Quitting Smoking: Strategies Used and Variables Associated With Success in a Stop-Smoking Contest

Journal of Consulting and Clinical Psychology 1985, Vol. 53. No. 6. 905-912 Copyright 1985 by the American Psychological Association, Inc. 0022-006X/85/S00.75 Quitting Smoking: Strategies Used and Variables Associated With Success in a Stop-Smoking Contest Russell E. Glasgow Oregon Research Institute J. Scott Mizes Geisinger Medical Center Robert C. Klesges North Dakota State University Terry F. Pechacek University of Minnesota One-hundred and thirty-four participants in a communitywide stop-smoking contest were assessed via telephone interviews upon entry into the contest (before the quit date) and within a week of the conclusion of the month-long contest. Subjects initially provided information on demographic characteristics, smoking history and smoking patterns, degree of nicotine addiction, perceived stress, and level of general social support, which were used to prospectively predict success at quitting. The followup interview collected short-term retrospective reports of cognitive, behavioral, and general smoking modification strategies used and amount of social support received specific to stopping smoking. Subjects reported using a variety of cognitive strategies but relatively few behavioral techniques during their attempts to quit. Although discriminant function analyses to differentiate quitters and nonabstinent subjects were statistically significant, few individual variables were strongly associated with smoking status. The only variable to prospectively predict success was degree of perceived stress. Successful abstainers used self-reward strategies and positive selfstatements more often than did less successful subjects. The implications of these results and the potential value of further investigations of quitting smoking contests are discussed. It is well known that the majority of exsmokers in our country have quit on their own without the assistance of formalized smoking cessation programs (Fisher, 1982; Schachter, 1982). However, although there has been an outpouring of research on clinic-based treatments, until recently there has been very little research on the minimally aided or self-quitting process. Pioneering work in this area by Perri and Richards (1977) and Perri, Richards, and Schultheis (1977) identified self-control strategies (e.g., self-reward) used by individuals who had been successful at modifying their Portions of this article were presented at the annual meeting of the Association for the Advancement of Behavior Therapy, Philadelphia, 1984. Appreciation is expressed to Cynthia Sillers and to memhers of the Fargo-Moorhead Heart Health Smoking Task Force for their superb work on the contest and for allowing us to collect data on the project. Thanks also go to Karen Morray for her assistance in data analysis and to Ed Lichtenstein for his comments on an earlier draft of this article. Requests for reprints should be sent to Russell E. Glasgow, Oregon Research Institute, 195 West 12th Avenue, Eugene, Oregon 97401. 905 smoking. Other researchers attempted to identify personality or subject variables associated with success at self-quitting (Baer, Foreyt, & Wright, 1977; Pederson & Baskerville, 1983). Unfortunately, such studies have been characterized by several methodological problems, such as relying predominantly on retrospective analyses, using small and possibly unrepresentative samples, and being relatively narrow in scope (e.g., assessing only personality variables or only behavioral procedures used). In one of the most sophisticated investigations of the stop-smoking process, Shiffman (1984) recently reported on coping strategies used by subjects who had been abstinent for an average of slightly over a month (range = 2 days to 1 year) and who had called into a hot-line relapse prevention phone service. The Shiffman study, as well as a recent report on the results of a stop-smoking contest sponsored by a city newspaper (Klepac, Lander, & Godding, 1984), presented data on maintenance strategies used by abstinent subjects to stay off cigarettes. In contrast, the present study investigated subject/environmental characteristics and strategies associated with success or

906 GLASGOW, KLESGES, MIZES, AND PECHACEK failure during the first month of attempted abstinence following a quit date. The study was conducted as part of a community-wide stop-smoking contest conducted by the Minnesota Heart Health Program (see Pechacek, Arkin, Jacobs, & Miles, 1982, for a more complete description of a similar contest). Such contests and lotteries provide unique opportunities to study both individual and social factors among a relatively large number of individuals attempting to quit smoking over a short period of time. The purposes of the present investigation were to (a) prospectively evaluate subject characteristics, smoking history variables, and stress and social support factors potentially predictive of success; (b) identify cognitive, behavioral, and general self-control strategies used by subjects during a month-long quit-smoking contest; and (c) determine which strategies were associated with success at stopping smoking. Subjects and Contest Method Subjects were drawn from current smokers in the Fargo- Moorhead area (population 135,000) who registered for a community-wide stop smoking contest. The contest, entitled "Quit and Win," was sponsored by the Minnesota Heart Health Program and was heavily publicized by a task force of community volunteers via radio, TV, and newspaper announcements as well as posters and brochures distributed in schools, worksites, and medical facilities. Contest eligibility criteria included being at least 18 years of age; smoking an average of at least 10 cigarettes per day for at least the past year, living within a 10-mile radius of Fargo, Moorhead, or West Fargo; and completing a legible entry form. Registration for the contest took place between November 16 and December 31, 1983. Participants could register in several ways: at registration booths at a local supermarket chain staffed by community volunteers and Heart Health staff members (more than 85% of registrants chose this method), by signing up at the Heart Health screening center, or by having a physician or dentist certify that the participant met the criteria listed above. In ail cases, participants were informed that biochemical tests (saliva thiocyanate and carbon monoxide) would be used to verify the reported smoking status of contest winners. Expired-breath carbon monoxide (CO) samples were collected and analyzed at the time of registration from all those registering at the recruitment booths and at the Heart Health Center. This CO reading needed to be at least 12 parts per million. To be eligible for a contest prize, participants were required to completely abstain from all forms of tobacco use from January 1 through January 31, 1984. Local merchants donated numerous prizes for the contest, including the grand prize of a trip for a family of four to Disney World. Other prizes included health-related equipment such as bicycles and aerobic weights and memberships in local health clubs or the YMCA. During each week of registration, 30 names were randomly selected from that week's registrants to be included in the study.' One hundred and fifty-four individuals were contacted for the initial phone interview (from 1,044 total registrants), and 150 (97%) of these persons agreed to participate. Eighty-four women and 66 men constituted this initial sample. These subjects averaged 34 years of age, reported smoking an average of 25 cigarettes per day, smoked cigarettes with an average nicotine yield of.80 mg per cigarette, and had an average score of 6.1 on the Fagerstrom (1978) Tolerance Scale. It was possible to contact 134 (89%) of these individuals within a week after the close of the contest for the follow-up phone interview described below. Procedure and Measures The initial interview, which occurred within 1 week of each participant's registration and before the January 1 quit date, involved collecting demographic and smoking history information as well as data on other potential predictors of success. Calls were approximately 20 min long and included questions on perceived stress, general level of social support, and degree of nicotine addiction. Phone interviewers were graduate-level research associates and faculty members working on a smoking modification project; they read questions from a standardized interview protocol. Demographics and smoking patterns. Background information collected included subjects* sex, age, marital and employment status, years of education, and number of previous attempts to stop smoking. Information on current smoking patterns included brand and number of cigarettes smoked, depth of inhalation, use of tobacco products other than cigarettes, and the Fagerstrom (1978) Tolerance (addiction) Scale. The Tolerance Scale has been found to be useful in predicting smoking behavior in experimental setlings (Fagerstrom, 1978) and in predicting treatment outcome in clinic-based cessation programs (Fagerstrom, 1982). Stress and social support. Cohen, Kamarck, and Mermelstein's (1983) brief version of their Perceived Stress Scale was administered at both phone interviews. This fouritem scale assesses one's appraisal of the amount of stress one has experienced in the past month (e.g., "In the last month, how often have you felt that difficulties were piling up so high that you could not overcome them?"). This version of the scale, designed to be used in telephone interviews, has been found to possess adequate psychometric qualities (e.g., coefficient alpha =.72; test-relest reliability over 2 months =.55 see Cohen et al., 1983, for more details). Social support was assessed at the initial interview in two ways: Availability of general social support was assessed via the Appraisal scale from Cohen, Mermelstein, 1 Although this was a stratified random sampling procedure (stratified by week of registration) rather than a completely random sampling method because more participants registered toward the end of the registration period, subject characteristics of the resulting sample were representative of the individuals participating in the contest.

STOP-SMOKING CONTEST 907 Kamarck, & Hoberman's (in press) Interpersonal Support Evaluation List (ISEL). This 10-item scale measures perceived support (e.g., "When I need suggestions for how to deal with a personal problem I know there is someone I can turn to.") and has been found to be associated with health-related behaviors in previous investigations (see Cohen et al., in press). The ISEL Appraisal scale has been reported to have internal reliability scores (coefficient alpha) of.70-.92 and a test-retest reliability of.87 over 4 weeks and.60 over 6 months. Smoking-specific social support was assessed via questions concerning the number of significant others (e.g., friends, family members, co-workers) who smoked and the number (if any) of these individuals who were attempting to stop smoking. Follow-up phone interviews, conducted during the first week of February, consisted of questions about the results of subjects' quit attempt and a discussion of the general approach to cessation adopted, as well as checklists of behavioral and cognitive strategies used and withdrawal reactions experienced. Finally, amount of social support received from significant others specifically for attempting to quit smoking was assessed via a 38-item version of the Mermelstein. Lichtenstein, and Mclntyre (1983) Partner Interaction Questionnaire (PIQ), which was mailed to participants. Mermelstein et al. (1983) found a correlation of.48 between their PIQ scale and smoking status at longterm follow-up. Example items from the PIQ include "Talked you out of smoking a cigarette," and "expressed confidence in your ability to quit." Seventy-seven participants returned completed PIQ questionnaires. Strategies used. A checklist was developed to assess general approaches to quitting, as well as specific behavioral and cognitive strategies. The checklist was designed to require little or no judgment on the part of interviewers as subjects were simply asked whether or not they had used each of a number of different strategies. General-approach items included cold turkey versus gradual reduction; use of brand fading techniques or commercial filters to reduce nicotine intake; use of oral substitutes (e.g., gum, candy, toothpicks); increased physical activity; direct involvement of others in the subject's quit attempt (e.g., a buddy system or a bet with someone else about quitting); and use of aversive procedures, self-hypnosis, or meditation/prayer. Behavioral strategies inquired about included self-reward and/or self-punishment procedures, relaxation techniques, stimulus control procedures, self-monitoring, and the use of specific alternative behaviors when experiencing an urge to smoke. Cognitive techniques assessed involved selfstatements about the health consequences of smoking, reminding oneself of the commitment he/she had made to stop and/or the example he/she was setting, thinking about the money that would be saved by not smoking and/or possibly winning a contest prize, and use of distraction techniques or encouraging "pep talks" to oneself. Cognitive strategies also included self-statements such as "telling myself I really don't need a cigarette," "thinking about how far I've come in quitting already," and "thinking of how weak I'll be if I give in and smoke." Preliminary Analyses Results The 16 subjects who were not able to be contacted at the end of the contest did not differ from the remaining 134 subjects on any demographic or smoking pattern variables. After being reminded that biochemical validation of smoking status would be required of all contest finalists, 55 participants (37% of the original sample and 41% of subjects contacted) reported abstinence throughout the monthlong contest. 2 For purposes of the analyses reported below, subjects needed to report continuous abstinence throughout the month of January to be classified as "successful quitters" because this was the criteria on which the contest was based. It was assumed that subjects who could not be contacted for follow-up were smoking. Parallel analyses simply dropping these subjects produced virtually identical results. Preliminary univariate analyses of variance (ANOVAS) for continuous measures and chisquare analyses for dichotomous variables revealed that there were no significant differences between men and women on success rates, smoking history, or smoking pattern measures with the exception of number of cigarettes smoked (M = 28.6 for men and 21.4 for women), ((148) = 3.97, p <.001, and degree of nicotine addiction, with men scoring as more addicted, /(136) = 1.98, p <.05. Analyses of possible sex differences on strategies used revealed a significant difference on only 1 of more than 30 analyses conducted. Finally, inspection of relations between predictor variables and success revealed highly similar patterns for both sexes. Therefore, the data were collapsed across sex for the remaining analyses. Strategies Used General. The vast majority (91%) of participants used cold-turkey rather than gradual reduction approaches to quitting. Few subjects changed brands (14%) or used commercial cigarette filters (2%) in preparation for quitting. However, 62% of participants used oral substitutes (e.g., candy, mints), and 41% reported increasing their level of physical activity. Less than 16% of participants used any of the following: aversion strategies, self-hypnosis, or 2 In a separate random sample of 100 individuals selected as contest finalists, 38% reported being abstinent throughout January, and 84% of these individuals were confirmed as abstinent by saliva thiocyanate testing.

908 GLASGOW, KLESGES, MIZES, AND PECHACEK meditation/prayer. Most subjects apparently preferred to "go it alone"; 17% made bets with others; and 34% attempted to quit, using a buddy system. In genera], subjects tried quitting abruptly without making many specific preparations or coping plans. Behavioral. Participants used behavioral techniques relatively infrequently. No more than 20% used either self-reward or self-punishment procedures, and less than 10% used self-monitoring. More subjects used some type of stimulus control technique (39%), such as restricting smoking to certain locations or times, or relaxation procedures (31%). Subjects did not report having applied these procedures in a very consistent or systematic manner. This was also true of the use of alternative behaviors ("doing something in place of smoking"), which was the most frequently reported behavioral technique (62%). Cognitive. Most subjects reported using a number of cognitive strategies (M = 8.6). The most frequently reported types of self-statements were telling oneself "I don't need a cigarette" (81%) and reminding oneself of the commitment that he or she had made to quitting (80%). Seventy-six percent of participants reported reminding themselves of the health consequences of smoking, and each of the following cognitive procedures was reported by 68%-70% of participants: using self-statements to distract oneself when experiencing an urge to smoke; thinking of the example one was setting by stopping smoking; thinking of the money that would be saved by quitting smoking; and reminding oneself about the possibility of winning a contest prize. Two additional open-ended questions were asked concerning subjects' perceptions of what contributed the most to their success or failure at stopping smoking. Abstinent subjects were asked, "What single factor do you think contributed the most to your success at quitting?" More subjects listed self-motivation (31%) than they did any other reason. Other frequently mentioned factors were health reasons (16% of successful subjects), social support received from others (15%), and the possibility of winning a contest prize (13%). Nonabstinent subjects were asked, "What single factor do you think was most responsible for your not succeeding at quitting this time?" Stress (29%) and lack of motivation (also 29%) were the most frequently given reasons. The only other factor mentioned by more than 10% of the nonsuccessful subjects was socializing with other smokers (10.3%). Predictors of Success We investigated three types of predictor variables: demographic and smoking history variables; stress and social support measures; and coping strategies. For each of these categories of predictor variables, a separate discriminant function analysis was performed, combining individual variables within that category to predict postcontest smoking status. If the discriminant function analysis produced significant results, variables that met inclusion criteria for the discriminant function were analyzed separately. T tests were performed on continuous predictor variables to identify variables that differentiated successful quitters from less successful subjects. For dichotomous predictors, such as use/nonuse of particular strategies, chi-square analyses were conducted. Due to the large number of individual tests conducted, an alpha level less than.01 was set for the univariate analyses. Demographic and smoking pattern variables. The discriminant function analysis produced significant results (Wilks's lambda = 0.90, p <.01). However, the discriminant function correctly classified only 67% of the subjects. Univariate analyses of the four variables entering into the equation failed to produce significant differences between subjects who became abstinent and those who did not. Stress and social support. Two discriminant function analyses were conducted involving stress and social support variables. An initial analysis was conducted on the variables available at pretest (perceived stress at entry, general social support, and percentage of friends and family members who smoked) and the interaction between stress and social support to prospectively predict smoking status. This analysis produced significant results (Wilks's lambda = 0.93, p <.005) but correctly classified only 60% of the participants. Univariate analyses were conducted on the variables that met inclusion criteria for entry into the discriminant function. The only individual variable associated with success was perceived stress. Cohen et al.'s

STOP-SMOKING CONTEST 909 (1983) four-item Perceived Stress Scale, collected at the initial phone call, was prospectively related to outcome,?(147) = 2.62, p <.01. In contrast, the pretest measures of social support were not significantly related to outcome. Furthermore, the interaction of Stress X Social Support did not enter into the discriminant function, thus failing to reveal mediating or "stress buffering" effects of social support. A second discriminant function analysis was performed on stress and social support variables collected at posttest (perceived stress at the end of the contest and social support received specific to smoking cessation) and the interaction of stress and social support to concurrently predict smoking status. This analysis was marginally significant (Wilks's lambda = 0.91, p <.08) but only correctly classified 58% of participants. Follow-up univariate analyses on variables entering into the discriminant function revealed that once again only level of perceived stress during the month-long contest significantly differentiated abstinent and nonabstinent subjects, (128) = 2.67, p <.01. Strategies related to outcome. Strategies from our checklist that were reported by 20%- 80% of subjects were considered as possible predictors of outcome and entered into a discriminant function analysis. This analysis produced highly significant results (Wilks's lambda = 0.58,p <.001), correctly classifying 81% of the subjects. However, these results must be interpreted with caution because of the relatively small ratio of subjects (131 with complete data on all variables) to predictor variables (20 were included as possible predictors). The 10 strategies (2 general, 3 behavioral, and 5 cognitive) that were included in the resulting discriminant function were subjected to chi-square analyses to identify individual strategies associated with success. The four strategies for which significant chi-square values (p <.01) were obtained are listed in Table 1. The only general approach strategy associated with outcome was reducing the number of cigarettes smoked in preparation for quitting, with fewer abstinent than nonabstinent subjects using this strategy. Of the behavioral strategies, only self-reward strongly differentiated quitters and smokers. As can be seen in Table 1, the use of stimulus control strategies (e.g., restricting one's smoking to certain times and places) was inversely related to outcome a finding which may be partially artifactual because the use of some stimulus control strategies (e.g., smoking in only a certain room of the house) implies that one is still smoking. Two types of self-statements were significantly related to outcome. As can be seen in Table 1, the use of the self-statement "think of the example I'll set by stopping smoking" was used by more successful than nonsuccessful subjects. The use of the negative self-statement "think how weak I'll be if I give in and smoke" was inversely associated with success. Combined use of strategies. A discriminant function analysis using the number of cognitive, behavioral, and general coping strategies used to predict smoking status was not successful in identifying abstinent subjects. It is possible that the simple number of coping strategies used might not be associated with outcome across subjects, but that being able to use a variety of individually tailored techniques would predict success (Meichenbaum, 1977). In an analysis of factors associated with maintenance of initial abstinence, Shiffman (1984) found that subjects who used a combination of at least one behavioral and one cognitive strategy were more successful than were subjects who did not. Similar chi-square analyses of the present data and related analyses of subjects who used at least two behavioral and two cognitive strategies failed to reveal significant effects. Discussion The present study is one of the few investigations to prospectively evaluate variables potentially predictive of success at stopping smoking without the aid of a formal cessation clinic. It also used a larger and more representative sample and a more comprehensive assessment of predictor variables than did previous investigations (e.g., Baer et al., 1977; Perri & Richards, 1977; Pederson & Baskerville, 1983). Our results suggest that standard demographic and smoking pattern variables such as sex, number of cigarettes smoked, number of years smoked, and degree of nicotine dependence are not meaningfully related to success among smokers attempting to quit without professional assistance. Possibly the most important finding to

910 GLASGOW, KLESGES, M1ZES, AND PECHACEK Table 1 Differences Between Abstinent and Nonabstinent Subjects on Strategies Used Percentage of subjects using strategy Strategy N Abstinent Nonabstinent X 2 (D General Cutting down on number 8 Behavioral Self-reward Stimulus control* Cognitive "Think of the example I'll set" "Think of how weak I'd be'" 132 131 131 131 131 24 34 24 82 33 53 8 51 58 64 10.4" 13.0" 9.1* 7.3* 11.6" ' Inversely related to outcome. emerge from the present study was the relation between perceived stress and success at stopping smoking. Perceived stress was one of the strongest predictors in the study, and it was consistently predictive of outcome in both prospective and concurrent analyses of the stress scale used. The ability of this measure (Cohen et al.'s, 1983, Perceived Stress Scale) to prospectively predict short-term success suggests that the often-heard attribution of failure at behavior change to high stress levels is not solely a post hoc rationalization. Stress was also mentioned frequently on the openended question about the most important reason for failure. Replications of this finding that stress is associated with the outcome of quit attempts are indicated, as are more finegrained investigations of the relative merit of life events versus daily hassles versus appraisaloriented approaches (as were used in this study) to the measurement of stress. Determination of whether less successful subjects actually experience more life events or if they appraise similar events as more stressful than do subjects who eventually quit could aid in better understanding of this relation and possibly in the development of stress-management strategies that might facilitate success. Measures of social support were not predictive of treatment outcome, either by themselves or when combined with perceived stress to evaluate possible stress-buffering effects (Thoits, 1982). It is possible that different measures of social support would have produced different results. We did, however, use three different social support measures assessing diverse aspects of social support that have proven useful in other health-related contexts (Cohen et al., in press; Mermelstein et al., 1983) and of which two are smoking specific. All of these scales revealed considerable variability among subjects, suggesting that the lack of association was not due to a restriction of range problem. Coppotelli and Orleans (1984) and Mermelstein et al. (1983) reported that social support was related to the maintenance of nonsmoking rather than to initial abstinence, and it may be that social factors play a greater role in preventing relapse than in determining initial success. It is not entirely clear from our short-term retrospective analyses of strategies utilized what particular coping techniques should be recommended to subjects. Although the overall discriminant function analysis was highly significant, few individual strategies differentiated successful quitters versus nonabstinent subjects. Two cognitive strategies were significantly related to success at quitting, but the strategy most strongly associated with outcome (use of negative self-statements about "how weak I'll be if I smoke") was used less frequently by abstainers than by smokers. This suggests that it may be helpful to instruct smokers attempting to quit what not to do as well as what to do. The finding that the use of punitive selfstatements was inversely associated with outcome is consistent with the findings of Shiffman (1984). Although that study investigated behavioral and cognitive strategies associated

STOP-SMOKING CONTEST 911 with maintenance rather than initial success at quitting and used a different categorization of strategies, it is interesting to compare the results of the two studies. Both studies found that subjects were more likely to report using cognitive strategies rather than behavioral strategies. This may be because most of the cognitive strategies assessed in both studies require little effort or investment of time compared with the more demanding behavioral strategies. Both studies found that the simple number of strategies used was not predictive of outcome. Shiffman (1984) found that the use of a combination of behavioral and cognitive strategies was significantly more effective than the use of either alone. The present study failed to confirm these findings. This may be because it is less critical to have a variety of coping strategies during the initial quitting process than it is during the later maintenance phase, or because less successful subjects had to deal with a greater number of problematic situations over time. Analyses such as those Shiffman used may be more appropriate for analyzing coping strategies used to deal with a single temptation situation rather than a number of such situations over time. Given the number of analyses conducted, particular strategies associated with success should be interpreted conservatively. The fact that previous studies have also found the use of self-reward to be one of the distinguishing characteristics of subjects who were successful in modifying their smoking (Perri et al., 1977) and changing other health-related behaviors (Bellack, Glanz, & Simon, 1976; Perri & Richards, 1977) increases our confidence that this was not a chance finding. In their study of subjects attempting to lose weight, Rozensky and Bellack (1974) found, as we did in the present study, that subjects successful at selfcontrolling their behavior used more self-rewards and fewer self-punishments (negative self-statements) than did less successful subjects. Although the present investigation was able to identify some self-control strategies associated with success, there is an important limitation to these data. Like almost all other investigations of coping techniques associated with successful cessation, this aspect of our study was retrospective in nature. Our data were collected much more closely in time to subjects* actual quit attempt than has often been the case (e.g., Baer et al., 1977; Perri & Richards, 1977), but they are still subject to the interpretive problems of subject recall. In addition, biochemical measures were not actually collected to confirm smoking status. 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