t e i f you c o m p l e t e some t a s k . no v e r y l e s s t h a n more t h a n v e r y c r a v i n g s l i g h t a v e r a g e a v e r a g e a v e r a g e s t r o n g s e v e r e - 3 - 1 0 11 12 13 When y o u f i n d a c i g a r e t t e i n y o u r mouth and d o n ' t remember h a v i n g l i t i t . no v e r y l e s s t h a n c r a v i n g s l i g h t a v e r a g e - 3 - 2 - 1 When you a r e r e s t i n g . no v e r y l e s s t h a n c r a v i n g s l i g h t a v e r a g e - 3 - 1 When you f e e l d e p r e s s e d . no v e r y l e s s t h a n c r a v i n g s l i g h t a v e r a g e more t h a n v e r y a v e r a g e a v e r a g e a v e r a g e a v e r a g e a v e r a g e a v e r a g e s t r o n g s e v e r e more t h a n v e r y s t r o n g s e v e r e more t h a n v e r y s t r o n g s e v e r e - 3 1 76 14. 15. 18, 19. 20. - 3 -When you want to f e e l smoke i n your l u n g s . no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 - 1 When you want to cheer up. no v e r y l e s s than c r a v i n g s l i g h t average more than v e r y average average 0 1 s t r o n g s e v e re 2 3 more than v e r y average average -3 -2 •1 0 s t r o n g s e v e re 2 3 16. When you ta k e a break from work or some o t h e r a c t i v i t y . no v e r y l e s s than more than v e r y c r a v i n g s l i g h t average average average s t r o n g s e v e r e -3 - 2 - 1 0 1 2 3 17. When you want to f e e l more mature and s o p h i s t i c a t e d . no v e r y l e s s than more than v e r y c r a v i n g s l i g h t average average average s t r o n g severe -3 -2 -1 1 When you l i g h t up a c i g a r e t t e t o go al o n g w i t h some a c t i v i t y you are d o i n g ( f o r example, w h i l e f i x i n g a b i c y c l e , w r i t i n g a l e t t e r , d o i n g housework). no v e r y l e s s than more than v e r y c r a v i n g s l i g h t average average average s t r o n g s e v e r e -3 1 When you r e a l i z e you are l i g h t i n g a c i g a r e t t e even though you j u s t put one out. no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 When you f e e l t e n s e . no v e r y l e s s than c r a v i n g s l i g h t average more than v e r y average average 0 1 s t r o n g s e v e re more than v e r y -3 -2 -1 average average 0 1 s t r o n g s e v e re 77 - 4 -When you f e e l embarrassed. no v e r y l e s s than more than v e r y c r a v i n g s l i g h t average average average s t r o n g - 3 - 2 - 1 0 1 2 When you r e a l i z e t h a t you won't be a b l e to smoke f o r a no c r a v i n g -3 When you no c r a v i n g v e r y l e s s than s l i g h t average -2 -1 are w o r r i e d . more than v e r y average average s t r o n g v e r y s l i g h t -2 l e s s than average -1 more than v e r y average average s t r o n g 0 1 2 -3 When you are w a i t i n g f o r someone or something no c r a v i n g -3 When you no c r a v i n g v e r y l e s s than s l i g h t average -2 -1 f e e l n e r v o u s . v e r y l e s s than s l i g h t average more than v e r y average average s t r o n g -2 -1 more than v e r y average average s t r o n g 0 1 2 - 3 When you want to i n c r e a s e your s e l f - c o n f i d e n c e , no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 When you f e e l i m p a t i e n t . no v e r y l e s s than c r a v i n g s l i g h t average more than v e r y average average s t r o n g 0 1 2 more than v e r y average average s t r o n g s e v e r e 3 w h i l e . s e v e r e 3 severe 3 s e v e r s 3 severe 3 severe 3 severe 78 -5~ When you are i n a s i t u a t i o n i n which you n o r m a l l y smoke ( f o r example you may smoke b e f o r e you go to bed, or when you are g e t t i n g ready to go o u t ) . no v e r y l e s s than c r a v i n g s l i g h t average average -3 -2 -1 0 When you want to keep y o u r s e l f busy. more than average v e r y s t r o n g no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 When you f e e l bored. no v e r y l e s s than c r a v i n g s l i g h t average average 0 more than average v e r y s t r o n g -3 -2 -1 average 0 more than average v e r y s t r o n g When you are d r i n k i n g c o f f e e or t e a , no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 average 0 more than average v e r y s t r o n g When you r e a l i z e you have run out of c i g a r e t t e s , no v e r y l e s s than c r a v i n g s l i g h t average more than average v e r y s t r o n g average - 3 - 2 - 1 0 1 2 When you want to have time t o t h i n k i n a c o n v e r s a t i o n . no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 When you f e e l u n c o m f o r t a b l e . more than average average 0 1 v e r y s t r o n g no c r a v i n g v e r y s l i g h t l e s s than average average more than average v e r y s t r o n g s e v e r e 3 severe 3 sev e r e 3 severe 3 severe 3 severe 3 sev e r e 79 35, 36. 37. 38, 39, 40, 41 - 6 -When you are angry w i t h y o u r s e l f . no c r a v i n g -3 When you no c r a v i n g -3 When you no c r a v i n g -3 When you no c r a v i n g -3 When you no c r a v i n g -3 When you no c r a v i n g -3 When you no c r a v i n g -3 v e r y l e s s than more than s l i g h t average average average -2 -1 0 f e e l you need more energy. 1 v e r y l e s s than s l i g h t average more than average average - 2 - 1 0 1 want to f l i c k c i g a r e t t e ashes. v e r y l e s s than s l i g h t average -2 -1 are f e e l i n g hungry. v e r y l e s s than s l i g h t average more than average average 0 1 more than average average - 2 - 1 0 1 want to keep from s l o w i n g down. v e r y l e s s than more than s l i g h t average average average -2 -1 want to c o n c e n t r a t e . 0 1 v e r y s t r o n g v e r y s t r o n g v e r y s t r o n g v e r y s t r o n g v e r y s t r o n g v e r y l e s s than more than s l i g h t average average average - 2 - 1 0 1 want t o f i l l a pause i n a c o n v e r s a t i o n , v e r y s t r o n g v e r y l e s 6 than s l i g h t average -2 -1 more than average average v e r y s t r o n g s e v e r e i severe 3 severe 3 sev e r e 3 severe 3 severe 3 0 1 severe 3 80 - 7 -42. When you are annoyed w i t h nonsmokers and smoke j u s t t o s p i t e them. no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 When you want t o r e l a x . no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 When you want to keep s l i m . l e s s than more than average average 0 1 more than average average no v e r y c r a v i n g s l i g h t average -3 -2 -1 0 When you are t r y i n g t o pass time 1 more than average average 1 no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 When you f e e l angry. no v e r y l e s s than c r a v i n g s l i g h t average more than average average 0 1 more than average average -3 -2 -1 When you want something i n your mouth. no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 When you f e e l annoyed. no v e r y l e s s than c r a v i n g s l i g h t average more than average average 0 1 more than average average v e r y s t r o n g 2 v e r y s t r o n g v e r y s t r o n g v e r y s t r o n g v e r y s t r o n g v e r y s t r o n g v e r y s t r o n g s e v e r e 3 sev e r e 3 sev e r e 3 sev e r e 3 severe 3 sev e r e 3 -3 -2 -1 s e v e r e 3 81 - 8 -When you want t o f e e l more a t t r a c t i v e . no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 wi When you f e e l t i r e d . no v e r y l e s s than c r a v i n g s l i g h t average more than average average v e r y s t r o n g -3 -2 -1 more than average average 0 1 v e r y s t r o n g When you are d r i n k i n g an a l c o h o l i c beverage. no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 When you f e e l f r u s t r a t e d no v e r y l e s s than c r a v i n g s l i g h t average more than average average 0 1 more than average average v e r y s t r o n g v e r y s t r o n g -3 -2 -1 When you want t o s m e l l a c i g a r e t t e b u r n i n g . no v e r y l e s s than c r a v i n g s l i g h t average more than average average v e r y s t r o n g -3 -2 -1 0 When someone o f f e r s you a c i g a r e t t e . no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 When you f e e l r e s t l e s s . no v e r y l e s s than c r a v i n g s l i g h t average more than average average 0 1 more than average average v e r y s t r o n g v e r y s t r o n g s e v e r e 3 severe 3 s e v e r e 3 s e v e r e 3 s e v e r e 3 s e v e r e 3 -3 -2 -1 s e v e r e 3 82 9 -56. 57 58. 59. 60, 61. 62. When you have f i n i s h e d a meal or snack. no v e r y l e s s than c r a v i n g s l i g h t average average -3 -2 -1 0 When you f e e l u p s e t . no v e r y l e s s than c r a v i n g s l i g h t average average -3 -2 -1 0 When you see o t h e r s smoking. no v e r y l e s s than c r a v i n g s l i g h t average average -3 -2 -1 0 When you a r e o v e r l y e x c i t e d . more than average 1 more than average v e r y s t r o n g s e v e r e 3 v e r y s t r o n g s e v e r e 3 no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 average 0 more than average 1 more than average v e r y s t r o n g s e v e r e 3 v e r y s t r o n g 1 s e v e r e 3 When you are i n a s i t u a t i o n i n which you f e e l smoking i s a p a r t of your S e l f image. no v e r y l e s s than c r a v i n g s l i g h t average average -3 -2 -1 0 When you want to a v o i d e a t i n g sweets. no v e r y l e s s than c r a v i n g s l i g h t average average -3 -2 -1 0 When you f e e l o v e r s e n s i t i v e . more than average 1 more than average v e r y s t r o n g s e v e r e 3 v e r y s t r o n g 1 s e v e r e 3 no v e r y l e s s than c r a v i n g s l i g h t average -3 -2 -1 average 0 more than average v e r y s t r o n g s e v e r e 3 83 - 10 -63. When you want to watch a c i g a r e t t e b u r n i n g . no v e r y l e s s than more than v e r y c r a v i n g s l i g h t average average average s t r o n g severe - 3 - 2 - 1 0 1 2 3 84 ITEMS ON THE IMAGERY SCALE* Instructions: I am going to present you with a number of scenes one at a time. After I've presented a scene to you I'd l i k e you to spend about 20 seconds trying to imagine i t as c l e a r l y as you can and then to give a rating of how v i v i d l y and c l e a r l y you were able to imagine that item. Here goes: 1. Think of seeing the sun sinking below the horizon and consider ca r e f u l l y the image which comes to the mind's eye (vis u a l ) . 2. Think of a group of people drinking at a pub and consider the image which i t brings ( s o c i a l ) . 3. Think of hearing the sound of escaping steam and consider care-f u l l y the image which comes to the mind's ear (auditory). 4. Think of your f r u s t r a t i o n as you struggle to thread cotton through the eye of a meedle and consider the image which comes to mind (frustration). 5. Think of feeling the prick of a pin and consider c a r e f u l l y the image which comes to mind ( t a c t i l e ) . 6. Think of yourself relaxing after dinner i n an easy chair with a coffee i n your hand and consider the image i t evokes (relaxation). 7. Think of your movements as you run upstairs and consider the image which i t evokes (kinaesthetic). 8. Think of your feelings as you come out of your boss's o f f i c e after he has informed you of a promotion and consider c a r e f u l l y the image i t evokes (elation). 9. Think of the taste of an orange and consider car e f u l l y the image i t brings to mind (gustatory/taste). 10. Think of yourself as you wait on a street corner for someone who i s already 15 minutes late and consider c a r e f u l l y the image that comes to mind (anger). 11. Think of the smell of cooking cabbage and consider c a r e f u l l y the image which comes to the mind's nose (olfactory/smell) 12. Think of yourself trying to s i t down and study or read from a r e a l l y boring book and consider the image i t evokes (concentra-tion) . Subjects rated the vividness after each image on a 5 point scale. 85 13. Think of feeling drowsy and consider the image i t evokes (orgasmic). 14. Think of yourself waiting up at 2 AM for your c h i l d who i s 2 hours late and consider the image i t evokes (anxiety). 86 A-3 Personality Measures HEALTH ATTITUDE SCALE The f o l l o w i n g q u e s t i o n s a r e a b o u t y o u r a t t i t u d e s t o h e a l t h . Answer e a c h q u e s t i o n by p u t t i n g an- "X" i n t h e r a t i n g box w h i c h b e s t e x p r e s s e s y o u r r e a c t i o n s t o t h e q u e s t i o n s -] > >• QJ ' r H r H • C Qi Oil 5- •IJ C c t « c CO U) i & ..—I co p. c Cii CU CS • H n 0) •CD 0; • H h Qi Qi >: Qi U GJ r H cd •0) Qi u rJ c Qi Qi o .U TD < !-J O 4- ' < 21 CO I f I t a k e c a r e o f m y s e l f . I can a v o i d i l l n e s s . Whenever I g e t s i c k i t i s b e c a u s e of s o m e t h i n g I ' v e done or n o t done. 3. Good h e a l t h i s l a r g e l y a m a t t e r of good f o r t u n e . 4 . No m a t t e r what I d o , i f I am g o i n g t o g e t s i c k I w i l l g e t s i c k . 5 . Mo s t p eop1 ex t e n t t o , con t r o l l e d e dc n o t r e a l i z e t h e w h i c h t h e i r i l l n e s s e s a r e ,by_ ^ . . a c c i d e n t a l h a p n e n i n g s 6. I c a n o n l y me t o do. do what my d o c t o r t e l l s 7. T h e r e a r e a r o u n d t h a :—^.^or—v.h_an y_o. so many s t r a n g e d i s e a s e s t you can n e v e r know how u-'-m.ig.ht . p i c k one .up, 8. When I f e e b e c a u s e I —- .- ..t.h.e_ p.r.o.per 1 i l l , I know i t i s have n o t been g e t t i n g . e x e r c i s e or e a t i n g . r i g h t 9 . P e o p l e who D l a i n l u c k 1 n e v e r g e t s i c k a r e i u s t oo 1 0 . P e o p l e ' s i t h e i r own 11 h e a l t h r e s u l t s f r o m c a r e l e s s n e s s . II. I am d i r e c t l y r e s p o n s i b l e f o r rn.y h e a l t h . "88 SM PERSONAL REACTION INVENTORY The statements below concern your personal reactions to a number of -different situations. No two statements are exactly a l i k e , so consider each statement c a r e f u l l y before answering. I t i s important that you answer each question as frankly and as honestly as you can. Answer a l l questions by indicating true or false on the attached answer sheet. 1. I fi n d i t hard to imitate the behaviour of other people. 2. My behaviour i s usually an expression of my true inner feelings, attitudes and b e l i e f s . 3. At parties and s o c i a l gatherings, I. do not attempt to do or say things that others w i l l l i k e . A. I can only argue for Ideas which I already believe. 5. I can make impromptu speeches even on topics about which I have almost no Information. 6. I. (mess I put on a show to Impress or entertain people. 7. When I am uncertain how to act i n a s o c i a l s i t u a t i o n , I look to the behavior of others for cues. 8. I would probably make a good actor. 10. 12. 14, I rarely need the advice of my friends to choose movies, books, or music. I sometimes appear to others to be experiencing deeper emotions than I actually am. 11. I laugh more when I watch a comedy with others than when alone. In a group of people I am rarely the centre of attention. 13. In different situations and with different peoole, I often act l i k e very different persons. I am not p a r t i c u l a r l y good at making other people l i k e me. 15. Even i f I am not enjoying myself, I often pretend to be having a pood time. 16. I'm not always the person I appear to be. 89 Page 2 17. I would not change ray opinions (or the way I do things) i n order to please someone else or win t h e i r favour. 18. I have considered being an entertainer. 19. In order to get along and be l i k e d , I tend to be what people expect tne to be rather than anything else. 20. I have never been good at games l i k e charades or improvisational actinp. 21. I have trouble changing my behaviour to s u i t different people and different situations. 22. At a party I l e t others keep the jokes and stories going. 23. I f e e l a b i t awkward l n company and do not show up quite so wel l as I should. 24. I can look anyone i n the eye and t e l l a l i e with a straight face ( i f for a righ t end). 25. I way deceive people by being f r i e n d l y when I r e a l l y d i s l i k e them. 90 ANSWER SHEET PERSONAL REACTION INVENTORY Name : (Please print) Bate: 2 ' True F a l g e - True ^ *• ~ - m s e 2 2 * ^ ^ ' ~ ^ False 2 3 ' ^ 5 ' True True -** True -True -. False — ~ F a l s e 7' True True v . — ~ _ False • F a l s e 8* True - True _ False 1 0- — True n F a i s e T ™ e 12 F A L S E False — False Tru " ~~ — - False 5" T ™ *alse __ False , TrUe *ta 1 S- True — False True _ . False 91 A - 4 M o t i v a t i o n T h e r m o m e t e r s 92 Name: Date: MOTIVATION THERMOMETER We need an i d e a of j u s t how s t r o n g l y you'd l i k e t o g i v e up smoking. Would you p l e a s e i n d i c a t e on the " m o t i v a t i o n thermometer" below how strorvg you f e e l your m o t i v a t i o n t o q u i t i s . Mark the thermometer w i t h a l i n e at the l e v e l which your m o t i v a t i o n r e a c h e s . Make sure you r a t e your c u r r e n t m o t i v a t i o n to q u i t . 10 An e x t r e m e l y s t r o n g d e s i r e t o q u i t 9 8 7 6 5 4 3 2 1 0 No d e s i r e t o q u i t at a l l . ' P e r f e c t l y happy w i t h smoking. 93 Name: . Date: DESIRE THERMOMETER In a s i m i l a r way, we'd l i k e to know how much you l i k e t he i d e a of smoking. How s t r o n g i s your d e s i r e to smoke i n terms of t h i n g s you l i k e about smoking? When t h i n k i n g of your d e s i r e do not c o n s i d e r p h y s i c a l c r a v i n g s you may have from time t o tim e . R a t h e r , t e l l us how much do you l i k e smoking. j10 Very s t r o n g l o v e f o r c i g a r e t t e s . (Want t o smoke more than a n y t h i n g e l s e , and can't imagine not b e i n g a b l e t o ) . 9 8 7 6 5 4 3 2 1 CO Never want a c i g a r e t t e . No d e s i r e at a l l . ) 94 A-5 Agreements and Approva l s 95 DATA DEPOSIT AGREEMENT You and t h e Smoking C l i n i c b o t h p r o v i d e i m p o r t a n t s e r v i c e s t o each o t h e r . The c l i n i c o p e r a t e s as a p u b l i c s e r v i c e , h e l p i n g you q u i t smoking and g u a r a n t e e i n g s u p p o r t i n s t a y i n g o f f c i g a r e t t e s . I n r e t u r n f o r t h i s s e r v i c e , we ask you t o h e l p us w i t h our r e s e a r c h . F u l l c o - o p e r a t i o n and complete i n f o r m a t i o n about you and your smoking a r e a b s o l u t e l y e s s e n t i a l t o our r e s e a r c h . Remember t o o , t h a t t h e aim o f t h i s r e s e a r c h i s t o d e v e l o p a s t a n d a r d p r o c e d u r e w h i c h can be used by o t h e r p u b l i c h e a l t h p r o f e s s i o n a l s . We need t o f o l l o w t h a t s t a n d a r d p r o c e d u r e w i t h a l l o f you, so a g a i n , your c o - o p e r a t i o n i s e s s e n t i a l . P e o p l e t e n d t o be more c o n s c i e n t i o u s when t h e y have a commitment t o a p r o j e c t . We ask a l l c l i e n t s t o make a commitment t o our r e s e a r c h by p r o v i d i n g a d a t a d e p o s i t o f $25.00. The d e p o s i t g u a r a n t e e s your a c t i v e c o - o p e r a t i o n w i t h t h e r e s e a r c h . I t i s r e t u r n e d a t a three-month f o l l o w - u p o f t h e c l i n i c i f you have * 1. A t t e n d e d a l l s c h e d u l e d s e s s i o n s . 2. S u b m i t t e d complete r e c o r d s o f your smoking d u r i n g and a f t e r t h e c l i n i c . 3. Completed and r e t u r n e d a l l q u e s t i o n n a i r e s r e l a t e d t o t h e r e s e a r c h . P l e a s e r e a l i z e t h a t we must be q u i t e s t r i c t i n r e q u i r i n g t h i s c o - o p e r a t i o n — k e e p i n g a p p o i n t m e n t s , c o m p l e t i n g r e c o r d s , and r e t u r n i n g f o l l o w - u p s . I f you c a n ' t make t h i s commitment, say so now. Note t h a t v r h i l e you o f c o u r s e e x p e c t n o t t o be smoking t h r e e months a f t e r t h e c l i n i c , i f you were,- you'd s t i l l g e t your d e p o s i t back. The d e p o s i t i s n o t t i e d i n any way t o your smoking, s i m p l y t o your c o - o p e r a t i o n . Your d e p o s i t w i l l be i n t h e form o f a cheque, f o r $25.00, made p a y a b l e t o t h e B.C. T u b e r c u l o s i s S o c i e t y . The cheque w i l l be r e t u r n e d uncashed a t t h e three-month f o l l o w - u p , p r o v i d i n g you have met a l l t h e c o n d i t i o n s above. F o r f e i t e d d e p o s i t s w i l l he donated t o t h e B.C. T u b e r c u l o s i s S o c i e t y . I , , agree t o c o - o p e r a t e w i t h t h e r e s e a r c h r e q u i r e m e n t s o f t h e Smoking C l i n i c . My d a t a d e p o s i t o f $25.00 may be f o r f e i t e d a t t h e C l i n i c ' s d i s c r e t i o n , and donated t o th e B.C. T u b e r c u l o s i s S o c i e t y , i n t h e ev e n t t h a t I f a i l t o a t t e n d s e s s i o n s and/or p r o v i d e n e c e s s a r y i n f o r m a t i o n . Date; S i g n a t u r e 96 Research Participation Consent Form I agree to participate in this research project. The procedures have been described to me and i t has been made clear that I can withdraw from participation in the project at any time or decline to undergo a specif ic procedure. I understand that I may be asked to undergo aversive procedures involving excessive exposure to cigarette smoke. These procedures may involve considerable discomfort including nausea, dizziness, a sore throat and cough, headaches, and lack of energy. More serious side effects are theoretically possible but I understand they have never been documented and the r i sk appears minimal. (Signature) (Cl inic Personnel) Subject's Name^  Subject's lumber: Date: SMOKING CLINIC PHYSICIAN APPROVAL FORM 97 Dear Doctor: has applied for our Smoking C l i n i c , a research/public service programme sponsored by Health and Welfare Canada. The programme employs only validated procedures and, based on our previous evaluations, there is a very good chance we can help your patient stop smoking. One of the stages in the c l i n i c , however, may involve a small degree of r i s k , and in this regard we have asked that you be consulted and your approval secured. The most effective means, discovered to date, for helping smokers become abstinent are aversive oversmoking procedures. We use two variations. The f i r s t , "satiation", ca l l s for increasing the normal smoking rate s ignif icant ly , usually to about double, for three days just prior to stopping smoking. The second, "rapid smoking", asks the smoker to smoke rapidly (a drag every six seconds) u n t i l he/she can't bear to take another puff. Typical ly , between two and five cigarettes might be rapid smoked before reaching, the tolerance l imi t . Following a rest , the smoker may repeat the procedure, again u n t i l the person's individual tolerance level i s reached. Participants in the programme w i l l be trained in the rapid smoking procedure at the c l i n i c and thereafter perform the technique at home, at f i r s t once a day and then gradually less frequently. Over the f i r s t two weeks of stopping smoking, rapid smoking may occur up to seven times but never more than once a day. Both procedures have been shown effective in achieving cessation. Our research programme aims to improve success by adding training to help the cl ient cope with problematic occasions for smoking and thus remain abstinent permanently. The research also aims to develop manuals and training programmes so that interested health professionals can offer the service in their practice. The oversmoking procedures have been extensively used over the past five years by us and other researchers. Many hundreds have participated successfully without any known i l l effects. On the other hand, oversmoking l ike normal smoking does lead to considerable nicotine intake which w i l l stress the cardiovascular system. Therefore, we wish to exclude anyone with a history of heart disease, cardiovascular disease, or with diabetes. About 90% of the nicotine in tobacco is absorbed Into the body when smoking. There i s an immediate r i se in heartbeats per minute and a r t e r i a l blood pressure. The production of epinephrine and norepinephrine is stimulated as is the production of free fatty acids. These findings on human subjects are summarized in a chapter entitled 'Tobacco and the Cardiovascular System'' in The Heart, J . W i l l i s Hurst, M.D. (Ed.), McGraw-Hill, 1974. This source also notes that in animals the inhalation of cigarette smoke i s followed by a "significant and prolonged reduction of the threshold for ventricular f i b r i l l a t i o n " . There are no reported episodes of regular smoking or the c l i n i c a l use of oversmoking producing acute, cardiac or vascular symptoms in humans. We have enclosed a recent a r t i c l e summarizing the research on physiological effects of rapid smoking, In our opinion, the demonstrated benefit of the procedure's use jus t i f i es the small degree of r i sk providing there are no medical considerations which contraindicate oversmoking. We ask that you review your information on the patient, conduct any further examination you may think necessary, and then Indicate v i f your patient ought not participate in oversmoking procedures. If there are medical reasons to rule out oversmoking, our project w i l l s t i l l provide a programme to offer what assistance we can. We are trying to develop alternatives to oversmoking procedures but to date research suggests that they remain the most re l iable methods 9 8 - 2 -for stopping smoking. We welcome your interest in our Cl in ic and hope you w i l l contact us i f you have any questions. If you would l ike an independent medical opinion, contact Dr. Bass at the address given below. J . Allan Best, Ph.D. Assistant Professor Director, Smoking Cl in ic Medical Consultant: Dr. F. Bass, M.D. , P.Sc. Consultant in Preventive Medicine Vancouver Health Department 1060 Uest 8th Avenue VANCOUVER, B.C. To my knowledge there are no medical contraindications to this patient's undergoing oversmoking procedures. Date: . M - D -(Signature) Would you please return the signed consent promptly so that your patient can begin the programme as soon as possible. Use the enclosed envelope to send the form to-Smoking C l i n i c Department of Psychology U n i v e r s i t y of B r i t i s h Columbia VANCOUVER, B.C. V6T lW!i 99 A-6 Confederate Tallying 100 Name: Date: CONFEDERATE FOR TALLYING Our r e s e a r c h r e q u i r e s that we o b t a i n as complete and a c c u r a t e a d e s c r i p t i o n and r e c o r d of your smoking as p o s s i b l e . We have found i n the past that two heads are b e t t e r than one and ask that you a c q u i r e the he lp of a c l o s e f r i e n d or r e l a t i v e to work w i t h you on your t a l l y i n g r e c o r d . The two of you w i l l d i s c u s s your reasons f o r smoking and check to make sure that a l l your c i g a r e t t e s are accounted f o r . We w i l l c o n t a c t your c o n f e d e r a t e d u r i n g the course of the c l i n i c to d i s c u s s h i s or her p e r c e p t i o n s of your t a l l y i n g progres s over the past p e r i o d . W i l l you p l e a s e p r o v i d e us w i t h the f o l l o w i n g I n f o r m a t i o n about your c o n f e d e r a t e . Name: Age: (p l ease p r i n t ) R e l a t i o n s h i p to you: Home A d d r e s s : Te l ephone : Home: Bus ines s : Does your c o n f e d e r a t e smoke? I f so , i s he or she t r y i n g to q u i t at t h i s t ime? 101 A-7 Posttreatment Forms for the Evaluation of C l i n i c Impact 102 COMBINED COm^-l TREATMENT EVALUATION Wame; Date-: ___ 1 . What p a r t s o f t h e c l i n i c d i d y o u f i n d most u s e f u l ? P l a c e a ' " 1 " n e x t t o t h e most i m p o r t a n t p a r t , a ' ' 2 n e x t t o t h e s e c o n d most i m p o r t a n t , and c o n t i n u e r i g h t down t o t h e l e a s t i m p o r t a n t f a c t o r t N o t e t h a t a l l f a c t o r s s h o u l d be r a t e d . T a l l y i n g _ D i s c u s s i n g and A n a l y s i n g R e a s o n s S a t i a t i o n R a p i d Smoking A l t e r n a t i v e s t o Smoking S e l f S t a t e m e n t s R e l a x a t i o n _ ' Reward P r o g r a m S u p p o r t f r o w T h e r a p i s t and G roup O t h e r ( p l e a s e s p e c i f y ) 2 o How d i f f i c u l t was i t f o r y o u t o g u i t ? ( c i r c l e one) no e f f o r t s l i g h t m o d e r a t e d i f f i c u l t v e r y d i f f i c u l t 3 . How c o n f i d e n t do y o u f e e l t h a t y o u w i l l be a b l e t o s t a y o f f c i g a r e t t e s ? ( c i r d e one) 0% 20% 40% 60% 80% 100% 4, What a d v i c e c a n y o u g i v e us as t o how we w i g h t i m p r o v e o u r p r o c e d u r e s ? 103 B E H A V I O U R A L BEM02 T RRATWENT EVALU AT I ON Maine :• Date-1. What p a r t s of the c l i n i c d i d you f i n d most u s e f u l ? P l a c e a "1" next t o the most, important p a r t , a "2C next t o the second most important and continue r i g h t down t o the l e a s t im-p o r t a n t f a c t o r ? Note t h a t a l l f a c t o r s should be r a t e d . T a l l y i n g D i s c u s s i n g and A n a l y s i n g Reasons _ S a t i a t i o n Rapid Smoking A l t e r n a t i v e s t o Smoking R e l a x a t i o n Reward Program Support from T h e r a p i s t and Group Other (please s p e c i f y ) 2. How d i f f i c u l t was i t f o r you t o q u i t ? ( c i r c l e one) no e f f o r t s l i g h t moderate d i f f i c u l t v ery d i f f i c u l t 3. How c o n f i d e n t do you f e e l t h a t you w i l l be able t o stay o f f c i g a r e t t e s ? ( c i r c l e one) 0% 20% 40% 60% 80% 100% 4. What advice can you g i v e us as t o how we might improve our procedures? 104 COGNITIVE COGC3 TREATMENT EVALUATION Name - Date •? What parts of the c l i n i c did you f i n d most useful? Place a "1" next to the most important p a r t ? a S| 2 ? next to the second most important and continue r i g h t down to the least important factor? Note that a l l factors should he rated. T a l l y i n g Discussing and Analysing Reasons Satiation Rapid Smoking Alternatives to Smoking Self Statements Support from the Therapist and Group Other (please specify) 2. How d i f f i c u l t was i t for you to quit? ( c i r c l e one) no e f f o r t s l i g h t moderate d i f f i c u l t very d i f f i c u l t 3. How confident do you f e e l that you w i l l be able to stay o f f cigarettes? ( c i r c l e one) 0% 20% 40% 60% 80% 100% 4 . What advice can you give us as to how we might improve our procedures? 105 OVERSMOKING 0SC4 TREATMENT EVALUATION Name- D a t f V What parts of the c l i n i c did you fi n d most useful? Place a 'I' 1 next to the most important part, a next to the second most important, and continue r i g h t down to the leas-* important factor? Note that a l l factors should be rated. T a l l y i n g Discussing and Analysing Reasons Satiation Rapid Smoking _ Support from the Therapist And Group Other (Please Specify) 2. How d i f f i c u l t was i t for you to quit? ( c i r c l e one) no e f f o r t s l i g h t moderate d i f f i c u l t very d i f f i c u l t 3. How confident do you f e e l that you w i l l be able to stay o f f cigarettes? ( c i r c l e one) 0% 20% 40% 60% £0% 100% 4. T'Jhat advice can you give us as to how we might improve our procedures? APPENDIX B Handouts and Rating Scales Given to Subjects During the Course of the C l i n i c 107 B-l Handouts and Rating Scales Given to A l l Subjects i n the Treatment Condition 108 No. 1 TALLY SYSTEM Throughout the c l i n i c , you are going to be , ; keeping a d e t a i l e d r e c o r d of your c i g a r e t t e smoking i n the T a l l y Book p r o v i d e d . There are t h r e e reasons f o r r e c o r d i n g now: (a) i t i s e s s e n t i a l that you and we r e a l l y t h o r o u g h l y unders tand your smoking h a b i t , (b) t a l l y i n g makes you more aware of your smoking. You come to know more about your smoking, and as a r e s u l t , you a r e : i n a much b e t t e r p o s i t i o n to s t a r t changing the smoking h a b i t , and (c) f o r our r e s e a r c h purposes 'we must have as e x h a u s t i v e and a c c u r a t e ' p i c t u r e of your smoking as p o s s i b l e . T h i s ,1 sr why we asked' you to nominate a c o n f e d e r a t e to work; w i t h you.< an- t h i s t a l l y i n g . D e t a i l e d ' g u i d e l i n e s f o r t a l l y i n g f o l l o w : 1. You should b e g i n r e c o r d i n g immediate ly and c o n t i n u e for, ;t-he remainder of the c l i n i c . 2. For each and every c i g a r e t t e you smoke, w r i t e down the , (a) t ime . (b) p l a c e : where you are at the moment e . g . i n l i v i n g room at home, i n the c a r , w a l k i n g down s t r e e t , e t c . (c) a c t i v i t y : what you are do ing at tha t moment e . g . s h o v e l l i n g snow, d r i n k i n g , . s tudying* c l e a n i n g house , j u s t f i n i s h i n g a m e a l , e t c . • (d) r e a s o n : the reason you t h i n k you are smoking the c i g a r e t t e . e . g . to r e l a x , w i t h c o f f e e , because you re b o r e d , your mouth i s d r y , e t c . For eacn c i g a r e t t e p l e a s e w r i t e t ime , p l a c e , and a c t i v i t y on one l i n e , and the reason on the l i n e below. 3. Use a s eparate page(s) f o r each day w r i t i n g the day and the date at the top of each page. Count the day as ex tend ing from when you wake up u n t i l when you wake the f o l l o w i n g m o r n i n g . Don' t cramp 109 ' - 2 -y o u r s e l f by t r y i n g t o g e t a l l o f one d a y on a s i n g l e p a g e b u t do s t a r t a new page e v e r y m o r n i n g . T o w a r d s t h e end o f e a c h d a y , s i t down w i t h y o u r c o n f e d e r a t e and d i s c u s s t h e d a y ' s t a l l y i n g . W r i t e i . the t o t a l number, . o f c i g a r e t t e s smoked a t t h e t o p o f t h e p a g e . When y o u a r e b o t h c o n f i d e n t t h a t t h e t a l l y i 6 a c c u r a t e and c o m p l e t e , y o u s h o u l d . b o t h s i g n t h e d a y ' s t a l l y a t . the b o t t o m t o s i g n i f y t h a t t h e r e c o r d h a s b e e n c h e c k e d . . . 4 . R e c o r d t h e t im.e y o u o p e n a p a c k o f c i g a r e t t e s ..and t h e t i m e y o u t h r o w ^ i t away.? T h i s s e r v e s as a c h e c k f o r y o u on y o u r t a l l y i n g a c c u r a c y * . Y o u know y o u h a v e 20 ( o r 25 ) c i g a r e t t e s , , t o a c c o u n t f o r i n b e t w e e n and i f t h e t o t a l i s n ' t r i g h t y o u may be a b l e t o f i g u r e o u t w h e r e y o u l o s t o n e . I t w o u l d h e l p , t o n o t e any c i g a r e t t e s y o u e i t h e r a c c e p t f r o m o t h e r s o r g i v e away so t h a t y o u c a n g e t t h e t o t a l t o c h e c k . ' .. ; . :, 5 . I t i s e x t r e m e l y i m p o r t a n t t h a t y o u t r y t o smoke e x a c t l y as y o u n o r m a l l y w o u l d i f n o t r e c o r d i n g . T h e r e i s a s t r o n g t e n d e n c y f o r p e o p l e t o c h a n g e t h e i r s m o k i n g h a b i t s and p a t t e r n when t h e y h a v e t o k e e p a r e c o r d . We n e e d t o u n d e r s t a n d y o u r n o r m a l s m o k i n g ; x t c a n n o t be s t r e s s e d t o o s t r o n g l y t h a t y o u mus t t r y n o t t o l e t t h e r e c o r d i n g i n t e r f e r e . 6 . I f y o u h a v e . any. q u e s t i o n s o r i f a n y t h i n g a b o u t t h e p r o c e d u r e i s u n c l e a r , no m a t t e r how. s m a l l a d e t a i l , p l e a s e p h o n e 228-6255. 7 . A l w a y s b r i n g y o u r t a l l i e s t o t h e n e x t s e s s i o n . 8 . A t t h e end o f t h i s f i r s t w e e k , s u m m a r i z e y o u r r e a s o n s f o r s .mpking on t h e q u e s t i o n n a i r e p r o v i d e d and b r i n g , t h e summary t o t h e n e x t s e s s i o n . 110 TALLY SUMMARY N a m e : Date: B e f o r e y o u r n e x t s e s s i o n make s u r e you have completed t h e t a l l y summary f o r each day o f t a l l y i n g . T o t a l t h e number o f c i g a r e t t e s you smoked f o r v a r i o u s r e a s o n s each day and e n t e r i t under t h e r e s p e c t i v e c a t e g o r y . Then, f i r s t g e t an o v e r a l l t o t a l by a d d i n g up t h e c i g a r e t t e s f o r each day ( i . e . add up t h e t o t a l s a t t h e bottom o f each column). Second, c a l c u l a t e t h e o v e r a l l t o t a l a g a i n as a check by a d d i n g t h e t o t a l s f o r each d i f f e r e n t r e a s o n ( i . e . t h e t o t a l s f o r d i f f e r e n t r o w s ) . These two numbers s h o u l d be t h e same. Dates  (month) Reasons T o t a l s R e l a x a n t A f f e c t C r a v i n g D e s i r a b i l i t y S t i m u l a n t H a b i t Reward Ot h e r T o t a l s Below you w i l l f i n d d e s c r i p t i o n s o f p o s s i b l e r e a s o n s f o r smoking. C o n s i d e r them as t h e y a p p l y t o y o u r smoking. 1. Sometimes t h e c i g a r e t t e a c t s as a s t i m u l a n t , t h a t i s t o make you more a l e r t and a t t e n t i v e when you a r e p e r f o r m i n g a t a s k s u c h a s d r i v i n g a c a r o r s t u d y i n g . I n t h i s same c l a s s y o u may smoke because you a r e b o r e d o r have n o t h i n g b e t t e r t o do. 2. A n o t h e r r e a s o n why one may smoke i s because t h e c i g a r e t t e a c t s as a r e l a x a n t . You may be a n x i o u s o r t e n s e o r u p s e t and a c i g a r e t t e would t h u s a c t t o c a l m you down? i t w o u l d h e l p you g e t c o n t r o l o f t h e s i t u a t i o n and y o u r s e l f . 3. A n o t h e r r e a s o n why p e o p l e may smoke i s because t h e y c r a v e a c i g a r e t t e . You may smoke a c i g a r e t t e because you d e e p l y want one. You may f e e l t h a t y o u r mouth i s d r y , you c a n ' t c o n c e n t r a t e and you f e e l you need n i c o t i n e . You a r e aware o f t h e f a c t t h a t you a r e n o t smoking and you l i g h t up a c i g a r e t t e t o remove t h e d i s c o m f o r t o f n o t smoking. x I l l - 2 -4. A n o t h e r r e a s o n why p e o p l e smoke i s because i t i s t h e socially  d e s i r a b l e t h i n g t o do. You l i g h t - u p a c i g a r e t t e because others a r e smokang, o r someone has o f f e r e d you a c i g a r e t t e and you do n o t w i s h t o r e f u s e . F o r example, you may be a t a p a r t y or w i t h someone e l s e and t h e "suave" t h i n g t o do i s smoke. 5. A n o t h e r r e a s o n why you may l i g h t up a c i g a r e t t e i s because of a f f e c t o r mood s t a t e you a r e i n . You may l i g h t up a cigarette to c h e e r y o u r s e l f up, o r because you're m e l a n c h o l y , o r aggravated. 5. A n o t h e r r e a s o n why you may smoke i s because o f h a b i t . You light-up a c i g a r e t t e f o r no p a r t i c u l a r r e a s o n o t h e r t h a n the fact you u s u a l l y smoke a c i g a r e t t e i n t h i s s i t u a t i o n . F o r example, a c i g a r e t t e may u s u a l l y accompany a c o f f e e b r e a k , o r a r r i v i n g a t work, o r w i t h a d r i n k . Be s u r e when you use t h i s r e a s o n t h a t t h e o t h e r r e a s o n s a r e n o t a p p l i c a b l e . 7. A n o t h e r r e a s o n why p e o p l e may smoke i s f o r t h e purpose of self- rewards. Sometimes you g i v e y o u r s e l f a c i g a r e t t e because of a 30b w e l l done. You d e s e r v e some s m a l l t r e a t f o r an accomplishment so you t a k e a c i g a r e t t e o r a c i g a r e t t e "break". 8. F i n a l l y you may d e c i d e t h a t t h e r e a s o n you smoke i s for some o t h e r r e a s o n t h a n what we have c o v e r e d . F o r example/ you l i g h t -up a c i g a r e t t e because you don't want t o e a t , o r because you have t o do something w i t h y o u r hands, e t c . S a t i a t i o n 112 S a t i a t i o n I n v o l v e s g r e a t l y i n c r e a s i n g your d a i l y smoking for a b r i e f p e r i o d of time j u s t p r i o r to q u i t t i n g . The important p o i n t s to remember are these : 1. A rough g u i d e l i n e to he lp you d e c i d e how much to smoke when s a t i a t i n g i s that most people f i n d they r o u g h l y double t h e i r normal r a t e . 2. The r e a l t e s t f o r whether you are s a t i a t i n g w e l l enough i s a check on how you f e e l . You should be i n c r e a s i n g your smoking as much as you p o s s i b l y c a n , u n t i l you cannot t o l e r a t e anymore. Whatever i t takes to reach that p o i n t i s what you must do - -some people i n c r e a s e t h e i r smoking as much as 5 t imes t h e i r normal r a t e . By the end of each day , you should f e e l that you s imply cou ld not smoke another c i g a r e t t e . 3. Remember that the harder you work at the s a t i a t i o n now, the s t r o n g e r the c o n d i t i o n i n g of n e g a t i v e r e a c t i o n s to smoking, and the e a s i e r you w i l l f i n d i t i n the long r u n . 4. In the evening b e f o r e each s a t i a t i o n day , s i t down and p lan your s a t i a t i o n f o r the f o l l o w i n g day u s i n g an hour by hour quota systems Take the t o t a l number of c i g a r e t t e s you p l a n to smoke d u r i n g the day, based on an e s t imate of double your normal r a t e . Let us say , f o r example, that you n o r m a l l y smoke 25 c i g a r e t t e s per day. You w i l l be t r y i n g to smoke 50 c i g a r e t t e s the f i r s t day of s a t i a t i o n . Take that d o u b l e - n o r m a l smoking f i g u r e and d i v i d e i t by the number of hours that you expect to be awake on the f i r s t day of s a t i a t i o n . For example, i f you expect to be awake 16 hours your smoking quota w i l l r e q u i r e you to smoke j u s t over 3 c i g a r e t t e s every h o u r . Now, a s s i g n the 50 c i g a r e t t e s to the d i f f e r e n t hours of the day c o u n t i n g on about 3 per hour . I f there i s a p e r i o d d u r i n g the day when you cannot smoke as many as 3, take the l e f t o v e r c i g a r e t t e s and a s s i g n them to the hour immediate ly p r e c e d i n g a n d / o r f o l l o w i n g the p e r i o d i n q u e s t i o n . For example, i f you knew you were going to be i n a meet ing between 11:00 a.m. and 12:00 a.m. when you would not be ab le to smoke at a l l , you mi£.h t.-talue.. ._2-~o-f- the- c-i-gar-ett es and a s s i g n - 2 -113 t h e m t o t h e 1 0 : 0 0 - 1 1 : 0 0 q u o t a , b r i n g i n g i t up t o 5 and t h e 1 c i g a r e t t e t o t h e 1 2 : 0 0 - 1 :00 q u o t a , b r i n g i n g i t t o a t o t a l o f 4 . A s y o u go t h r o u g h t h e d a y s m o k i n g t h e s e c i g a r e t t e s , s i m p l y p u t a t i c k mark i n t h e t a l l y c o l u m n as y o u smoke e a c h c i g a r e t t e . A t t h e end o f t h e f i r s t d a y , t o t a l up t h e c i g a r e t t e s y o u a c t u a l l y smoked and p u t t h e t o t a l i n t h e s p a c e on t h e q u o t a s h e e t . On I t , we h a v e l i s t e d a l l t h e r e a c t i o n s w h i c h p e o p l e n o r m a l l y r e p o r t t o s a t i a t i o n . C o n s i d e r e a c h r e a c t i o n s e p a r a t e l y , d e c i d i n g w h e t h e r y o u e x p e r i e n c e d t h a t symptom t o some e x t e n t . R a t e t h e s e v e r i t y o f e a c h symptom on a 5 - p o i n t s c a l e as d e s c r i b e d on t h e r a t i n g f o r m . N o w , c o n s i d e r c a r e f u l l y w h e t h e r y o u s h o u l d i n c r e a s e y o u r q u o t a f o r t h e f o l l o w i n g d a y . I f y o u f e e l y o u c o u l d > t h e n y o u s h o u l d as much as y o u p o s s i b l y c a n . F o l l o w t h e same p r o c e d u r e a t t h e end o f d a y t w o , i n c r e a s i n g y o u r q u o t a i f n e c e s s a r y . Y o u may w e l l f i n d t h a t y o u r q u o t a d o e s i n c r e a s e o v e r t h e 3 - d a y p e r i o d . B r i n g y o u r s a t i a t i o n q u o t a s h e e t and t h e Symptom R a t i n g F o r m t o t h e n e x t s e s s i o n so t h a t we h a v e a r e c o r d o f y o u r s a t i a t i o n e x p e r i e n c e . 114 SATIATION QUOTA AND TALLY SYSTEM Name; DAY 1 DAY 2 DAY 3 Date: Quota Tall y Quota T a l l y Quota T a l l y 6:00 - 6:59 a.m. 7:00 - 7:59 a.m. 8:00 - 8.59 a.m. 9:00 - 9:59 a.m. 10:00 - 10:59 a.m. 11:00 - 11:59 a.m. 12:00 - 12:59 p.m. 1:00 - 1:59p.m. 2:00 - 2:59 p.m. 3:00 - 3:59 p.m. 4-:00 - 4:59 p.m. 5:00 - 5:59 p.m. 6:00 - 6:59 p.m. 7 :00 - 7:59 p.m. 8:00 - 8:59 p.m. 9:00 - 9:59 p.m. 10:00 - 10:59 p.no. 11,00 - 11 :59 p.m. i 12:00 - 12:59 a.m. 1:00 - 1:59 a.m. 2:00 - 2:59 a.m. 3:00 - 3:59 a.m. TOTAL i 115 Form R SYMPTOM RATING SCALE Name: i Date : Time r a p i d smoking s e s s i o n began: C i g a r e t t e s r a p i d smokedi T r i a l 1 T r i a l 2 T r i a l 3 D e s c r i b e your r e a c t i o n s to t h i s r a p i d smoking s e s s i o n by c i r c l i n g the a p p r o p r i a t e number f o r each p o s s i b l e symptom. Did not E x p e r i e n c e S l i g h t Moderate Strong Sevei 1. Nausea 1 2 3 4 5 2. Headache 1 ?. 3 4 5 3. coughing 1 2 3 4 5 4. bad t a s t e 1 2 3 4 5 5. f u z z i n e s s 1 2 3 4 5 6. mouth water ing 1 2 3 4 5 7. hear t r a t e i n c r e a s e 1 2 3 4 5 8. raspy b r e a t h i n g 1 2 3 4 5 9. hand tremour 1 2 3 4 5 10. c o l d 1 2 3 4 5 11. shor tness of b r e a t h 1 2 3 4 5 12. f e e l i n g of s e d a t i o n 1 2 3 4 5 13. unp leasant s m e l l 1 2 3 4 5 14. sore t h r o a t 1 2 3 4 5 15. w a t e r i n g or s t i n g i n g i t c h y eyes 1 2 3 4 5 16. nose t i n g l e y 1 2 3 4 5 17. weak knees 1 2 3 4 5 18. dry mouth 1 2 3 4 5 19. d i z z y 1 2 3 4 5 20. t i n g l i n g of hands & l egs 1 2 3 4 5 21. f e e l i n g f a i n t 1 2 3 4 5 22. nose r u n n i n g 1 2 3 4 5 23. t i n g l i n g or sore l i p s 1 2 3 4 5 24. hot 1 2 3 4 5 Now, p l a c e a ' l r j u s t to the l e f t of the symptom whieh bothered you most , a "2': next to the symptom which bothered you second most , and a 13' next to the t h i r d most bothersome symptom. 1 1 6 PROCEDURE FOR RAPID SMOKING One of your major tasks over the next couple of weeks i s to b u i l d up as powerfu l a set of n e g a t i v e a s s o c i a t i o n s to smoking as p o s s i b l e . Rapid smoking i s the way to do t h a t . Rapid smoking i s of course u n p l e a s a n t , and because of t h a t , i t i s hard to push y o u r s e l f to r a p i d smoke as much as you s h o u l d . Remember though, that the harder you can work at r a p i d smoking now, the e a s i e r i t w i l l be f o r you to s tay o f f smoking i n the long r u n . For the next three days you should r a p i d smoke once a day. Then r a p i d smoke every second day; then r a p i d smoke every t h i r d day. I f you c o n s i d e r as' day one the day of your r a p i d smoking at the ' c l i n i c , then you w i l l be r a p i d smoking once a day on days 1, 2, 3, 5 , 7 , 10, arid 13. You should make a note of your r a p i d smoking da fys on a c a l e n d a r at home. Each time you r a p i d smoke, It i s important to remember that you should c o n t i n u e every t r i a l f o r as long as you p o s s i b l y c a n , and take as many t r i a l s as you p o s s i b l y can . You should p i c k a t ime and p l a c e where t h i n g s are f a i r l y q u i e t and you w i l l not be d i s t u r b e d . Then , s i t down at a t a b l e w i t h a l i t cand le and f o l l o w these s t e p s . 1. Set out on the t a b l e as many c i g a r e t t e s as you expect you w i l l need for the f i r s t t r i a l . Leave the package open on the t a b l e so you can get more i f you need them. 2. Be sure you have some way of pac ing your p u f f s at one every 5 or 6 seconds . A watch or c l o c k w i t h a sweep second hand, on the w a l l i n f r o n t of you or on the t a b l e , i s b e s t . 3. L i g h t your f i r s t c i g a r e t t e and beg in t a k i n g p u f f s every 5 or 6 seconds . 4. When you f i n i s h a c i g a r e t t e , l i g h t a new one from the candle wi thout paus ing and c o n t i n u e to r a p i d smoke. 5. When you cannot t o l e r a t e any more, but t out your c i g a r e t t e In an a s h t r a y . As you do so , say out loud a phrase which w i l l emphasize f o r you the unpleasantness of r a p i d smoking eg. " t h i s c i g a r e t t e t a s t e s t e r r i b l e " , I d o n ' t want to smoke anymore". 117 - 2 -Now focus your a t t e n t i o n on your s t r o n g e s t r e a c t i o n to the r a p i d smoking and t r y to form a v i v i d awareness of t h i s symptom and to h o l d that a t t e n t i o n for 10 - 15 seconds . Then focus on the second most n o t i c e a b l e r e a c t i o n f o r 10 - 15 seconds , then the t h i r d , e t c . 6. Make a r e c o r d of how many c i g a r e t e s you smoked, e s t i m a t i n g to "the n e a r e s t 1/4 c i g a r e t t e . Example: 6%s 4%, e t c . 7. As soon as you f e e l a b l e , go on w i t h another t r i a l i n e x a c t l y the same manner as the f i r s t . A f t e r each t r i a l focus your a t t e n t i o n on your r e a c t i o n s , and r e c o r d the number of c i g a r e t t e s smoked, and go on to another t r i a l as soon as you are a b l e . 8. When you f e e l you are unable to go on to another t r i a l , complete the Symptom R a t i n g S c a l e and then you are done. 118 Form R SYMPTOM RATING SCALE Name: Date Time r a p i d smoking s e s s i o n began; C i g a r e t t e s r a p i d smoked; T r i a l 1 T r i a l 2 T r i a l 3 D e s c r i b e your r e a c t i o n s to t h i s r a p i d smoking s e s s i o n by c i r c l i n g the a p p r o p r i a t e number f o r each p o s s i b l e symptom. •1. 2 . 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. D id not Exper ence Nausea Headache coughing bad t a s t e f u z z i n e s s mouth w a t e r i n g hear t r a t e i n c r e a s e raspy b r e a t h i n g hand tremour c o l d shor tness of b r e a t h f e e l i n g of s e d a t i o n unp leasant s m e l l sore t h r o a t w a t e r i n g or s t i n g i n g i t c h y eyes -nose t i n g l e y weak knees d r y mouth d i z z y t i n g l i n e of hands £ l egs f e e l i n g f a i n t nose r u n n i n g t i n g l i n g or sore l i p s hot S l i g h t Moderate Strong Severe 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Now, p l a c e a " l ' " j u s t to the l e f t of the symptom which bothered you most , a "2" next to the symptom which bothered you second most , and a • 3 1 ; next to the t h i r d most bothersome symptom. 119 B-2 Handouts for the Subjects i n the Combined Condition 1 120 COWBCI REWARD PAOCRAW.ME Smoking i s o f t e n seen by smokers as e n j o y a b l e , a r e a l s o u r c e o f p l e a s u r e . Even I f you have s t o o p e d e n j o y i n g c i g a r e t t e s and f i n d t h e h a b i t d i s t a s t e f u l , g i v i n g i t up can s t i l l p r o v e s t r e s s f u l . I t i s c r i t i c a l t h a t we do what we can to make n o t - s m o k i n g as s a t i s f y i n g as p o s s i b l e . L e a r n i n g how to be a nonsmoker r e q u i r e s a c t i v e e f f o r t and you s h o u l d be rewarded f o r t h o s e e f f o r t s . You can t h i n k of not smoking as a s e t of s k i l l s you l e a r n --making a d e c i s i o n n o t t o have a c i g a r e t t e , s a y i n g no t o an o f f e r e d one and f i n d i n g a l t e r n a t i v e ways of c o p i n g . P e o p l e l e a r n b e t t e r when t h e y  a r e r e w a r d e d f o r d o i n g i t r i g h t . T h i s i s t h e p r i n c i p l e o f reinforcement.-, t h o s e t h i n g s we do w h i c h p r o v e s u c c e s s f u l or g i v e s a t i s f a c t i o n , we tend t o do a g a i n , f i n d i n g them e a s i e r t o do t h e n e x t t i m e a r o u n d . I f not smoking p r o v e s s t r e s s f u l , u n s a t i s f y i n g , or u n p l e a s a n t , i t ' s h a r d e r t o become a c o n f i r m e d non-smoker, T h i s i s t h e r e a s o n f o r a reward programme, to p r o v i d e r e w a r d f o r n o t smoking and t o s t r e n g t h e n non-smoking s k i l l s . I t ' s , a v e r y i m p o r t a n t p a r t of any p l a n f o r q u i t t i n g . In t h e n e x t s e s s i o n , w e ' l l d i s c u s s how you can d e s i g n a re w a r d nroeramr.e f o r y o u r s e l f . Between now and t h e n , you need t o p l a n some r e w a r d s or r e i n f o r c e r s . A r e i n f o r c e r i s s o m e t h i n g p o s i t i v e w h i c h you can make happen f o r not smoking. T.t can be s o m e t h i n g you ? i v e y o u r s e l f , s o m e t h i n g you l i k e to clo, b e i n g w i t h someone whose comnany you e n j o y , or s a v i n g s o m e t h i n g p l e a s a n t to y o u r s e l f or s i m p l y i m a g i n i n g s o m e t h i n g p l e a s u r a b l e . F o r example* i t i s l i k e l y t h a t at l e a s t some of t h e t h i n g s i n t h e f o l l o w i n g l i s t a r e r e i n f o r c i n g f o r you. g o i n g o u t t o d i n n e r m o v i e s or p l a y s a d r i n k b e f o r e d i n n e r a walk a f t e r s u p p er b u y i n g r e c o r d s s p e n d i n g money r e a d i n c making d e c i s i o n s about how t h e f a m i l y w i l l spend t h e weekend t e l l i n g y o u r s e l f " w e l l done, I've coped'' t e l l i n g y o u r s e l f " I can be proud of m y s e l f s i t t i n g a l o n e and i m a g i n i n g a n y t h i n g p l e a s a n t u s i n g y o u r i m a g i n a t i o n - 2 -121 R e i n f o r c e m e n t I s a v e r y i n d i v i d u a l t h i n g . Y o u r r e i n f o r c e r s h a v e t o b e r e w a r d i n g f o r y o u . P u r i n e t h e c o n i n g , w e e ' - , t h i n k o f p o o d r e i n f o r c e r s a n d w r i t e t h e m d o w n . L i s t a s m a n y r e i n f o r c e r s a s y o u c a n , t h e m o r e t h e b e t t e r . We c a n p i c k a c o m b i n a t i o n o f t h e b e s t o n e s u n t i l n e x t w e e k . When v o u a r e t r y i n g t o d e c i d e o n r e i n f o r c e r s t o l i s t , a s k y o u r s e l f t h e s e q u e s t i o n s ; W h a t do y o u e n j o y t h a t y o u n e v e r p e t e n o u g h o f ? I f y o u h a d a w h o l e a f t e r n o o n f r e e , how w o u l d y o u s p e n d i t ? Who w o u l d y o u s p e n d i t w i t h ? W h a t m a k e s y o u f e e l g o o d ? W h a t d o y o u r e a l l y h a t e d o i n g a n d w i s h y o u c o u l d p e t o u t o f m o r e o f t e n ? A r e t h e r e t h i n g s v o u c o n s i d e r l u x u r i e s a n d n o r m a l l y d o n ' t a l l o v y o u r s e l f t o b u y ? W h a t d o y o u do t o p e t a w a y f r o m i t a l l ? How d o y o u l i k e t o s p e n d , t i m e a l o n e ? Who d o y o u m o s t l i k e t o b e w i t h ? W h a t d o y o u do f o r f u n ? W h a t w o u l d I l i k e t o ' b e a b l e t o s a y t o m y s e l f t h a t w o u l d m a k e me f e e l g o o d ? W h a t i s r e w a r d i n g . l u s t t o i m a g i n e i t ? B y n o w , y o u m a y h a v e t h o u p . h t o f o u i t e a f e w r e i n f o r c e r s . A g o o d r e i n f o r c e r h a s s e v e r a l i m p o r t a n t p r o p e r t i e s . F i r s t , a s w e ' v e s a i d , , i t ' s p l e a s u r a b l e f o r y o u . T l i e m o r e p l e a s u r a b l e o r r e w a r d i n g , t h e b e t t e r . S e c o n d , v o u m u s t b e a b l e t o c o u n t o n i t w h e n y o u d o n ' t s m o k e . G o i n g t o t h e n o v i e F r i d a y n i g h t w i t h , v o u r w i f e i s f i n e , b u t o n l y i f s h e ' s a g r e e d t o g o . l e t t i n g y o u r k i d s t o do t h e d i s h e s i s r e w a r d i n g , b u t w i l l o n l v b e a p o o d r e i n f o r c e r i f t h e y p r o m i s e t o do t h e m i f y o u d o n ' t s m o k e a n d s t i c k t o t h e i r p r o m i s e . A t h o u s a n d d o l l a r s a t t h e e n d o f e a c h w e e k y o u d o n ' t s m o k e w o u l d b e r e i n f o r c i n g , b u t i t ' s n o p o o d i f y o u c a n ' t a f f o r d i t . T h e t h i r d p r o p e r t y a g o o d r e i n f o r c e r h a s i s t h a t i t c o m e s f a i r l y s o o n . A p i e c e o f p i e a f t e r d i n n e r m a y b e a b e t t e r r e i n f o r c e r t h a n C h r i s t m a s i n H a w a i i b e c a u s e i t ' s m o r e i m m e d i a t e . H a v i n g y o u r c h i l d r e n t e l l y o u a t l u n c h h o w p l e a s e d t h e y a r e y o u h a v e n ' t s m o k e d a l l m o r n i n g may b e a b e t t e r r e i n f o r c e r t h a n a l o n g w e e k e n d n e x t m o n t h . S o , h a v e f u n l i s t i n g s o n e p o s s i b l e r e i n f o r c e r s a n d l o o k f o r w a r d t o n e x t w e e k w h e n y o u ' l l s t a r t p e t t i n g s ome o f t h e m . 122 COMC 1 RELAXATION Many people find practising relaxation useful. Learning to relax i s c r u c i a l in learning to become a nonsmoker. There are two major reasons why smoking quitters should improve their relaxation s k i l l s . Firstly,, almost a l l smokers report that they use cigarettes as a means of relaxation. By learning to relax e f f e c t i v e l y , you can use this s k i l l as an alternative to cigarettes which you can use to relax. Secondly, a number of the other s k i l l s which you w i l l he practising work better under relaxation. There are two main components to the approach to relaxation which we present. F i r s t l y , you learn to relax by concentrating on the difference between tension and relaxation in muscle groups and secondly., by using relaxing thoughts which include words such as calm, and tranquil and scenes such as relaxing in a hammock. Learning to relax involves a certain amount of practise. At f i r s t you may f e e l awkward doing i t but f a i r l y soon by pushing yourself beyond the f i r s t stages of f r u s t r a t ion, you w i l l experience the s a t i s f a c t i o n of deep relaxation. In the beginning the relaxation periods should take about 20 minutes but you w i l l be able to reduce this time u n t i l eventually by learning to focus on tense areas of the body or by using some of the relaxing thoughts you have practised, you can relax in as l i t t l e as 30 seconds. So this can become a very powerful technique which can be used v i r t u a l l y anywhere, anytime. The following i s a summary of the muscle groups you should concentrate on and of the kind of relaxation thoughts demonstrated in the session. A. MUSCLE GROUPS 1. Right hand and forearm 2. Right biceps 3. Left hand and forearm 4. Left biceps 5. Forehead 6. Upper cheeks and nose 7 . Lower cheeks and jaw 8. Neck and throat 9. Chest, shoulders, and upper back 10. Stomach region 2 11. Right thigh 12. Right calf 13. Right foot 14. Left thigh 15. Left calf 16. Left foot 123 -- 2 — You s h o u l d t e n s e e a c h m u s c l e group f o r about 7 s e c o n d s and t h e n r e l a x . F o c u s a l l t h e t i n e on t h e d i f f e r e n c e between t e n s i o n and r e l a x a t i o n and become f a m i l i a r w i t h t h e good f e e l i n g s o f r e l a x a t i o n . B. RELAXATION THOUGHTS As you r e l a x , t h i n k of r e l a x i n g words and s c e n e s . You s h o u l d use words and s c e n e s w h i c h you f i n d r e l a x i n g . Examples a r e words s u c h as calm., t r a n q u i l i t y , s e r e n i t y . S c e n e s may be o f any s o r t w h i c h you f i n d r e l a x i n g - j u s t l y i n g b a c k , or o t h e r more a c t i v e e v e n t s s u c h as h i k i n g or j o g g i n g . Many p e o p l e f i n d s e x u a l s c e n e s r e l a x i n g w h i l e o t h e r s f i n d p l a y i n g s p o r t s r e l a x i n g . I t i s i m p o r t a n t t o f i n d t h e t h o u g h t s w h i c h work f o r you. F i n a l l y , l i k e l e a r n i n g any s k i l l . , t h e more you p r a c t i s e t h e q u i c k e r and b e t t e r you w i l l l e a r n i t . You s h o u l d p r a c t i s e r e l a x a t i o n at l e a s t once e v e r y day and i f p o s s i b l e t w i c e . 1 2 4 URGE MANAGEMENT C h a n g i n g how you t h i n k about s m o k i n g , and s t r e n g t h e n i n g y o u r a b i l i t y t o make.the d e c i s i o n t o n o t smoke, a r e i m p o r t a n t s t e p s i n l e a r n i n g how t o r e m a i n o f f c i g a r e t t e s . You can change " t h i n k i n g h a b i t s ' 7 j u s t as you can change a c t u a l smoking b e h a v i o u r . The r u l e i s s i m p l e : you s y s t e m a t i c a l l y f o l l o w a t h o u g h t you want t o weaken w i t h n e g a t i v e c o n s e q u e n c e s and s y s t e m a t i c a l l y f o l l o w t h e t h i n k i n g you want t o s t r e n g t h e n w i t h p o s i t i v e c o n s e q u e n c e s . I t works l i k e t h i s : E a c h t i m e you g e t an u r g e t o smoke, you s h o u l d i m m e d i a t e l y t h i n k about n e g a t i v e c o n s e q u e n c e s of smoking. T h a t w i l l s e r v e to weaken t h e smoking u r g e , so t h a t i t w i l l be l e s s i n t e n s e and l e s s o f a p r o b l e m i n t h e f u t u r e . Then, you make t h e d e c i s i o n t o n ot have a c i g a r e t t e . T h a t i s a r e s p o n s e you want t o s t r e n g t h e n , so you s h o u l d i m m e d i a t e l y t h i n k about t h e p o s i t i v e b e n e f i t s of n o t smoking, So, t h e r e a r e f o u r s t e p s i n c h a n g i n g y o u r t h i n k i n g about smoking. F i r s t comes t h e u r g e , t h e n t h e t h o u g h t of n e g a t i v e a s s o c i a t i o n s , t h e n t h e d e c i s i o n t o n o t smoke, and t h e n f i n a l l y t h e t h o u g h t of some r e w a r d s f o r n o t smoking. What you need t o do now i s t o p l a n good n e g a t i v e and p o s i t i v e t h o u g h t s t o u s e . S i t down and draw up two l i s t s , w r i t i n g down as many p o s s i b l e p o s i t i v e and n e g a t i v e a s s o c i a t i o n s to smoking as you c a n . F o r example, i n t h e n e g a t i v e l i s t m i g ht go t h i n g s l i k e t h i n k i n g of the r e a c t i o n s you g e t t o o v e r s m o k i n g , p i c t u r i n g y o u r s e l f w i t h emphazima or l u n g c a n c e r , f a n t a s i z i n g y o u r c h i l d r e n c r y i n g t h e m s e l v e s to s l e e p b e c a u s e t h e y w o r r y about y o u r smoking, t h i n k i n g about how u n p l e a s a n t smokers' b r e a t h i s f o r o t h e r p e o p l e , or about how much you d i s l i k e b e i n g d ependent upon t h e "weed''. P o s i t i v e a s s o c i a t i o n s m i g h t be t h i n g s l i k e t h e c l e a n t a s t e you have i n y o u r mouth when you d o n ' t smoke, the p l e a s u r e you g e t from h a v i n g l i c k e d t h e h a b i t , how much b e t t e r a b l e you a r e t o p a r t i c i p a t e i n s p o r t s , or t h e money you s a v e t o w a r d s o t h e r t h i n g s you want to buy. 125 - 2 -Both p o s i t i v e and n e g a t i v e a s s o c i a t i o n s can be of d i f f e r e n t k i n d s . One k i n d of a s s o c i a t i o n to use i s a v i v i d mental p i c t u r e of how t h i n g s l o o k , t a s t e , s m e l l , or f e e l . For example, you might p i c t u r e y o u r s e l f c l i m b i n g s t a i r s , h a v i n g to s top every second s t e p , weez ing , and out of b r e a t h . O r , you might imagine y o u r s e l f e a t i n g your f a v o u r i t e food and r e a l l y t a s t i n g how good i t i s ; l i k e you never d i d when you smoked. A s s o c i a t i o n s can a l s o take the form of s a y i n g something to y o u r s e l f . You may not want to say i t out l o u d , but you can say t h i n g s to y o u r s e l f l i k e "smoking i s a r e a l l y d i s g u s t i n g h a b i t " or ''good, t h a t ' s g r e a t . I ' v e r e a l l y got t h i s l i c k e d now". Once you 've made a complete l i s t of a l l the p o s s i b l e p o s i t i v e and n e g a t i v e a s s o c i a t i o n s f o r y o u r s e l f , you should go through these l i s t s and p i c k out between f i v e and ten a s s o c i a t i o n s , f o r each p o s i t i v e and n e g a t i v e , which are the s t r o n g e s t or best ones for you . W r i t e these oh the Urge Management A s s o c i a t i o n L i s t which you are go ing to r e t u r n to the next s e s s i o n . Then s t a r t s y s t e m a t i c a l l y u s i n g these p o s i t i v e and n e g a t i v e a s s o c i a t i o n s to s t r e n g t h e n your d e c i s i o n to not smoke and to weaken the smoking u r g e . Each time you do f o l l o w the urge w i t h n e g a t i v e a s s o c i a t i o n s and f o l l o w the d e c i s i o n w i t h p o s i t i v e a s s o c i a t i o n s , you w i l l f i n d i t i s J u s t a l i t t l e b i t e a s i e r to not smoke the next t i m e . 126 Name: Date : URGE MANAGEMENT ASSOCIATION LIST L i s t , i n order of how powerfu l they are f o r you or how w e l l you t h i n k they w i l l work, the p o s i t i v e and n e g a t i v e a s s o c i a t i o n s you are u s i n g i n urge management. P l e a s e r e t u r n t h i s l i s t to the next s e s s i o n . P o s i t i v e A s s o c i a t i o n s Negat ive A s s o c i a t i o n s SELF-STATEMENTS 127 We t a l k e d p r e v i o u s l y about the d i f f e r e n t k i n d s of t h i n g s people say or t h i n k to themselves which a f f e c t t h e i r smoking behav iour or r a t h e r which tend to i n c r e a s e the p r o b a b i l i t y of smoking. We c a l l e d t h i s t a l k i n g or t h i n k i n g to y o u r s e l f " s e l f - s t a t e m e n t s " . Here are the d i f f e r e n t k inds of s e l f - s t a t e m e n t s we t a l k e d about , some examples of them and some ideas of what to do w i t h them; 1) S e l f - s t a t e m e n t s which d e f i n e the s i t u a t i o n . Examples: 1 ) I smoke i n the c a r . 2) I smoke a f t e r d i n n e r . 3) I smoke at p a r t i e s . Ideas* 1) Redef ine the s i t u a t i o n . P r a c t i c e s a y i n g to y o u r s e l f that you d o n ' t smoke i n the c a r . 2) P r a c t i c e s a y i n g t h i n g s to y o u r s e l f which are about how to cope i n the s i t u a t i o n . "I f I set my mind to i t I can do wi thout smoking i n the car ' . The car i s a p l a c e i n which I l i k e to d r i v e , t a l k , and l i s t e n to the r a d i o and that i s a l l . : 3) Use ' f u n c t i o n a l i m a g e r y ' . Imagine y o u r s e l f - the s i t u a t i o n and see y o u r s e l f cop ing wi thout smoking. P r a c t i c e the imagery when you are p r a c t i c i n g the r e l a x a t i o n p r o c e d u r e . 2. S e l f - s t a t e m e n t s about what w i l l happen i f you d o n ' t smoke. Examples? 1) I f I d o n ' t smoke I c a n ' t c o n c e n t r a t e . 2) I f I d o n ' t smoke the guys won't l i k e me. 3) I f I d o n ' t smoke I won't be a b l e to r e l a x . Ideas ; 1) Think about the r a t i o n a l i t y of which you are sav ing to y o u r s e l f . i . e . How r e a s o n a b l e i s i t to t h i n k that i t i s the c i g a r e t t e which he lps you to c o n c e n t r a t e or to be l i k e d by other p e o p l e . 2) T h i n k through the consequences of not smoking and see j u s t how bad they a r e . For example, 'so i f the guys d o n ' t l i k e me t h a t ' s not the end of the world and i n any case i f they l i k e me because I smoke w e l l t h a t ' s not v e r y s t rong? ' Qr think; ahoin what w i l l happen i f you c a n ' t c o n c e n t r a t e and what the consequences w i l l be . 3) Where a p p r o p r i a t e use f u n c t i o n a l imagery. Imagine y o u r s e l f working and. c o n c e n t r a t i n g wi thout a c i g a r e t t e or r e l a x i n g and cop ing w i t h a s i t u a t i o n you f i n d t ense . A g a i n , p r a c t i c e the imagery when yo-are p r a c t i c i n g the r e l a x a t i o n p r o c e d u r e s . 128 2 4) P r a c t i c e s a v i n s t h i n g s to y o u r s e l f which a r e about c o p i n g and remind you of the i r r a t i o n a l i t y of your p r e v i o u s s e l f - s t a t e m e n t s • For example, by u s i n g the r e l a x a t i o n p r o c e d u r e s I can manage to r e l a x and i n any case i f I'm. t e n s e on o c c a s i o n w i t h o u t a c i g a r e t t e so what. 3. S e l f - s t a t e m e n t s about what w i l l happen i f you do smoke. Examples? 1) I f I smoke I w i l l l o o k sexy. 2) I f I smoke I w i l l be a b l e to c o n t r o l my hands. 3) I f I smoke I won't be l o n e l y . Ideas These are s i m i l a r to (2) above and the same i d e a s a p p l y . 1) Think about how r a t i o n a l , , how much sense the s e l f - s t a t e m e n t s make. 2) T h i n k about t h e i r consequences t h r o u g h . 3) Use f u n c t i o n a l imagery. 4) U s i n g c o p i n g s e l f - s t a t e m e n t s . 4 . S e l f - s t a t e m e n t s about your s e l f - c o n t r o l . Examples" 1) I can't q u i t because I've got no w i l l p o w e r . 2) I l a c k d i s c i p l i n e i n my smoking. 3) I f a i l e d q u i t t i n g l a s t time and am l i k e l y t o do the same t h i s time. I d e a s : 1) Think p o s i t i v e l y . T h i n k i n g o p t i m i s t i c a l l y about your chances of s u c c e s s i n your p r e s e n t e f f o r t s d i r e c t l y i n c r e a s e s your chances of s u c c e s s . W h i l e t h i n k i n g p e s s i m i s t i c a l l y has the o p p o s i t e a f f e c t . 2) Use ' f u n c t i o n a l imagery' and imagine y o u r s e l f as a s u c c e s s f u l non-smoker. 3) Thought s t o p p i n g -~ stop the s e l f - d e f e a t i n g t h oughts by s h o u t i n g stop 5" to y o u r s e l f and then r e p l a c i n g the stopped t h o u g h t s w i t h o p t i m i s t i c thoueht s. F i n a l l y , remember t h a t what you are t r y i n g to do i s r e p l a c e your h a b i t u a l n e g a t i v e s e l f - s t a t e m e n t s w i t h new p o s i t i v e ones. To do so means p r a c t i c i n g the new ones so t h a t they can be i n the f o r e f r o n t . I f you want to c o n t r o l your own thoughts i t does r e q u i r e p r a c t i c i n g the new t h o u g h t s 0 a good time to do so i s when you are p r a c t i c i n g r e l a x a t i o n . Handouts for Subjects i n the Cognitive Only Condition (Subjects i n t h i s condition also received "Self-Statements" cf B-2) 130 C O G C 3 REWARD PROGRAMME Smoking i s o f t e n seen by smokers as e n j o y a b l e , a r e a l s o u r c e of p l e a s u r e . Even i f you have s t o p p e d e n j o y i n g c i g a r e t t e s and f i n d t h e h a b i t d i s t a s t e f u l , g i v i n g i t up can s t i l l p r o v e s t r e s s f u l . I t i s c r i t i c a l t h a t we do what we can t o make n o t - s m o k i n g as s a t i s f y i n g as p o s s i b l e . L e a r n i n g how t o be a nonsmoker r e q u i r e s a c t i v e e f f o r t and you s h o u l d be rewar d e d f o r t h o s e e f f o r t s . You can t h i n k o f n o t smoking as a s e t of s k i l l s you l e a r n making a d e c i s i o n n o t t o have a c i g a r e t t e , s a y i n g no t o an o f f e r e d one, and f i n d i n g a l t e r n a t i v e ways of c o p i n g . P e o p l e l e a r n b e t t e r when t h e y  a r e r e w a r d e d f o r d o i n g i t r i g h t . T h i s i s t h e p r i n c i p l e of r e i n f o r c e m e n t r t h o s e t h i n p s we do w h i c h p r o v e s u c c e s s f u l or g i v e s a t i s f a c t i o n , we t e n d to do a g a i n , f i n d i n g them e a s i e r t o do t h e n e x t t i m e a r o u n d . I f n o t smoking p r o v e s s t r e s s f u l , u n s a t i s f y i n g , o r u n p l e a s a n t , i t ' s h a r d e r t o become a c o n f i r m e d non-smoker. T h i s i s t h e r e a s o n f o r a reward programme; t o p r o v i d e r e w a r d f o r n o t smoking and t o s t r e n g t h e n non-smoking s k i l l s . I t ' s a v e r y i m p o r t a n t p a r t o f any p l a n f o r q u i t t i n g . In t h e n e x t s e s s i o n , w e ' l l d i s c u s s how you can d e s i g n a reward programme f o r y o u r s e l f . Between now and then,, you need t o p l a n some r e w a r d s or r e i n f o r c e r s . In our programme we a r e g o i n g t o use i m a g i n a l s c e n e s and s e l f -s t a t e m e n t s as r e i n f o r c e r s . By u s i n g t h a t k i n d of r e i n f o r c e r you a r e i n c r e a s i n g t h e r a n g e of r e i n f o r c e r s a v a i l a b l e t o yovi as your i m a g i n a t i o n may t a k e you anywhere and you may say what you c h o o s e t o y o u r s e l f . A l s o , you a r e i n c r e a s i n g t h e p o r t a b i l i t y of your r e i n f o r c e r s -- t h e v can be used anywhere, a n y t i m e . A r e i n f o r c e r i s a n y t h i n g p o s i t i v e you can i m a g i n e o r s a y t o y o u r s e l f f o r n o t smokintr. You may i m a g i n e any s c e n e w h i c h g i v e s you p l e a s u r e , i t can be pure f a n t a s v or e l s e you may i m a g i n e y o u r s e l f d o i n g s o m e t h i n g you e n j o y d o i n g , s e e i n g someone s p e c i a l , b e i n g c l o s e t o someone s p e c i a l , b e i n g i n a f o r e i g n c o u n t r y , e a t i n g a gourmet m e a l , c o n d u c t i n g t h e V a n c o u v e r Symphony O r c h e s t r a , o r b e i n g e l e c t e d P r i m e M i n i s t e r o f Canada, w i n n e r of a" l o t t e r y , or h e i r t o t h e R o t h s c h i l d f o r t u n e s by some d i s t a n t f a m i l y l i n k . You may say r e i n f o r c i n g t h i n g s to y o u r s e l f l i k e r e m i n d i n g y o u r s e l f of y o u r p o s i t i v e , q u a l i t i e s , o r your f a m i l y ' s q u a l i t i e s , o r how e f f e c t i v e y o u r c o p i n g b e h a v i o r has been and p r a i s e y o u r s e l f f o r y o u r good b e h a v i o u r . R e i n f o r c e m e n t i s a v e r y i n d i v i d u a l t h i n g . Your r e i n f o r c e r s have t o be rewarding, f o r you. D u r i n g t h e coming week t h i n k o f good r e i n f o r c e r s and w r i t e them down. We can p i c k a c o m b i n a t i o n o f t h e b e s t ones n e x t week.. 131 - 2 -A s y o u c o n s i d e r s o m e r e i n f o r c e r s , r e m e m b e r a g o o d r e i n f o r c e r h a s s e v e r a l i m p o r t a n t q u a l i t i e s . F i r s t , i t m u s t b e p l e a s u r a b l e f o r y o u . S e c o n d l y , y o u s h o u l d b e a b l e t o c o u n t o n i t w h e n y o u w a n t i t ( a n a d v a n t a g e o f i m a g i n a l r e i n f o r c e r s ) a n d t h i r d l y , i t s h o u l d o c c u r c l o s e i n t i m e t o t h e b e h a v i o u r w h i c h i s b e i n g r e w a r d e d . 132 COGC 3 RELAXATION Many people find learning to relax b e n e f i c i a l and as part of a quit smoking program i t has been found to he c r u c i a l i f you are to succeed. Given the stresses and strains - the pace of modern l i f e i t i s not surprising that most smokers report that they smoke at least some of their cigarettes to relax. Furthermore, i t Is often under tension that i t i s most d i f f i c u l t to r e s i s t the urge to make. Another thing that we have found i s that many of the other strategies which we w i l l suggest to you work better when you are relaxed. A relaxed mind i s far freer to use i t s imagined power and to exert control over thought processes. So far at least, two major reasons i t i s important that you learn to relax: 1) because the s k i l l of relaxation can be used as an alternative to the cigarette,you would otherwise have had to relax and 2) because a relaxed person i s generally able to use and control his mental processes better. Learning to relax, l i k e learning any other s k i l l , may at f i r s t f e e l awkward but i f you nee the f i r s t stages of f r u s t r a t i o n through, you w i l l soon f e e l the benefits of good relaxation. At f i r s t a practise session should take 15-20 minutes but soon you w i l l be able to reduce that time and eventually you w i l l be able to relax in as l i t t l e as 30 seconds. So you see this technique can become very powerful and can be used almost anywhere, anyt ime. As you become more s k i l l e d , you should practise saying a relaxing word or imagining a relaxing scene and simply the assoc-i a t i o n w i l l serve as a stimulas to relaxation. Of course l i k e anv s k i l l , the more you practise the better you w i l l become. You should practise at least once a day and i f possible twice. The following i s a summary of the things you should be using" a) Make yourself as comfortable as possible b) Relax and l e t go c) Use relaxing imagery eg. l i v i n g on the beach and tanning" or sexual imagery which many people find e ffective- or any other imagery which you find relaxing. d) Coping statements - as you feel relaxed say things to yourself which are relaxing such as that you can cope with a l l situations (name them) and that nothing i s so important etc. 2 133 e ) S a y r e l a x i n g w o r d s t o y o u r s e l f s u c h a s c a l m , t r a n q u i l i t y , p e a c e , s e r e n i t y f ) F o c u s y o u r a t t e n t i o n o n a n i m a g e a n d r e l a x - i t i s t h e c o u n t i n g s h e e p p h e n o m e n o n . Y o u c a n u s e a n y t h i n g , e g . c h a n g i n g n u m b e r s o n a b l a c k b o a r d i . e . f i r s t u s e t h e 1 t h e n t h e "'21' a n d s o o n . I n a l l t h e n , i t i s i m p o r t a n t t o b e a w a r e a l l t h e t i m e o f t h e d e e p e r r e l a x a t i o n a n d b e c o m e f a m i l i a r w i t h t h e f e e l i n g s . 134 B-4 Handouts for Subjects i n the Behavioural Only Condition 135 C 0 G C 3 REWARD PROGRAMME Smoking i s o f t e n seen by smokers as e n j o y a b l e , a r e a l s o u r c e of p l e a s u r e . Even i f you have s t o p p e d e n j o y i n g c i g a r e t t e s and f i n d t h e h a b i t d i s t a s t e f u l , g i v i n g , i t up can s t i l l p r o v e s t r e s s f u l . I t i s c r i t i c a l t h a t we do what we can t o make n o t - s m o k i n g as s a t i s f y i n g as p o s s i b l e . L e a r n i n g bow t o be a nonsmoker r e q u i r e s a c t i v e e f f o r t and you s h o u l d be rewar d e d f o r t h o s e e f f o r t s . You can t h i n k of n o t smoking as a s e t of s k i l l s you l e a r n — making a d e c i s i o n n o t t o have a c i g a r e t t e , s a y i n g no t o an o f f e r e d one, and f i n d i n g a l t e r n a t i v e ways of c o p i n g . P e o p l e l e a r n b e t t e r when t h e y  a r e r e w a r d e d f o r d o i n g i t r i g h t . T h i s i s t h e p r i n c i p l e o f r e i n f o r c e m e n t : t h o s e t h i n g s x<re do w h i c h p r o v e s u c c e s s f u l or g i v e s a t i s f a c t i o n , we tend t o do a g a i n , f i n d i n g t^em e a s i e r t o do t h e n e x t t i m e a r o u n d . I f not smoking p r o v e s s t r e s s f u l , u n s a t i s f y i n g , o r u n p l e a s a n t , i t ' s h a r d e r t o become a c o n f i r m e d non-smoker. T h i s i s t h e r e a s o n f o r a reward programme, t o p r o v i d e r eward f o r n o t smoking and t o s t r e n g t h e n n on-smoking s k i l l s . I t ' s a v e r y i m p o r t a n t p a r t o f any p l a n f o r q u i t t i n g . In t h e n e x t s e s s i o n , w e ' l l d i s c u s s how you can d e s i g n a re w a r d programme f o r y o u r s e l f . Between now and then,, you need t o p l a n some r e w a r d s o r r e i n f o r c e r s . I n our programme we a r e g o i n g t o u s e i m a g i n a l s c e n e s and s e l f -s t a t e m e n t s as r e i n f o r c e r s . Ry u s i n g t h a t k i n d of r e i n f o r c e r you a r e i n c r e a s i n g t h e r a n g e of r e i n f o r c e r s a v a i l a b l e t o you as y o u r i r a a p i n a t i o r may t a k e you anywhere and you may say what you c h o o s e t o y o u r s e l f . A l s o , you a r e i n c r e a s i n g t h e p o r t a b i l i t y o f your r e i n f o r c e r s -- t h e y can be used anywhere, a n y t i m e . A r e i n f o r c e r i s a n y t h i n g p o s i t i v e you can i m a g i n e or s a y t o y o u r s e l f f o r n o t smoking. You may i m a g i n e any s c e n e w h i c h g i v e s you p l e a s u r e , i t can be pu r e f a n t a s v or e l s e you may i m a g i n e y o u r s e l f d o i n g s o m e t h i n g you e n j o y d o i n g , s e e i n g someone s p e c i a l , b e i n p c l o s e t o someone s p e c i a l , b e i n g i n a f o r e i g n c o u n t r y , e a t i n g a gourmet m e a l , c o n d u c t i n g t h e V a n c o u v e r Symphony O r c h e s t r a , or b e i n g e l e c t e d P r i m e M i n i s t e r o f Canada, w i n n e r o f a' l o t t e r y , o r h e i r t o t h e R o t h s c h i l d f o r t u n e s by some d i s t a n t f a m i l y l i n k . You may say r e i n f o r c i n g t h i n g s t o y o u r s e l f l i k e r e m i n d i n g y o u r s e l f of y o u r p o s i t i v e q u a l i t i e s , o r your f a m i l y ' s q u a l i t i e s , or how e f f e c t i v e y o u r c o p i n g b e h a v i o r has been and p r a i s e y o u r s e l f f o r y o u r good b e h a v i o u r . R e i n f o r c e m e n t i s a v e r y i n d i v i d u a l t h i n g . Your r e i n f o r c e r s have t o be r e w a r d i n g f o r you. D u r i n g t h e coming week t h i n k of good r e i n f o r c e r s and w r i t e them down. We can p i c k a c o m b i n a t i o n of t h e b e s t ones n e x t week. 136 - 2 -As you c o n s i d e r some r e i n f o r c e r s , remember a good r e i n f o r c e r has s e v e r a l i m p o r t a n t q u a l i t i e s . F i r s t , i t must be p l e a s u r a b l e f o r you. S e c o n d l y , you s h o u l d be a b l e to c o u n t on i t when you want i t (an a d v a n t a g e of i m a g i n a l r e i n f o r c e r s ) and t h i r d l y , i t s h o u l d o c c u r c l o s e i n t i m e t o t h e b e h a v i o u r w h i c h i s b e i n g r e w a r d e d . 137 BEMC 2 R E L A X A T I O N It i s not surprisinps considering the stresses and strains of everyday l i f e that most smokers report that they smoke at least some of their cigarettes to relax. Furthermore, i t i s often under tension that the smoker finds i t most d i f f i c u l t to muster the courage to say "no". Many people find learning to relax bene-f i c i a l and as part of a quit smoking program, i t has been found to be c r u c i a l i f you are to succeed. Learning to relax l i k e learning any other s k i l l requires practise. It i s l i k e learning to s k i , or to ride a b i c y c l e . At f i r s t i t feels awkward and clumsy but eventually i t , with practise, comes. And of course, the people who practise most learn i t quickest. Anyways pretty soon you w i l l f e e l the bene-f i c i a l effects of the relaxation program. Our approach uses deep muscular relaxation. We emphasize the following components in learning the s k i l l . 1) concentrate on the difference between the feelings of tension and feelings of relaxation in the muscle groups 2) pay attention to your breathing. Set your breating, S2t the beat for your t o t a l rhythm. By co n t r o l l i n g your breathing, you can control your relaxation. You should practise as often as possible. At least once ar day and i f possible twice. At f i r s t a relaxation session should take you about 20 minutes but with practise you can learn to eventually concentrate on the tense areas of your body and relax them in as l i t t l e as 30 seconds. So i t can become a very powerf technique to be used anywhere,, anytime. The following are the muscle groups you should concentrate on and in that order. You should tense the muscles, hold i t fpr about 7 seconds and then relax. You may want to do each group twice before going on to the next. But that i s not ess e n t i a l . MUSCLE GROUPS Right hand and forearm Chest,shoulders and upper back Domenant biceps Abdominal or stomach region Nondomenant hand and forearm Right thigh Nondomenant biceps Right calf Forehead Right foot Upper cheeks and nose Left thigh Lower cheeks and jaws Left calf Neck and throat Left foot If at the end of session you find certain muscle groups to be tense then go back to them and practise further on relaxing them APPENDIX C Data Analyses 139 Table C-l Analysis of Variance for Pre-estimated Smoking Rates -A l l Conditions Source df SS MS F P A l l Conditions 4 60.383 15.096 0.128 >.75 Subjects 60 7067.03 117.78 140 Table C-2 Analysis of Variance for Recorded Operant Smoking Rates -Four Treatment Conditions Source df SS MS p Treatment Conditions 3 62.47 20.82 >.75 Subjects 48 3980.05 82.92 141 Table C-3 Repeated Measures Analysis of Variance on Posttreatment and Follow-up Smoking Rates as Percentage Preestimated Over Time - A l l Conditions Source df SS MS A l l Conditions (A) 4 76466.56 19116.64 4.89 <.005 Subjects (A) 60 234315.5 3905.26 Time (T) A x T Subjects (T) 2 3135.79 1567.9 4.05 <.05 8 2264.42 283.05 0.73 >.50 120 46446.37 387.05 142 Table C-4 Repeated Measures Analysis of Variance on Posttreatment and Follow-up Smoking Rates as Percentage Operant Over Time - Four Treatment Conditions Source df SS MS F £ Treatment Conditions (A) 3 50244.81 1674.83 2.63 >.65 Subjects (A) 47 299127.06 6354.4 Time (T) 3 43717.41 14752.47 15.96 <.001 A x T 9 8153.3 905.92 >.25 Subjects (A x T) 141 128741.63 913.06 143 Table C-5 Pearson Product-Moment Correlations for Posttreatment Smoking Behaviour for Individual, Treatment Process and Evaluation Variables Posttreatment 1 month 2 months 3 months Demographic Age Sex Education Occupation -0.2921 -0.0524 -0.0942 0.1077 0.0537 -0.0234 -0.0055 0.0324 0.0303 -0.0093 -0.0124 0.0834 0.0436 0.1533 -0.0292 0.0308 Motivation Motivation Thermometer -0.2358 Desire Thermometer 0.0081 -0.0372 0.1724 -0.1713 0.0763 -0.1225 0.1044 Personality HLOC 0.1145 Self-Monitoring (PRI) 0.3406 Smoking History How Long -0.2051 Pre-estimated Rate 0.0707 Proportion Inhaled 0.0674 Depth Inhaled 0.1456^ , No. Quit Attempts -0.2655 Operant 0.0862 Reasons for Smoking Relaxation -0.0153 Affect 0.0896 Craving 0.0107 D e s i r a b i l i t y -0.1479 Stimulant 0.0894 Habit -0.0394 Reward 0.0992 AA 0.0576, 0.2374' 0.0153 0.4864 0.1371 0.0515 -0.2137 0.5326' AAA A AAA -0.0712 0.0326 -0.0683 -0.1102 0.0358 0.1205 -0.0184 -0.0199 0.1387 -0.0160^ 0.5996 0.1956 0.1154 0.5739 -0.1280 0.0057^ -0.2371 -0.0652 -0.0738^ 0.2862 -0.0273 0.0769 0.0512 -0.0042 0.5264" 0.1996 0.0863^ -0.3181 0.5549' AAA AAA -0.1359 -0.0137 -0.0869 -0.0109 -0.1166 0.1274 -0.0212 Core Process Variables Sessions Attended -0.0697 No Cigs. i n Treatment 0.6028 AAA 0.1014, 0.5142' A A 0.1256 0.4557 AAA 0.0910 0.4420 AAA continued 144 Table C-5 continued Posttreatment 1 month 2 months 3 months Mean/Satiation 0. 2218 0. 0663 0. 2987 0. 2251 Satiation as $ Operant 0. 0071 -0. 0466 0. 0135 -0. 0730 Satiation Reactions -0. 1680 -0. 0154 0. 0791 -0. 0158 Satiation Discomfort 0. 0467.. -0. 0965 -0. 1375 -0. 1812 Total Rapid Smoking 1355 Sessions V.0- 2706 -0. 2336 -0. 2236 -0. Mean T r i a l s per Session , 0. 1018 0. 1201 0. 1707 0. 2344 Mean c i g s / t r i a l -0. 0182 -0. 0327 0. 1770 0. 0680 Mean RS Reactions 0. 0678 -0. 0456 0. 0682 -0. 1195 RS Discomfort 0. 0844 0. 0090 0. 0879 -0. 0697 Posttreatment Evaluation Tallying -0. 1547* -0. 1589* -0. 1565* -0. 0968 Discussion -0. 2550 -0. 2497 -0. 2355 -0. 1196 Satiation 0. 0574 0. 1659 0. ,1540 0. ,1538 Rapid Smoking 0. 0399 -0. 0817 -0. 0457 -0. ,1140 Alternatives 0. 1789 0. 0104 -0. 0479 -0. ,0911 Self-Statments 0. 0678 0. 0462 -0. ,0899* -0. .1628. Relaxation 0. ,1966 -0. ,2228 -0. ,3442 -0. ,3504 Reward Programme 0. ,0390 0. ,0539 0. ,0819 . 0. .1078 Therapist -0. • 0 6 2 5 * * -0. • ° 0 6 2 * * -0. .0817* 0, .0542, D i f f i c u l t y 0. 0, 0. • 3352.., . 0, .4550, Confident -0. .5867 -0. .5054 -0, .4324 -0, .5205 * p < .05 p_ < .01 *** £ < .001 APPENDIX D Means and Standard Deviations for Variables Decript ive of, the Course of Treatment 146 Table D Means and Standard Deviations for Variables Descriptive of the Course of Treatment X SD Total number of sessions attended 4. 77 0. 43 Average number of cigarettes per day 3. 95 5. 81 Average number of cigarettes per sat i a t i o n day 43. 19 15. 18 Satiation as percentage operant 202. ,14 49. 80 Mean t o t a l s a t i a t i o n reactions 21. ,00 27. 02 A Mean rating s a t i a t i o n discomfort 1. ,82 1. 54 Total rapid smoking sessions 5. ,85 1. 38 Mean t r i a l s per session 1. ,97 0. 65 Mean cigarettes per t r i a l 1. ,97 0. 93 Mean t o t a l rapid smoking reactions 15. ,64 4. 15 A Mean rating rapid smoking discomfort 2. .24 0. 70 5 point scale 

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