Self-help movements
Although clinical and public health interventions have proliferated over the past few decades, up to 90 per cent of ex-smokers report having stopped without any formal help (Fiore et al. 1990). Lichtenstein and Glasgow (1992) reviewed the literature on self-help quitting and reported that success rates tend to be about 10–20 per cent at one-year follow-up and 3–5 per cent for continued cessation. The literature suggests that lighter smokers are more likely to be successful at self-quitting than heavy smokers and that minimal interventions, such as follow-up telephone calls, can improve this success.
Research also suggests that smokers are more likely to quit if they receive support from their partners and if their partners also stop smoking (Cohen and Lichtenstein 1990) and that partner support is particularly relevant for women trying to give up smoking during pregnancy (e.g. Appleton and Pharoah 1998). However, although many ex- smokers report that ‘I did it on my own’, it is important not to discount their exposure to the multitude of health education messages received via television, radio or leaflets.
Public health interventions: promoting cessation
professionals are also illustrated by the results of the OXCHECK and Family Heart Study results (Muir et al. 1994; Wood et al. 1994), which are described in Chapter 9.
2 Worksite interventions. Over the past decade there has been an increasing interest in developing worksite-based smoking cessation interventions. These take the form of either a company adopting a no-smoking policy and/or establishing work-based health promotion programmes. Worksite interventions have the benefit of reaching many individuals who would not consider attending a hospital or a university-based clinic. In addition, the large number of people involved presents the opportunity for group motivation and social support. Furthermore, they may have implications for reducing passive smoking at work, which may be a risk factor for coronary heart disease (He et al. 1994). Research into the effectiveness of no-smoking policies has produced conflicting results with some studies reporting an overall reduction in the number of cigarettes smoked for up to 12 months (e.g. Biener et al. 1989) and others suggesting that smoking outside work hours compensates for any reduced smoking at the workplace (e.g. Gomel et al. 1993) (see Focus on research 5.2, page 122). In two Australian studies, public service workers were surveyed following smoking bans in 44 government office buildings about their attitudes to the ban immediately after the ban and after six months. The results suggested that although immediately after the ban many smokers felt inconvenienced, these attitudes improved at six months with both smokers and non-smokers recognizing the benefits of the ban. However, only 2 per cent stopped smoking during this period (Borland et al. 1990). Although work- site interventions may be a successful means to access many smokers, this potential does not yet appear to have been fully realized.
3 Community-based programmes. Large community-based programmes have been established as a means of promoting smoking cessation within large groups of individuals. Such programmes aim to reach those who would not attend clinics and to use the group motivation and social support in a similar way to worksite interventions. Early community-based programmes were part of the drive to reduce coronary heart disease. In the Stanford Five City Project, the experimental groups received intensive face-to-face instruction on how to stop smoking and in addition were exposed to media information regarding smoking cessation. The results showed a 13 per cent reduction in smoking rates compared with the control group (Farquhar et al. 1990). In the North Karelia Project, individuals in the target community received an intensive educational campaign and were compared with those in a neighbouring community who were not exposed to the campaign. The results from this programme showed a 10 per cent reduction in smoking in men in North Karelia compared with men in the control region. In addition, the results also showed a 24 per cent decline in cardiovascular deaths, a rate twice that of the rest of the country (Puska et al. 1985). Other community-based programmes include the Australia North Coast Study, which resulted in a 15 per cent reduction in smoking over three years, and the Swiss National Research Programme, which resulted in an 8 per cent reduction over three years (Egger et al. 1983; Autorengruppe Nationales Forschungsprogramm 1984).
4 Government interventions. An additional means to promote both smoking cessation and healthy drinking is to encourage governments to intervene. Such interventions can take several forms:
I Restricting/banning advertising. According to social learning theory, we learn to smoke and drink by associating smoking and drinking with attractive charac- teristics, such as ‘It will help me relax’, ‘It makes me look sophisticated’, ‘It makes me look sexy’, ‘It is risky’. Advertising aims to access and promote these beliefs in order to encourage smoking and drinking. Implementing a ban/restriction on advertising would remove this source of beliefs. In the UK, cigarette advertising was banned in 2003.
I Increasing the cost. Research indicates a relationship between the cost of cigarettes and alcohol and their consumption. Increasing the price of cigarettes and alcohol could promote smoking and drinking cessation and deter the initiation of these behaviours, particularly among children. According to models of health beliefs, this would contribute to the perceived costs of the behaviours and the perceived benefits of behaviour change.
I Banning smoking in public places. Smoking is already restricted to specific places in many countries (e.g. in the UK most public transport is no smoking). A wider ban on smoking may promote smoking cessation. According to social learning theory, this would result in the cues to smoking (e.g. restaurants, bars) becoming eventually disassociated from smoking. However, it is possible that this would simply result in compensatory smoking in other places as illustrated by some of the research on worksite no-smoking policies.
I Banning cigarette smoking and alcohol drinking. Governments could opt to ban cigarettes and alcohol completely (although they would forego the large revenues they currently receive from advertising and sales). Such a move might result in a reduction in these behaviours. However, other drugs such as cannabis are illegal in most countries, and this is still smoked by large percentages of the population. In addition, prohibition in the USA was remarkably unsuccessful.
F O C U S O N R E S E A R C H 5 . 2 : P U T T I N G T H E O RY I N T O P R A C T I C E – W O R K S I T E S M O K I N G B A N
A pilot study to examine the effects of a workplace smoking ban on smoking, craving, stress and other behaviours (Gomel et al. 1993).
Over the past few years many organizations have set up workplace bans. These offer an opportunity to examine the effects of policy of behaviour change and to assess the effectiveness of public health interventions in promoting smoking cessation.
Background
Workplace bans provide an opportunity to use group motivation and group social support to promote smoking cessation. In addition, they can access individuals who
would not be interested in attending clinics based in hospitals or universities. The present study examined the effect of worksite ban on smoking behaviour (both at work and outside) and also examined the interrelationship between smoking and other behaviours. The ban was introduced on 1 August 1989 at the New South Wales Ambu- lance Service in Australia. This study is interesting because it included physiological measures of smoking to identify any compensatory smoking.
Methodology
Subjects A screening question showed that 60 per cent of the employees were current smokers (n = 47). Twenty-four subjects (15 males and 9 females) completed all measures. They had an average age of 34 years, had smoked on average for 11 years and smoked an average of 26 cigarettes a day.
Design The subjects completed a set of measures one week before the ban (time 1), one week after (time 2), and six weeks after (time 3).
Measures At times 1, 2 and 3, the subjects were evaluated for cigarette and alcohol consumption, demographic information (e.g. age), exhaled carbon monoxide and blood cotinine. The subjects also completed daily record cards for five working days and two non-working days, including measures of smoking, alcohol consumption, snack intake and ratings of subjective discomfort.
Results
The results showed a reduction in self-reports of smoking in terms of number of cigarettes smoked during a working day and the number smoked during working hours at both the one-week and six-week follow-ups compared with baseline, indicating that the smokers were smoking less following the ban. However, the cotinine levels suggested that although there was an initial decrease at week one, by six weeks blood cotinine was almost back to baseline levels suggesting that the smokers may have been compensating for the ban by smoking more outside of work. The results also showed increases in craving and stress following the ban; these lower levels of stress were maintained, whereas craving gradually returned to baseline (supporting com- pensatory smoking). The results showed no increases in snack intake or alcohol consumption.
Conclusion
The self-report data from the study suggest that worksite bans may be an effective form of public health intervention for decreasing smoking behaviour. However, the physio- logical data suggests that simply introducing a no-smoking policy may not be sufficient as smokers may show compensatory smoking.
Methodological problems evaluating clinical and public health interventions
Although researchers and health educators are motivated to find the best means of promoting smoking cessation and healthy drinking, evaluating the effectiveness of any intervention is fraught with methodological problems. For smoking cessation these problems include:
I Who has become a non-smoker? Someone who has not smoked in the last month/week/
day? Someone who regards themselves as a non-smoker? (Smokers are notorious for under-reporting their smoking.) Does a puff of a cigarette count as smoking? Do cigars count as smoking? These questions need to be answered to assess success rates.
I Who is still counted as a smoker? Someone who has attended all clinic sessions and still smokes? Someone who dropped out of the sessions half-way through and has not been seen since? Someone who was asked to attend but never turned up? These questions need to be answered to derive a baseline number for the success rate.
I Should the non-smokers be believed when they say they have not smoked? Methods other than self-report exist to assess smoking behaviour, such as carbon monoxide in the breath, cotinine in the saliva. These are more accurate, but time-consuming and expensive.
I How should smokers be assigned to different interventions? In order for success rates to be calculated, comparisons need to be made between different types of intervention (e.g. aversion therapy versus cue exposure). These groups should obviously be matched for age, gender, ethnicity and smoking behaviour. What about stage of change (contemplation versus precontemplation versus preparation)? What about other health beliefs such as self-efficacy, costs and benefits of smoking? The list could be endless.
For interventions aimed at changing drinking behaviour, these problems include:
I What is the desired outcome of any intervention? Being totally abstinent (for the last month/week)? Drinking a normal amount? (What is normal?) Coping with life?
(What constitutes acceptable coping?) Drinking that is not detrimental to work?
(Should work be a priority?) Drinking that is no longer detrimental to family life?
(Should family life be a priority?) In his autobiography, John Healy (1991) describes his transition from an alcoholic living on the ‘Grass Arena’ in London to becoming addicted to chess. Is this success? Should the experts impose their view of success on a drinker, or should success be determined by them?
I How should drinking behaviour be measured? Should intrusive measures such as blood taking be used? Should self-reports be relied on?
S TA G E 4 : R E L A P S E I N S M O K I N G A N D D R I N K I N G
Although, many people are successful at initially stopping smoking and changing their drinking behaviour, relapse rates are high. Interestingly, the pattern for relapse is
consistent across a number of different addictive behaviours, with high rates initially tapering off over a year. This relapse pattern is shown in Figure 5.5.
Marlatt and Gordon (1985) developed a relapse prevention model of addictions, which specifically examined the processes involved in successful and unsuccessful cessation attempts. The relapse prevention model was based on the following concept of addictive behaviours:
I Addictive behaviours are learned and therefore can be unlearned; they are reversible.
I Addictions are not ‘all or nothing’ but exist on a continuum.
I Lapses from abstinence are likely and acceptable.
I Believing that ‘one drink – a drunk’ is a self-fulfilling prophecy.
They distinguished between a lapse, which entails a minor slip (e.g. a cigarette, a couple of drinks) and a relapse, which entails a return to former behaviour (e.g. smoking 20 cigarettes, getting drunk). Marlatt and Gordon examined the processes involved in the progression from abstinence to relapse and in particular assessed the mechanisms that may explain the transition from lapse to relapse (see Figure 5.6). These processes are described on page 126.