Hyperstress and outcomes in a long-term smoking intervention program

Using Guided Imagery as a Primary Intervention in the Development of a Smoking Cessation Program

A formal smoking cessation program was developed using guided imagery as a primary intervention. Seventy-five participants attended seven program sessions that focused on imagery training, practice, and reinforcement. General educational materials concerning smoking and health were also provided to participants. A 79O/6 success rate for smoking reduction/cessation was achieved. Program evaluations reflected that imagery was useful to 25% of the attendees. Other beneficial techniques included behavorial coping responses, behavior modification, and social support. Stress was identified as the major cause offailure to quit cigarettes. Study data provide guidance for the development offuture programs. Further validation and refinement of imagery as a nursing intervention is recommended.

Health Conception, Health Locus of Control, and Power as Predictors of Smoking Behavior Change

The purpose for this study was to examine the value of health conception, health locus of control, and power as predictors of success or failure with smoking behavior change. Discriminant analysis was used to differentiate between subjects who successfully abstained from smoking and those who resumed smoking following participation in a smoking control program. Results indicated that an external locus of control, including expected outcomes attributed to chance and powerful others, a clinical-based conception of health, and a heightened sense of awareness, distinguished recidivists from successful abstainers. Study findings may have implications for identifying smokers who have a high probability of failing in initial attempts to quit smoking. Special instructions and interventions need to be designed to help these smokers develop a broader definition of health as more than the absence of disease, a greater sense of internal control over health practices, and an increased sense of power for participating in behavioral change.

Stress and quitting among African American smokers

This study examined the relationship between stress and the likelihood of quitting among 300 urban African American smokers enrolled in the placebo arm of a controlled randomized trial assessing the efficacy of bupropion for smoking cessation. Participants were predominantly female, middle-aged, and of lower income. Participants received 7 weeks of placebo treatment and counseling as well as a self-help guide. Quit status and stress, measured with the Perceived Stress Scale and an adapted Hassles Index, were assessed at baseline, end of treatment, and 6 month follow-up. Results indicated that although baseline stress did not predict quitting at later visits, higher concurrent stress levels were associated with not being abstinent. Furthermore, changes (reductions) in perceived stress from baseline also predicted abstinence at the end of treatment. Results suggest that methods to help African Americans cope with stress as they attempt to quit smoking may prevent relapse to smoking.

Women's Initiative for Non-Smoking (WINS) VI: reliability and validity of health and psychosocial measures in women smokers with cardiovascular disease

PURPOSE

We present psychometric properties of 9 health and psychosocial measures in a sample of hospitalized women with cardiovascular disease. This information will be useful to others needing to make choices about selection of health and psychosocial measurements in women smokers.

METHODS

Psychometric properties were examined using baseline measures from a cross-sectional study, nested within a randomized clinic trial, Women's Initiative for Non-Smoking. Women smokers hospitalized with cardiovascular disease were recruited from 10 hospitals in the San Francisco Bay Area. Measures included the perceived stress scale, a depression screener, self-efficacy, the sense of mastery scale, and measures of health-related quality of life from the Medical Outcomes Study.

RESULTS

The sample of 277 women smokers ranged in age from 34 to 86 years (mean = 61 +/- 10.1). Studies of variability, including floor/ceiling effects, skewness, range, mean, and SD, indicated that most measures had sufficient variability to be predictive and detect both positive and negative changes over time. Internal-consistency reliabilities ranged from 0.63 to 0.86. Preliminary evidence of construct validity was found, with most hypotheses being confirmed.

CONCLUSIONS

The battery of tests included in the Women's Initiative for Non-Smoking trial may be useful in identifying women at high risk of relapse and in detecting short-term quality-of-life outcomes. The measures generally performed well and show promise for advancing our understanding of the process of successful smoking cessation in this population.

SUMMARY

Psychometric properties of the perceived stress scale, a depression screener, self-efficacy for quitting smoking, the sense of mastery scale, and measures of health-related quality of life from the Medical Outcomes Study in 277 women smokers hospitalized with cardiovascular disease were examined. The measures generally performed well and show promise for advancing our understanding of smokers in this population.

Eight-year follow-up of a community-based large group behavioral smoking cessation intervention

OBJECTIVE

To evaluate the effectiveness of a large group community-based behavioral smoking cessation intervention over an 8-year follow-up period and to determine precessation predictors of cessation at each follow-up time.

RESEARCH APPROACH

Behavioral intervention followed by three longitudinal follow-up interviews.

SETTING

Regional Outpatient Cancer Centre.

STUDY PARTICIPANTS

971 participants in smoking cessation clinics held between 1986 and 1990.

INTERVENTION

Eight 90-minute sessions over 4 months utilizing education, self-monitoring, nicotine fading, a group quit date and behavioral modification techniques. Up to 110 smokers participated in each group program.

MAIN OUTCOME MEASURES

Cessation rates at 3, 6, and 12 months postquit and at 8-year follow-up. Differences between successful and unsuccessful participants in precessation demographic, smoking history, and smoking behavior variables.

RESULTS

At 3 months postquit date, 39.3% of the 971 participants reported that they were not smoking, decreasing to 32.1% at 6 months and 26.0% at 12 months. At the 8-year follow-up, 33.9% of the original sample were contacted, and of those, 47.7% reported that they were currently not smoking. There were nine predictors of cessation at the end of the program (3 months), which were similar to those previously reported in the literature. Similarly, at 6 and 12 months, six factors were associated with not smoking. At the 9-year follow-up the only variable predictive of continued abstinence was being female (p < .05).

CONCLUSIONS

This program was successful in promoting smoking cessation and maintenance, even with its large-group format. Predictive factors were similar to those previously reported in the literature.

Psychological factors affecting a medical condition: ischemic coronary heart disease

The criteria for scientific validation of the entities currently subsumed under the DSM-IV category of "Psychological Factors Affecting a Medical Condition" have never been clearly enumerated. Historically, its precursor category ("Psychophysiological Disorder") was rarely used, and predicated upon clinical observation of personality styles among patients with specific physical illnesses, or clinical observations relating psychosocial events and symptom exacerbation. Because of logical flaws with either of these methods, clarification of the most rigorous criteria for demonstrating a cause-effect relationship is necessary. With the increase in well-designed and carefully executed epidemiological and treatment studies, this diagnostic category has evolved into an arena where cutting-edge insights and therapies are becoming available for a growing variety of medical conditions, especially ischemic coronary heart disease. The present article reviews the nature of the scientific evidence necessary to accept an etiological or aggravating role for psychological events.

Influences Affecting Maintenance and Cessation of Narcotics Addiction

A sample of 354 narcotics addicts remanded to the California Civil Addict Program (CAP) in 1962–64 was followed for over twenty-four years. Self-report data collected at initial treatment admission and in two follow-up interviews (1974–75 and 1985–86) included information on family history, patterns of drug use and criminal involvement, and other behaviors. The sample was classified into four exclusive groups: Winners (N=59), who had been abstinent from narcotics and other serious drug use and had not been involved in criminal activity during the thirty-six-month period prior to interview; Striving addicts ( N=46), who had been abstinent from narcotics use, but not necessarily other drugs, and had no incarceration for a period of twelve months prior to interview; Enduring addicts ( N=146), who had used narcotics and typically other drugs within the prior 12-month period, but had avoided incarceration; and Incarcerated addicts ( N=103), incarcerated at some time during the twelve-month period, and whose drug use was varied. Winners had generally negative familial experiences including little encouragement from parents, who in the main had adverse relationships, higher rates of sexual molestation, and were least happy in childhood. Despite this environment Winners evidenced early independence and self-confidence. Striving addicts were characterized by usually non-substance-using, church-going parents. Most had ceased narcotics use, but remained heavily involved with alcohol and marijuana. Enduring addicts, mostly from lower socioeconomic status families that exhibited extensive substance use and physical arguments, commonly accessed methadone treatment and avoided incarceration while persisting in narcotic addiction and crime. Incarcerated addicts, typically raised in dysfunctional, substance-using families, received the most parental caring along with the most severe punishment. They exhibited persistent involvement in crime, violence, and drug use.

Differential rates of relapse in subgroups of male and female smokers

Subjects for this study were 265 participants of stop-smoking clinics (mean age = 42.6 years; average number of cigarettes smoked daily = 26.0) who were examined before and immediately after cessation and then followed for 1 year. The objective of this study was to identify subgroups of smokers with different rates of relapse using tree-structured survival analysis, a multivariate approach to classification. Five distinct subgroups that differed with respect to the rate of relapse were identified: (I) subjects (n = 15) with very low precessation cotinine levels (< or = 129 ng/ml), who had an exceptionally low rate of relapse (mean abstinence time = 270 days); (II) women 32 years old and younger (n = 24), who had a very high rate of relapse (mean abstinence time = 30.5 days); (III) women over 32 years old (n = 121), with the next highest rate of relapse (mean abstinence time = 98.9 days); (IV) men 36 years old and younger (n = 31), who had a mean abstinence time of 196.7 days; and (V) men over 36 years old (n = 74), who abstained an average of 130.2 days before relapsing. Relapse curves for all groups (except III vs V) differed significantly from each other, p < 0.05. Results indicate that this approach can identify interactions among individual differences that are variably associated with relapse rates. Identification of relapse subgroups may have important implications for both theories and treatment of smoking relapse.

Preventing relapse in the treatment of nicotine addiction: current issues and future directions

Although smoking-cessation rates have continued to increase, the vast majority of smokers who quit eventually relapse. Between 1974 and 1985, over 1.3 million smokers quit during each of those years. However, 75% to 80% of those individuals resumed smoking within six months. This article describes the dynamic phenomenon of smoking relapse within the context of cyclical episodes of smoking and quitting during an individual's lifetime. Theories of the determinants of smoking relapse are reviewed and methods designed to prevent relapse are described. Smoking relapse is discussed in terms of three aspects of tobacco addiction: (1) biological-addiction mechanisms, (2) conditioning processes, and (3) cognitive-social learning factors. The major determinants of smoking relapse are reviewed, including nicotine withdrawal, stress, weight gain, social influences, conditioning factors, causal attributions, and environmental variables. A transtheoretical-developmental model is explored in the longitudinal investigation of the natural history of slips (lapses) and relapse episodes. Relapse prevention interventions are described that emphasize self-awareness, self-regulation, self-efficacy, affect regulation, social support, and lifestyle balance. Recent developments in pharmacological adjuncts to treatment are also examined. It is concluded that innovative relapse prevention methods need to be designed for hard-core smokers with histories of cessation failures, substance abuse and/or psychiatric impairment. These and other recommendations for future research on smoking relapse and relapse prevention are discussed.

Affect regulation, nicotine addiction, and smoking cessation

Numerous investigators have examined the role of negative affective states and affect regulation in the initiation and development of cigarette smoking behavior, smoking cessation, and relapse prevention. Affect regulation refers to any attempt to alleviate negative mood states by means of pharmacologic-, cognitive-, behavioral- or environmental-change methods. The psychological construct/process of affect regulation is examined in relation to (1) the initiation, development, and maintenance of the cigarette smoking habit; (2) the process of quitting smoking; and (3) the long-term maintenance of smoking abstinence versus relapse. Various psychosocial factors and physiological mechanisms are explored that have been hypothesized to be links between negative mood states, nicotine addiction, and smoking cessation. Implications for smoking cessation treatment are discussed in the areas of (1) the use of pharmacologic agents, such as clonidine, in the reduction of nicotine withdrawal symptoms; (2) nicotine replacement therapy; and (3) skills-training approaches to smoking cessation and relapse prevention.

Personal power imagery and relaxation techniques used in smoking cessation programs

BACKGROUND

Theoretically-based interventions are necessary for enhancing the power of self-control behaviors in smokers attempting to quit smoking cigarettes. The purpose of this study was to examine the use of guided imagery and relaxation techniques as interventions for smoking cessation. The relationship of imagery and self-control was also examined.

METHODS

A convenience sample of 84 adult smokers participated in one of three treatment conditions: power imagery (n = 28), relaxation imagery (n = 29), and "placebo" control (n = 27). Treatment group members were taught imagery during a six-session smoking cessation program, and the control group was provided imagery training upon study completion.

RESULTS

Smoking quit rates were 67% for the power imagery group, 69% for the relaxation group, and 27% for the control group. At a three-month follow-up, the power imagery group had a continued abstinence rate of 52% (relapse rate = 48%), the relaxation group had an abstinence rate of 55% (relapse rate = 45%), and the control group cessation rate remained at 27% (relapse rate = 73%). One-way and repeated measures MANOVAs demonstrated significant differences among the three groups at posttreatment, F (8, 158) = 13.92, p less than .05, and revealed that the practice of imagery treatments over time produced changes in power test scores and smoking rates, F (3, 127) = 24.67, p less than .05.

DISCUSSION

This study demonstrated that power and relaxation imagery treatments were equally effective in reducing smoking rates. Further investigations into the therapeutic uses of imagery are recommended.

Smoking, social support, and hassles in an urban African-American community

BACKGROUND

Despite public health efforts, the prevalence of smoking among African Americans remains high. The determinants of smoking behavior in this population must be elucidated so that interventions can be better targeted and more effective.

METHODS

As part of a prospective community intervention trial to reduce cancer mortality, we conducted a random household survey of 1137 African-American adults in San Francisco and Oakland between November 1985 and July 1986. The survey instrument included questions about social network characteristics, instrumental and emotional aspects of social support, smoking behavior, and stressors.

RESULTS

The overall prevalence of smoking (41.9%) was higher than that reported in national surveys. Logistic models revealed that persons reporting high levels of stress, represented by an abbreviated hassles index, were more likely to smoke than those reporting less stress. Women with poor social networks were more likely to smoke (odds ratio = 3.1) than women with optimal networks; however, this relationship did not hold among men. Indeed, men lacking emotional support from friends or family were less likely to smoke (odds ratio = 0.5) than men receiving such support. No interaction between social support and hassles was observed.

CONCLUSIONS

Stressful environments may contribute to high-risk smoking behavior among urban African Americans.

Preventing relapse in the treatment of nicotine addiction: current issues and future directions

Although smoking-cessation rates have continued to increase, the vast majority of smokers who quit eventually relapse. Between 1974 and 1985, over 1.3 million smokers quit during each of those years. However, 75% to 80% of those individuals resumed smoking within six months. This article describes the dynamic phenomenon of smoking relapse within the context of cyclical episodes of smoking and quitting during an individual's lifetime. Theories of the determinants of smoking relapse are reviewed and methods designed to prevent relapse are described. Smoking relapse is discussed in terms of three aspects of tobacco addiction: (1) biological-addiction mechanisms, (2) conditioning processes, and (3) cognitive-social learning factors. The major determinants of smoking relapse are reviewed, including nicotine withdrawal, stress, weight gain, social influences, conditioning factors, causal attributions, and environmental variables. A trans-theoretical-developmental model is explored in the longitudinal investigation of the natural history of slips (lapses) and relapse episodes. Relapse prevention interventions are described that emphasize self-awareness, self-regulation, self-efficacy, affect regulation, social support, and lifestyle balance. Recent developments in pharmacological adjuncts to treatment are also examined. It is concluded that innovative relapse prevention methods need to be designed for hard-core smokers with histories of cessation failures, substance abuse and/or psychiatric impairment. These and other recommendations for future research on smoking relapse and relapse prevention are discussed.

Affect regulation, nicotine addiction, and smoking cessation

Numerous investigators have examined the role of negative affective states and affect regulation in the initiation and development of cigarette smoking behavior, smoking cessation, and relapse prevention. Affect regulation refers to any attempt to alleviate negative mood states by means of pharmacologic-, cognitive-, behavioral- or environmental-change methods. The psychological construct/process of affect regulation is examined in relation to (1) the initiation, development, and maintenance of the cigarette smoking habit; (2) the process of quitting smoking; and (3) the long-term maintenance of smoking abstinence versus relapse. Various psychosocial factors and physiological mechanisms are explored that have been hypothesized to be links between negative mood states, nicotine addiction, and smoking cessation. Implications for smoking cessation treatment are discussed in the areas of (1) the use of pharmacologic agents, such as clonidine, in the reduction of nicotine withdrawal symptoms; (2) nicotine replacement therapy; and (3) skills-training approaches to smoking cessation and relapse prevention.

Risk factors for late relapse in male and female ex-smokers

Three hundred twenty-nine ex-smokers (149 males and 180 females) who had maintained abstinence for at least 3 months prior to intake were followed for a period of 1 year to ascertain individual characteristics from cognitive, behavioral, environmental, and health domains that were predictive of later relapse. Multiple logistic regression analysis revealed significant associations between relapse, family history, and stress variables in males and between relapse, family history, stress, pre- and postcessation smoking characteristics, work-related variables, and physical activity in females. Within the predictor sets, both risk and protective factors were identified. The male and female models are discussed separately, compared, and related to previous research. Implications for further model development are specified; most notably, the utility of conceptualizing relapse independent of gender is questioned. Future research efforts could focus on the role played by family smoking history in adult relapse behavior. Smoking cessation interventions may need to tailor their efforts specifically to men and to women. Along with techniques to manage stress both during and after cessation, women may benefit especially from interventions that provide nicotine replacement and counseling for work-related difficulties.

Addiction as an Adaptive Response: Is Smoking a Functional Behavior?

Theories on tobacco addiction divide into two camps, the exposure orientation and the adaptive orientation. The exposure orientation suggests that the use of tobacco is addictive because of the reinforcement properties of tobacco or because of tobacco's biochemical-altering effects. The adaptive orientation views tobacco addiction as a functional response to distress and, therefore, a form of sub-optimal adaptive behavior. Though the two views are not mutually exclusive, the case is made that the primary cause of addiction is explained by the adaptive orientation, and not the exposure orientation. Viewing not only tobacco addiction but all addictions from the adaptive orientation suggests different approaches to social policy and psychotherapy than those presently espoused by the exposure orientation.

Cigarette smoking outcomes at four years of follow-up, psychosocial factors, and reactions to group intervention

Carried out a study on a sample of male smokers (N = 182) who were at high risk of coronary heart disease (CHD) in order to determine the variables that discriminated between successful and nonsuccessful quitters in a group intervention program designed to lower CHD risk factors. The analysis revealed that baseline level of smoking, life events, personal security, and selected group process variables were predictive of success or failure in the intervention program. Recommendations for future study and clinical application were discussed.

Who quits smoking in a behavioral treatment program?

Data from a smoking cessation program were analyzed to identify the variables that best predicted posttreatment abstinence. Nonsmoking immediately following treatment was predicted by lower daily pretreatment intake of nicotine and total particulate matter (TPM), as well as higher score on the "handling" scale of the "Why Do You Smoke" scale. Abstinence at any time in the 6 months following treatment was also predicted by lower pretreatment nicotine and TPM intake; other predictors were lower scores on the "craving" scale, greater number of weeks spent participating in the program, citing reasons for wanting to quit smoking other than to overcome an addiction, and lower self-rated craving for cigarettes. Abstinence was not predicted by subjects' adherence to the treatment rules calling for changing the times, occasions and feelings that are associated with the heaviest smoking. Daily cigarette consumption dropped during treatment at similar rates for the smokers who would eventually be abstinent and those who would not. These results replicate the finding that a behavioral self-control program can bring about a reduction in smoking in many smokers, though relatively few actually quit smoking. Also, smokers who find the manipulations involved in smoking to be rewarding are more likely to be abstinent, at least temporarily, following a behaviorally oriented program than are smokers who are most rewarded by the self-administration of nicotine. Smoking cessation programs might benefit by tailoring treatment to such pretreatment subject characteristics.