Psychology in the public health arena : smoking control as an example

1.b1

PSYCI'IOLOGY

III

^TllE PUBLIC llEALTl.l ARIl|lA:

SI,IOK]I\IG CO|ITROL AS A1'l IXAI'.IPLI

Melanie

hlakefield, 8.4., Dlp.

^{App. Psych.}

Thesls submìtted

in fulfilment of the

requlrements

for the

Master

of Arts

^(Applled Psychoìogy)

Department

of

^PsychoìogY

UNIVERSITY OF ^ADELAIDE December,.l988

ABSTRACT

This thesis

^{focuses on}

the

emerging

field of pubìic

^health

psychology,

particularly

upon

the

ìssues

involved in

^planning,

implementing and

evaluating health

^promotion programmes

in a

^public

health setting (Kling,

1984; Roberts,

1987). It seeks to highìight

the

compìexities

in

applying psychologicaì

theory to the

development

of

heaìth prornotlon programmes and

the difficulty of evaluating

^such

programmes i

n

an

often

pol i

ti

cal

ìy

and bureaucrati ^cal

ly

turbul ent envi ronment.

The

objectives of

^my course

of

^{study were:}

l) to acquìre skìlls in appìying psychoìogical theory to health

behaviour change and

the

deveìopment

of health

^promotion

programmes;

Ð to develop skills in the design, impìementation and evaluation of

heal

th

^{promotìon ì} nterventions;

3) to demonstrate an abi ì i ty to thi nk cri ti cal ly about appl i ed

psychology and

health

promotion, and;

4) to develop skiììs in working ìn a multidisciplinary setting.

These

objectìves

^were

to

^{be met by} undertaking work

in a

^placement capacìty

at

one

or

^more appropriate

organisations

^and

to

^be

demonstrated by ^producing

a thesis containing

^two

reports or

^reviews

(Chapters

4

and

5)

^{and one} research study ^{(Chapter 6)} '

For

the fìrst six

^months,

I

^was

enrolìed

^as

a full-tÍme

student ^and attended

a

^placement

for

1"5 days each ^week

at

Health Promotion

Services,

South

Australian

Health Commission.

After this time,

^I

gained

part-time,

and

later, full-tìme

employment

with thÍs

organisation.

Over ^my almost

six-year association with this

^agency,

as Research

Officer,

and

later

^{Senior Research}

Officer, I have

contributed to the planning,

development and

evaluation of

^health

promotÍon programmes

for

smoking

cessatìon, breast

self-examination,

drink-driving,

Ìmmunization,

high

blood ^pressure

control,

cervical cancer and mammography.

As

a result of

my'involvement

in

these programmes,

I

^{produced a}

substantial

number

of reports for the

South

AustralÍan

Health

Commission, as

well

as

a

^number

of publications.

These

reports

and

publÍcations are

included

in this thesis

as evÌdence

of

^{having met}

the objectives of

^my course

of

^study.

The work presented

in this thesis

^has

therefore

been undertaken over

a six year period.

The two

small reports

^(Chapters

4

and

5)

were

origÌnally written in

^1982,

ear'ly in the

course

of

^{my placement,}

while

data

for the larger

^{study (Chapter}

6)

were

coìlected in late '1984.

_Because

of the

tìme

lag

between

the original writing of

^these

reports

and

their inclusion in the final thesis, a

commentary on nel'l

developments

in the subject

^{area and}

their implications for

the

originaì

concìusions has been included toward

the

end

of

Chapter 5, and

in the

discussion

of

^chapter

6.

^The

reports that I have

addìtìonal

ly elected to include

date from ^{1984, and}

the

^publ

ications

date from

1986. It should be noted that the authorship of reports prior to 1985 Uses my married name (Bullock), but subsequent reports have my present name as author.

1l

Chapter

I

introduces

the

^area

of health

promotÍon and

the fÍeld of

pubì Í

c

^heal

th

psychology.

Chapter

2 gives a descriptìon of the

venue

that

served as ^my placement and an overview

of the

programmes

I contributed to, as

wel

I

as sel ected

reports

and ^pub l i catìons ^.

Chapter

3 gives

an

introduction

and background

to the subject of

smoking

cessation, a field that

consumed much

of

^my

time

on

placement and on which

the folìowing three

chapters

are

based.

Chapter

4 gives

an account

of

^an attempt

to

introduce psychoìogical

theory to the

^pìanning

of a health

^promotion

intervention.

Specifically, lt examines the role of self-attribution in smoking

cessation and

its potential app'l ication in guiding the style and

content

of television

commercials

to

^{encourage and support smoking}

cessation.

Chapter

5

presents

the theoretical

background

to the

development

of a

^programme

for

^general

practitioners to assist thelr patients to

quit smoking. This

chapter discusses

the

reasons why

the

^programme

was

not

implemented and reviews more

recent intervention results

which would

lead to the

development

of quite a different

^programme

than ori gi nal

ly

recommended.

Chapter

6 detaìls

an

investigation of

relapse

crises

experienced by

ex-smokers using

a

teìephone

'Stay Quit Line'. This

^piece

of

research was undertaken

to

examine

the situations in

^{which an}

iii.

ex-smoker

is led closer to relapse, and the affective factors making relapse more lÍkelY.

Finally,

^Chapter

7

^provides an overview

of the

^issues

at

the

interface of publlc heaìth

^and

psychology. It also

^attempts

to

ldentify

some

of the training

^needs

for

psychologists

intending to

work

in this arqa,

and dìscusses ^some

of the

promlsing

directions that are

^emerging.

lv.

IABLI OF ^CONTENTS

PREFACE STATEMENT

ACKNOI{LEDGEMENTS

LIST OF APPENDICES

LIST OF FIGURES

LIST OF ^TABLES

I .4.

2.4 2.5 2.6 2.7

CHAPTER 3:

Page

lt

V

lx.

APTER

CH I

2 3

i

2 3

ER 2:

2.1 2.2 2.3

PUBLIC HEALTH AND PSYCHOLOGY-AN INTRODUCTION

Introduction

Hi

stori cal

development

of

^{publ i}

c

^heal th The

roìe of lifestyle

behaviours

in

heaìth and di sease

Health promotion:

a

chal lenging

field for

the

psychologi st

DESCRIPTION OF PLACEMTNT

.

Introduction

.

Description

of

Placement

.

^Exampl

e no.

^I

:

^{Improvi ng}

the

^{publ i}

c's

perception

of

road accident

risk

.

^Example

no. 2:

^Seìecting

priorÍties for

hea'l

th

^{promot ì on}

.

^Example

no. 3:

^Community

organisation for

heal

th

^promotion

.

^Example

no. 4;

^Banning

the sale of

^cìgarettes

in

^packs

of

¹⁵

.

Concìuding ^remarks

X

x'l ^.

5.

9.

12.

13.

t3.

15.

19.

26.

30.

33.

cHAPT

3.5

TOBACCO SMOKING

:

A CHALLENGE FOR THE PUBLIC HEALTH PSYCHOLOGIST

Introduction

The

health

consequences

of

^smoking

Patterns

of

^{smoKing cessation}

Effectiveness

of

^{smoking cessation}

i nterventi ons

Reducing

population

smoking prevalence:

a health

^{promotion objectìve}

CHAPTER

4:

^{THE ROLE} OF SELF-ATTRIBUTION

IN

^SMOKING

CESSATION AND ITS POTENTIAL APPLICATION ^TO MASS MEDIA COMMUNICATIONS

4. I

.

Introduction

4.2. Attributlons

and

the

maintenance

of

behaviour change

4.3.

^The experience

of

ex-smokers ^who

quit

wi

thout

assi stance 3.1

3.2 3.3 3.4

35.

36.

36.

39.

41 .

42.

48.

49.

49.

55.

V

4.4. Implications for a

^{mass medìa based stop}

smoki ng programme

4.5.

Concìuding ^remarks

DEVELOPMTNT OF A GENERAL PRACTITIONER MEDIATID SMOKING CESSATION INTERVENTION

Introduction

The GP'

s

ⁱ nfl uence ⁱ

n

^smoki ng cessation

Theoretical basis of the

^{GP mediated smoking} cessation ⁱ ntervention

0utline of the

interventìon

5.4.1. First patient

consultation:

preparation

to quit

5.4.2.

^Second

patient consultation: quitting 5.4.3. Third patient consultation:

maintenance Proposed eval uation

Outcome

of the

_Project

Experience

since

¹⁹⁸³

Concl udi ng remarks

AN INVESTIGATION OF RELAPSI CRISES EXPERIENCED

BY EX-SMOKERS USTNG A TELEPHONE .STAY

QUIT LINE'

.

Introduct'ion

.

^Rationale

for the

te'lephone

'Stay Quit

^Lfne'

.

Description

of the 'Stay Quit Line'

servìce

.

^Theoreti

cal

background

of the

research component

6.4.1.

Commonalities underìyÍng addictive

behav ⁱ our ^s

6.4.2. Theoretical

^models

of

addiction

6.4.3. Marlatt's

^model

of the relapse

^process

6.4.4.

Negative

affect

as

a

determinant

of

rel apse

6.4.5. Social

^pressure as

a

determìnant

of

reì apse

6.4.6.

Coping

with

reìaPse crises

6.4.7. Speciiìc

^study hypotheses

of interest

Page

56.

58.

CHAPTER 5:

5.1.

5.2.

5.3.

60.

6l ^.

6l.

66.

70.

84.

85.

86.

88.

90.

72.

72.

74.

76.

77.

79.

83.

5.4.

CHAPTER 6:

5.5.

5.6.

5.7 ^. 5.8.

6.1 6.2 6.3 6.4

9l ^. 95.

99.

t03 108.

1r0.

112.

I 14.

6.5.

6. 6,

Resul ts

6.5. I

.

Characteri

sti

cs

of

^{cal I}

ers to the

^Stay

Qui

t

^{Li ne}

6.5.2. Characteristics of

reìapse crises

6.5.3. Characteristics of relapse crises

over

ti

^me

6.5.4.

Coping

in

^relaPse

cri

^ses

6.5.5.

Coping

in

relapse

crises over

time Di scussìon

Methodologi

cal

^{ì ssues}

The Stay

Quit Line

^as

a

service Characteri

sti cs of

^{rel apse}

cri

^ses

Copi ng i

n

rel apse

cri

ses

It4. il5.

1 18.

124.

127 .

r3r. t3r.

132.

r 33.

135.

137.

6.6. ^I 6.6.2 6.6.3 6.6.4

6.7.

Concìuding ^remarks

vl.

Page CHAPTER 7:

BI

APPENDICES

7.1 . 7 .2.

ISSUES AT THE INTERFACE OF PUBLIC HEALTH

AND PSYCHOLOGY

Introduction

The

contrìbution of

psychology

to public

health

Practical dlfficulties

Training

needs and opportunites Concluding remarks

I 39.

I 40.

I 40.

152.

I 55.

I 59.

t6r.

182.

7 .3.

7 .4.

7 .5.

vii.

LIST OF ^APPENDICIS

l. List of reports and publications prepared during the period of candidature for the degree

2.

^Pubì

ications pertaining to

"Improving

the

^publ

ic's

perception

of

road accident

risk"

3. Pubìication pertaining to "Community organisation for

heal

th

promotion"

4.

^{Pubì i}

cations

^{pertai ni ng}

to

"Banni ng

the

sal e

of cigarettes in

^packets

of

^15"

5.

^Promotion

of the 'Stay Quit

^Line'

6.

Questionnare administered

to'Stay Quit Line' callers

7.

^{Reference manual used by Stay}

Quit Line

counsellors

8.

^Length

of time abstinent,

by ^presence

of

negative

affect

9.

^Length

of

^time

abstinent,

by presence

of

^social

pressure

lO.

Length

of time abstinent,

by ^presence

of

^coping

I

l.

^Length

of time abstinent,

by ^presence

of

behavioural

coP i ng

12.

Length

of time abstinent,

by presence

of

cognitive

cop i ng

13.

Length

of time abstinent,

by ^number

of

^coping

responses

14.

Length

of time abstinent,

by ^number

of

behavioural copi ng responses

15.

Length

of time abstinent,

by numder

of

^cognitive

copi ng responses

Page

182.

I 85.

r 86.

187 .

t 88.

r 89.

r 90.

I9t ^. 192.

I 93.

I 94.

t95

r 96.

197 .

r 98.

vllt.

LIST OF IIGURES

FIGURE

l:

^Flow

chart

(abstracted _from

draft

^copy

of

GP mediated

stop

smoking programme)

Page

71.

102.

r 08.

r 08.

128

129.

I 56.

FIGURE

FIGURE

FIGURE

FIGURE

FIGURE

2:

3:

4a:

4b:

5:

Re'lapse

rates for

^{smokers, al cohol i}

cs

^and

heroi

n

addi cts

Rel apse

prevention:

specì

fi c

i ntervention strategi es

Marlatt's

suggested

association

between

negative

affect

^{and relapse}

Negative

affect

^as

a

^medÌating

factor

between

nicotine

withdrawal and relapse

Plot of the proportion of

subjects ^who used

a

coping response,

by length of

^time

absti nent

92

FIGURE

6: Plot of the mean number of coping responses

for

those using coping,

by length of

time absti nent

FIGURE

7:

Three dìmensions

of

psychological

intervention pertaining to health

^promotìon

,j

'tx

LIST OF TABLIS

TABLE

I:

TABLE 2:

TABLE 3:

TABLE 4:

TABLE 5:

TABLE 6:

TABLE 7:

TABLE 8a:

TABLE 8b:

TABLE 9a:

TABLE 9b:

TABLE l0a:

TABLE ^ì Ob:

TABLE I ^I a:

TABLE l2a:

TABLE I2b:

TABLE I 3a:

Major causes

of

death and associated

risk factors, Australia,

¹⁹⁸⁶

Treatment

strategies at the three

stages

of

smoki ng cessatìon

Summary

of

^{Bri ckman}

et

^{al .}

's

^{( I 982)}

conceplualisation

of

^models

of

addiction

Analysis

of

relapse

sìtuations with alcoholics,

smokers and

heroin

addicts

Affect

preceding relaPse crises

Type

of interpersonal ìnfluence

^preceding rel apse

cri

^ses

Reìapse ^si tuations

Length

of time abstinent,

by ^presence

of

negative

affect

Length

of time abstìnent

(combined), by

presence

of

negative

affect

Length

of time abstinent,

by ^presence

of

negátive

affect

^{(heavY smokers)}

Length

of time abstinent

(combined), by preõence

of

^negative

affect

^{(heavy smokers)}

Length

of time abstinent,

^{by presence}

of

negiti ve

affect

^{( I i}

ght

^smokers)

Length

of time abstinent

(combined), _by preõence

of

^negatìve

affect (light

smokers) Type

of

^{smoker, by presence}

of

^negative

aifect in

smokers-abstinent

for

^{seven days}

or

^ìess

Length

of time abstinent,

^{bY tYPe}

of

negatìve

affect

exPerienced

Length

of time abstinent

(combined), by

typõ

of

^negative

affect

experienced Length

of time abstìnent,

^{by presence}

of

soci

al

^pressure

7

Page

70

95

100.

il6.

lt7.

il7.

ll9 il9.

r 20.

r 20.

t 2l ^.

t2r.

122

123.

123.

X

124

TABLE ^ì 3b:

TABLE I4:

TABLE

15:

^Type

of

coPi

ex-smokers ⁱ reported

Length

of time abstinent

(combined), _by presence

of social

Pressure

Number

of

coping responses

tried

^by

ex-smokers

in the

relapse

crisis

^being

reported

ng response(s)

tried

^bY

n the

relapse

crisis

^being

Page

124.

125.

125

126

126.

r 30.

't 30.

t30

TABLE

TABLE

TABLE

TABLE

TABLE

l6:

t7:

t8:

l9:

20'.

Presence ofcoping ^response, by ^presence

of

^{smokÍ ng}

Type

of

coping response, by ^presence

of

smoki ^ng

Consumption

of alcohol,

^{by presence}

of

copi ng response

Consumption

of alcohol,

by performance

of

cogni

ti ve

copi ng

Consumption

of alcohol,

^by performance

of

behaviouraì copi ^ng

xt.

STATEl'{Il\lT

This thesis contains

no

materìal

whìch has been accepted

for

the award

of

any

other

degree

or

^diploma

in

any

university

and,

to

the best

of

^{my knowledge and}

belief, the thesis

contains no material previous'ly publlshed

or written

by another person, ^{except when due} reference

ìs

^made

in the text of this thesis.

If

accepted

for the

award

of the

^degree,

I

^consent

to the

^thesis

being made

available for

photocopying and loan.

Melanie Nakefield December,.l988

xll

^.

ACKNOI^IL IDG Iþ1i l'lTS

I

wish

to

^{express my}

appreciation to

^my

supervisors, Dr.Mike

Innes' Department

of

Psychology,

University of Adelaide,

and

Dr.

Nevi I le Owen, Department

of

Communìty Medicine,

University of Adelaide, for

thei

r

sound advi

ce,

encouragement and pati

ence.

^Thei

r

constructi ^ve

criticism

^{and comments on}

the several drafts of this thesis

^were

of

immense val ue.

I

wouìd

also like to

thank

the

South

Australìan

Health CommÍssion

for

enabl ^Ì ng me

to

undertake ^pì acement acti vi

ti es

toward

the

ful

fi

^{I ment}

of

^{my course} requirements,

particularly:

^James Cowley, former

Director of the

Health Promotìon Branch, ^who agreed

to the

^placement;

David

Nilson, formerìy

^{Research Manager, Health} Promotion Branch,

for his

support and encouragement

during the

times

I

thought

this

^thesis

would never be

finished;

Deborah Massey, r¡ho typed

earìy drafts of the thesis;

Richard Rohrsheim,

for

data processing, and; ^Adrian Esterman

for

occasional

stati

stÌ

cal

^{advi ce.}

x.t't I