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University of Southern California Dissertations and Theses
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The Effect Of Nonspecific Factors On The Modification Of Smoking Behaviorin Treatment Follow-Up
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The Effect Of Nonspecific Factors On The Modification Of Smoking Behaviorin Treatment Follow-Up
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THE EFFECT OF NONSPECIFIC FACTORS ON THE MODIFICATION OF SMOKING BEHAVIOR IN TREATMENT FOLLOW-UP by Frederick Lee Richardson A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (Psychology) June 1972 INFORMATION TO USERS This dissertation was produced from a microfilm copy of the original document. While the most advanced technological means to photograph and reproduce this document have been used, the quality is heavily dependent upon the quality of the original submitted. The following explanation o f techniques is provided to help you understand markings or patterns which may appear on this reproduction. 1. The sign or "target" for pages apparently lacking from the document photographed is "Missing Page{s)'\ If it was possible to obtain the missing page(s) or section, they are spliced into the film along with adjacent pages. This may have necessitated cutting thru an image and duplicating adjacent pages to insure you complete continuity. 2. When an image on the film is obliterated with a large round black mark, it is an indication that the photographer suspected that the copy may have moved during exposure and thus cause a blurred image. You will find a good image of the page in the adjacent frame. 3. When a map, drawing or chart, etc., was part of the material being ‘ photographed the photographer followed a definite method in "sectioning" the material. It is customary to begin photoing at the upper left hand corner of a large sheet and to continue photoing from left to right in equal sections with a small overlap. If necessary, sectioning is continued again — beginning below the first row and continuing on until complete. 4. The majority of users indicate that the textual content is of greatest value, however, a somewhat higher quality reproduction could be made from "photographs" if essential to the understanding of the dissertation. Silver prints of "photographs" may be ordered at additional charge by writing the Order Department, giving the catalog number, title, author and specific pages you wish reproduced. University Microfilms 300 North Zeeb Road Ann Arbor, Michigan 48106 A Xerox Education Company 72-26,050 RICHARDSON, Frederick Lee, 1934- THE EFFECT OF NONSPECIFIC FACTORS ON THE MODIFICATION OF SMOKING BEHAVIOR IN TREATMENT FOLLOW-UP. University of Southern California, Ph.D., 1972 Psychology, clinical University Microfilms, A XEROX Company, Ann Arbor, Michigan THIS DISSERTATION HAS BEEN MICROFILMED EXACTLY AS RECEIVED. UNIVERSITY OF SOUTHERN CALIFORNIA THE GRADUATE SCHOOL UNIVER SITY PARK LOS ANGELES. C A LIFO R N IA 9 0 0 0 7 This dissertation, written by Frederick Lee Richardson....... under the direction of A.is.. Dissertation Com mittee, and approved by all its members, has been presented to and accepted by The Graduate School, in partial fulfillment of requirements of the degree of D O C T O R O F P H IL O S O P H Y Dean Date i£ u n e . . - 1 9 - 7 .2 . ............... DISSERTATION COMMITTEE Chairman PLEASE NOTE: Some pages may have in d istin ct p rin t. Filmed as received. University Microfilms, A Xerox Education Company TABLE OF CONTENTS Page INTRODUCTION ...................................... 1 Review of Literature............................ 1 Treatment Strategies............................ 2 Major Areas of Investigations .................. 6 Inferences from Above Studies .................. 7 Design Issues .................................. 9 Purpose of Present Study........................ 14 Experimental Hypotheses ........................ 20 PROCEDURE........................................... 22 Subjects......................................... 22 Design........................................... 22 Instruments.............................. 23 Recruitment of Subjects........................ 31 Answering Service .............................. 32 Answering Service Callback Procedure............ 34 Orientation.................................... 35 Treatment Session.............................. 39 Treatment Procedure ............................ 47 Follow-Up Procedure ............................ 52 ii Table of Contents — continued Page RESULTS............................................... 55 DISCUSSION........................................ 81 APPENDIX I - A d ............................... 89 II - Personal History................. 9 0 III - Self Evaluation Questionnaire..... 91 IV - Rotter Internal-External Scale .... 93 V - Conflict Resolution Inventory..... 97 VI - Horn Self-Testing Kit..............105 VII - Campus Poster...................... Ill VIII - Instructions for Research Assistants . 112 IX - Procedure for Orientation Meeting. . . 115 X - Daily Record Keeping Form.......... 122 XI - Final Follow-Up Instructions......123 REFERENCES...................................... . 127 ill LIST OF TABLES Page Table 1 MULTIVARIATE ANOVA (FOLLOW-UP FOR THE FOLLOWING VARIABLES: SEX, AGE, DAILY SMOKING RATE, AND YEARS SMOKED.............. 43 2 MULTIVARIATE ANOVA (MAIN EFFECT) FOR THE FOLLOWING VARIABLES: SEX, AGE, DAILY SMOKING RATE, AND YEARS SMOKED........ 44 3 MULTIVARIATE ANOVA (INTERACTION) FOR THE FOLLOWING VARIABLES: SEX, AGE, DAILY SMOKING RATE, AND YEARS SMOKED........ 45 4 GROUPS MEANS (WITH STANDARD DEVIATION) FOR AGE, DAILY SMOKING RATE, AND YEARS SMOKED VARIABLES.................... 46 5 MEANS, STANDARD DEVIATIONS, AND N FOR PRETREATMENT, TREATMENT, ANF FOLLOW-UP DAILY SMOKING RATE.......................... 61 5A MEANS, STANDARD DEVIATIONS, DIFFERENCES, AND WEEK SLOPE OF SMOKING RATE BEFORE AND AFTER FOLLOW-UP TELEPHONE CALLS ........ 63 6 TEST OF MAIN TREATMENT EFFECTS, SATIATION AND AWARENESS............................... 65 7 TEST OF FOLLOW-UP EFFECT..................... 66 8 TEST OF INTERACTION FOLLOW-UP CONTACTS AND MAIN TREATMENT.......................... 68 9 RELATIONSHIP BETWEEN STOPPING SMOKING AND TREATMENT CONDITION AT END OF TREATMENT AND END OF 7-WEEK FOLLOW-UP................ 77 10 RELATIONSHIP BETWEEN 50-99% REDUCTION IN SMOKING RATE AND TREATMENT CONDITIONS AT END OF TREATMENT AND END OF 7-WEEK FOLLOW-UP. 78 iv LIST OF FIGURES Page Figure 1 Research Design..................................18 1A Comparison of double satiation and awareness (weekly follow-up subgroups) during pretreat- ment, treatment, and follow-up.............. 69 2 Comparison of double satiation and awareness (biweekly-twice a week follow-up subgroups) during pretreatment, treatment, and follow-up. 70 3 Comparison of double satiation and awareness (biweekly follow-up subgroups) during pre treatment, treatment, and follow-up.............71 4 Comparison of double satiation and awareness (monthly follow-up subgroups) during pre treatment, treatment, and follow-up.............72 5 Comparison of double satiation and awareness (no contact follow-up subgroups) during pre treatment, treatment, and follow-up.......... 73 6 Comparison of all subgroups in double satiation and awareness groups during pre treatment, treatment, and follow-up.......... 74 7 Comparison of major groups (double satiation and awareness) at pretreatment, treatment, and follow-up................................ 75 v INTRODUCTION Review of Literature This section presents a selective but represen tative review of smoking modification studies. In general, the modification of smoking behavior received impetus following publication of the Surgeon General's Report in 1964. The hypothesis relating smoking to various health disorders has received substantial support since that time (National Clearinghouse for Smoking and Health, Annual Reports). Not all research on smoking is directed at the mod ification of this target behavior. The tobacco industry is supporting research, for example, aimed at removal of harmful substances from the tobacco leaf (Moshy and Walter, 1968) and development of improved filtration devices for cigarettes (George, 1968). However, the majority of behavioral research which receives only minor funding is directed at the modification of smoking be havior (Bernstein, 19 69; Keutzer, Lichtenstein, and Mees, 1968) . 1 Treatment Strategies An impressive array of therapeutic techniques has been directed at the modification of smoking behavior. Treatment strategies include coverant control - covert operant (Homme, 1965; Premack, 1971), coverant sensitiza tion (Marston and McFall, 1971), contractual management (Janis and Hoffman, 1971), operant conditioning with aver- sive consequences (Powell and Azrin, 1968), and operant conditioning without aversive consequences (Azrin & Powell, 19 68). Aversive techniques which employ hot, smoked filled air (Wilde, 1964) and apomorphone (Raymond, 1964) have also been utilized as treatment strategies. No attempt is here made to exhaustively enumerate the various treatments of smoking behavior. However, several widely employed treatments require noting. Phar maceuticals, i.e., Lobeline, Smokurb, and prescription medications were extensively employed before and after issuance of the Surgeon General's Report (Rapp, Dusza, and Blanchet, 1959; Swartz and Cohen, 1964). Addition ally, hypnosis (Moses, 1964), discussion groups (Janis and Hoffman, 1971), relearning (Pyke, Agnew, and Kopperud, 19 66), and group counseling (Lawton, 1962; Marston and McFall, 1971; Schwartz and Dubitzky, 1969; Weir, Dubitzky, and Schwartz, 1969) are extensively employed as treatment modalities. Experiments have also concentrated on various types of communication (Evans and Borgatta, 1970; Moan and Feick, 1968). The theoretical rationale of each of the above treatment strategies generally reflect the investigator's notion of what maintains or reinforces the smoking behav ior. In general, investigators that are behavioristically inclined view the maintenance of smoking behavior as being reinforced by a variety of environmental discriminative stimuli (Mauser, 1971; Roberts, 1969). In the aversive operant model, for example, treatment consists of the application of a noxious stimulus at the time the smoking behavior occurs and the variation of the CS-UCS interval. The noxious stimulus can be applied at various intervals (Powell and Azrin, 1968). However, Mauser (1971), and Azrin and Powell (19 68) note that shock and other forms of punishment are sufficiently aversive in the laboratory or therapeutic setting to: a) reduce the number of subjects with which this method can be employed and b) to reduce the probability of generalization to nonlaboratory/thera- peutic settings. In reference to point (a), Schwartz and Dubitzky (196 7b) in a large smoking study in Northern California found a wide variation among individuals who expressed willingness to try 10 different smoking with drawal methods. Most studies employing the above techniques report varying success rates at the end of treatment (Bernstein, 1969). If success is defined as the complete cessation of smoking at termination of treatment, the variation in success rate is quite large. Bernstein (1969) in a rather thorough review of the smoking modification literature reports that the success of smoking clinics ranged from 30 percent to 85 percent. Other reviewers (Bernstein, 1969; Keutzer et al., 1968) indicate that any and all treatment procedures result in a decline of smoking behavior at the end of treatment. (An excep tion is the study conducted by Greene (1964) with mental retardates. Here an increase in smoking rate during treatment was attributed to clicking sounds produced by the experimental apparatus). This reduction in the target behavior by the various forms of treatment is quite dismal and expensive when com pared to the data presented by Premack (19 71), as reported by Mauser (1971). This latter investigator indicates that approximately one million persons per year cease smoking without treatment. But even this large number of "quit ters" does not lessen the magnitude of the problem. Assuming that this rate were to remain constant, in 1975 there would remain at least 40 million persons smoking in the United States. Horn (1968) reports there are 49 million smokers in the nation. Therefore, the search for effective treatment variables for this population remains essential. This is indicated by an increase in the utilization of different treatment strategies simul taneously (e.g., Bernstein, 1970; Keutzer, 1968; Marston- McFall, 1971; Schwartz, et al. , 1967a, 1967b, 1968a, 1968b; Straits, 1970). There is no question that experimental as well as field investigations aimed at the modification of smoking behavior produces a decline in smoking behavior by the end of treatment. However, relapse to base rate smoking levels is the rule rather than the exception at follow-up (Bernstein, 1969; Cautela, 1970; Dubitzky and Schwartz, 1969). One of the most striking reports is that of Resnick (196 8) . This investigator employed double and triple cigarette smoking as treatment strategies. He reports that there were significant differences between the satiation and control groups at the end of treatment and at two-week and four-month follow-up in the mean number of cigarettes smoked (p. 503). Most studies, however, do not employ long-term follow-up (Baldridge, et al., 1968; Bernstein, 1969; Jenks Schwartz, and Dubitzky, 1969; Lawton, 1967; Elliott and Tighe, 1968). Those studies which report long-term follow-up indicate that the end of treatment success rate drops drastically to 12 percent to 20 percent at twelve to fifteen month follow-up periods (Bernstein, 1969; Mair, 1970). Most of the relapse rated is noted in two to four months following treatment (Pyke, et al., 1966; Dubitzky and Schwartz, 19 69). This relapse rate has captured the attention of investigators who are interested in the modification of smoking behavior, especially behavior therapists. This latter group of investigators/therapists have been suc cessful in the modification of other target behaviors with little or no relapse (e.g., Phobias cf. Paul, 1966; Paul, 1969). Bandura, Blanchard, and Ritter (19 6 8) found no re version to snake avoidance behavior in a follow-up study. Inasmuch as smoking is a well defined naturally occurring behavior, the relatively limited success with this target behavior has resulted in a tremendous search for corre lates of smoking behavior. Major Areas of Investigations A major focus of investigation has been the eluci dation of variables that would differentiate smokers from nonsmokers. Wolitzky (1967), employing the Stroop Color Word Test, found that certain smokers tend to minimize the relationship between smoking and health hazards. The two major types of variables investigated were constitutional and personality variables. A major effort has been aimed at distinguishing smokers from non-smokers (Baer and Katkin, 1971; Matarazzo and Saslow, 1960; Johnson, 19 68; Reiter, 1970; Smith, 1969; Walter, 1969). Schneider and Houston found that smokers have a higher anxiety score than nonsmokers (of., Walter, et al.). The characteris tics of post treatment successes from non-successes (Keutzer, 1968; Mann and Janis, 1968; Platt, et al., 1969; Walker, et al., 1969). Other investigators (e.g., Dies, Honeyman, Reznikoff, and White, 1969) seek genetic factors in examining the etiology of smoking behavior. Eysenck (1965) also posits a genetic factor as being involved in smoking behavior. The search for stable characteristics that have high or moderate correlation with the acquisition and/or ex tinction of smoking behavior has not yielded the results that were anticipated. Consequently, recent investigations have focused on dimensionalization of variables within the class of smokers. Inferences from Above Studies The studies cited above represent only a small sample of the population of smoking studies. Yet they appear to be representative of that population. There are several general conclusions that can be inferred from the above studies: A. Genetic or constitutional factors do not appear to be sufficient and necessary conditions for the acquis ition of smoking behavior. Dies', et al., (1969) research with a monozygotic twin population found that smoking acquisition was unrelated to genetic factors (cf. Forbes, 1970). B. The search for stable personality characteris tics of smokers and nonsmokers remains elusive (Bernstein, 1969; Mair, 1970). 1. Schwartz and Dubitzky (19 68b) found an inverse relationship between anxiety scores and modification of smoking behavior. Keutzer (19 68) did not find anxiety level related to modification of smoking behavior. Somewhat related to anxiety (however mea sured) is Eysenck's (1965) finding that smokers score higher on the extra-version dimension (cf., Schneider, 1970). 2. Rotter's (1966) measures of internal- external control (I-E) lias generally found a positive relationship between external control and smoking. James, Woodruff, and Werner (1965) report a relationship between external orientation and smoking. Straits and Sechrest (196 3) reported similar findings. Platt, Krassen, and Mausner (1969) report that subjects who reduce their smoking rate had lower I-E scores (cf., Hjelle and Clouser, 1970; James, et al., 1965). C. With respect to treatment or modification of smoking behavior, all techniques seem to be effective at end of treatment (cf., Bernstein (1969); Marston and McFall, 1971; Whitman, 1969). D. Post treatment relapse occurs rather extensively as evidence by smoking rate at subsequent follow-up periods (Bernstein, 1969; McFall and Hammen, In Press). Design Issues Critical issues have been raised by the past studies in regard to experimental design. Bernstein (19 69) attri butes the end of treatment success results to "nonspecific factors" that are inherent in the treatment process. He (p. 432) advocates the following controls for distin guishing "nonspecific effects" from treatment effects. A. Attention-Placebo Control; Here subjects in this treatment condition receive the same degree of ther apist contact, attention, and other variables except the experimental treatment. B. Effort Control; In this condition, subjects are told that they are acceptable for treatment but must wait for a specified time period (which corresponds to the duration of the experimental treatment period) prior to being accepted into the treatment program. C. Expectation Control; Here, subjects are asked to quit smoking on their own without external assistance. 10 D. Minimal Contact Control: Here, subjects that normally would be accepted for treatment are "... told that they are (for some innocuous reason) in fact unacceptable for treatment. They then could be contacted at times corresponding to contact with other control and treatment groups. This condition would correspond to the minimal contact and lack of participation awareness ..." (Bernstein, 1969, p. 432). In support of his speculation of signfiicant con founding of "nonspecific" variables with treatment vari ables, Bernstein (1969) cites his own work in which he found no difference in outcome between a treatment group and an "attention-placebo group (cf., Bernstein, 1970; McFall and Hammen, In Press). The operation of nonspecific variables in therapy becomes increasingly creditable when consideration is given to the following points: 1. The relatively homogeneous results that occur across studies irrespective of treatment modalities. 2. The inexplicable decline from base rate of persons in control groups, i.e., attention- placebo. Keutzer (1968), for example, found that a group given a placebo drug had a 45 percent reduction in smoking rate. 11 These points have raised methodological as well as theoretical issues in the modification of smoking behavior. The major methodological and theoretical concern seems to revolve around the dependent variable in smoking research. Clearly, a program aimed at the modification of smoking behavior must invoke as one of its dependent variables smoking rate. The theoretical issue raises the question of the extent to which cognitive variables are employed by persons in modifying their behavior. Festinger's (19 57) theory of cognitive dissonance is commonly employed to explain variations in smoking behavior. Carlin and Armstrong (19 68) treated three groups in an aversive conditioning paradign and used attitudinal scales as one of the dependent variables. These investigators acknow ledge the superiority of the aversive condition procedure but interpret the results as being due to arousal of a greater degree of cognitive dissonance in this condition than in other conditions (cf., Wolitzky, 1967). Frith (1971) in a similar vein views cognitive variables as important in the maintenance of this behavior. However, implicit in his formulation is a Hullian orientation. This is clearly evident by his statement, "For example, the ritual of lighting and holding a cigarette might be im portant in reducing the effect of the stressful situa tion." (p. 76-77). Lichtenstein, Keutzer, and Himee (1969) employing a role playing procedure found no significant 12 differences between experimental and control groups either on an attitude scale or behavioral change at the end of treatment. However, there were significant changes between pre and post measures on certain attitudinal items within each group. Finally, Orne (1970) in discus sing McFall's (1970) study raises the issue of public versus private behavior. This investigator contends that unobtrusive measures of smoking behavior raises the ques tion of deception. He indicates that it is difficult to determine if it is the subject or the experimenter that is being deceived. While the above investigators raise theoretical issues, such issues inevitably have methodological implications. Some smoking studies have required the subjects to keep rather detailed daily records of their smoking behavior $uring treatment. Kanfer (1970) and McFall (1970) discuss the reactivity of this proce dure. However, McFall (1970) attempted to ascertain the reliability of self-report by the utilization of indepen dent observers. He found a high correlation between self- report and the records of independent observers. Kanfer (19 70), however, raises the following issues in regard to self monitoring of smoking behavior: a) the reactivity of this procedure which may depress smoking rate, and b) the inability of this procedure to elicit information 13 regarding cognitive controls. While these theoretical and methodological issues require further investigation, the fact that diverse approaches to smoking behavior result in relatively homo geneous results requires continued investigation. The results of such investigations would contribute to the resolution of the theoretical and methodological problems raised. McFall and Hammen (In Press) in an ingenious experiment isolated three components that were common to all previous smoking studies: "a) subjects were volun teers who were motivated to stop smoking; b) subjects were instructed to follow a structured program for a fixed time period, with the expectation that they should stop smoking by the end of this period; and c) subjects self-monitored their smoking behavior and periodically reported these data to the smoking clinic." (p. 4) Employing four dif ferent monitoring procedures, McFall and Hammen found no essential differences between groups but did find that the end of treatment results paralled those of previous smoking studies. However, six-month follow-up results in this study were parallel to those of previous studies, i.e., there were no significant differences between base line smoking rate and smoking rate at six-month follow-up. This study provides rather strong support for the operation of selected nonspecific factors in smoking modification programs. However, there are several 14 important questions that are unanswered by this study. Are the nonspecific factors interactive in an additive or multiplicative fashion? Which factor, if any, is more important in terms of its contribution to end of treatment effect? The major question, however, is whether or not these or other nonspecific factors are operative during the follow-up period. It seems reasonable to assume that the act of monitoring one1s smoking rate is reactive both in treatment and in follow-up (McFall and Hammen, in Press). This can be considered as one nonspecific factor. Motivation shotrld not be considered as a nonspecific factor because of the various magnitudes that this con struct can assume. The level of motivation to cease smoking will vary both during treatment and follow-up. This variation is occasioned by many obvious factors, e.g., time of day, current life circumstances, perceptions of all types, etc. Purpose of Present Study The questions that this study proposes to address are: 1. Are each of the nonspecific factors identified by Marston and McFall (1971)and McFall and Hammen (In Press) necessary and sufficient variables to account for ■ the reduction in smoking rate at the end of treatment and follow-up? Are nonspecific factors operative in follow-up? In the McFall-Hammen study (In Press) self-monitoring apparently had no significant effect on maintenance of end of treatment gains at six-week1 and six-month follow- up. In the present study, two treatment groups (explained below) will receive varying degrees of "treatment" during follow-up. The results of the McFall and Hammen (In Press) study contrast sharply with those of Resnick (19 68). The rather impressive results achieved by this latter investigator through the use of stimulus satiation were also found in the McFall and Hammen study. However, the McFall and Hammen study employed "nonspecific" factors (p. 10) as an explanation of their results. Thus, it would appear particularly promising to employ both a replication of Resnick's stimulus satiation (19 68) and McFall and Hammen's "nonspecific" factors in one study for comparison of these "treatment" strategies. This study, however, exceeds the two previous studies in the following aspects: a) The sample of subjects for this study was re recruited from the general Los Angeles popula tion rather than the university (or more specifically, freshman or sophomore student) population. 1 However, the positive self monitoring group retained its "end of treatment gains at six-week follow-up but rever ted to baseline at six-month follow-up." 16 b) Subjects in each group were matched, as clearly as possible, on the following variables: 1) age (and years smoked) 2) smoking rate 3) sex 4) personality variables (see "instruments" under Procedure section). 2. Inasmuch as nonspecific factors have been shown to account for smoking reduction at end of treat ment (e.g., Bernstein, 1969; McFall and Hammen, In Press), •are such factors differentially operative in varying 4 ' degrees of follow-up? In the present study, there are two "sets" of nonspecific factors. The first set involves the employment of these factors identified by McFall and Hammen (In Press) as nonspecific factors, i.e., "motivated volunteers," adhering to a structured routine for a specific period and self monitoring of smoking behavior. This "set" of nonspecific factors is, for the purpose of this study, termed "awareness." The second "set" of nonspecific factors is the follow-up telephone contact that will occur following the treatment, i.e., "awareness" treatment. In contrast to the nonspecific factors admin istered to one group, the other group will receive a "specific treatment." Persons in this group will receive "stimulus satiation" as described by Resnick (1968). 17 However, this group will also receive the second set of "nonspecific" factors that the "awareness" group receives, i.e., telephone follow-up at the same frequency and of the same duration. 3. Do the two sets of nonspecific variables inter act? Is the effect of follow-up contact different for the stimulus satiation group than for the awareness group? 4. Follow-up nonspecific factors can be differen tiated as to intensity (total number of follow-up contacts) and latency (elapsed time between contacts). Questions 2 and 3 deal with the issue of intensity. However, the effect of latency is not addressed by the preceding ques tions. Thus, an important question that requires investi gation remains: Is the interval between contacts in follow-up related to maintenance of end of treatment gains? 5. The preceding question does not address the issue of interaction between latency in follow-up and type of treatment. Therefore, a second important question is: Does varying time intervals between contact in follow-up interact with type of treatment? It is proposed that the following design be employed to address these five questions (see Figure 1). Treatment Subqroups Treatment Means .Follow-Up (number of telephone contacts in weeks following treatment) Weeks 1 2 3 4 5 6 7 Total Number of Follow-Up Contacts S A Weekly 7 D A 0 T G B Biweekly (twice a U I R week) 7 B A 0 L T U C Biweekly 4 E I P 0 D Once per month 3 N 1 (Resnick E No Contact 2 Replication) A A Weekly 7 W A G B Biweekly (twice a R R week) 7 E 0 N u c Biweekly 4 E p S D Once per month 3 S 2 E No Contact 2 Figure 1. Research Design 19 It is obvious from Figure 1 that there are two distinct treatment groups: a) Double Satiation Group - which has subgroups nested within it, represents, in part, a replication of the Resnick (1968, 1971) study. The essential features of this study will be followed. How ever, the frequency of follow-up contact will vary; b) Awareness Group - which also contains nested groups, will replicate features that the McFall-Hammen (In Press) study considered as essential nonspecific factors. Subjects in each group will not be required to return to the clinic to deliver daily smoking records. Instead, the subject will be requested to mail such forms to the smoking clinic at weekly intervals. It is the comparison of the Double Satiation Group with the Awareness Group that will provide data bearing on the first question. Kanfer's (1970) cogent response to the McFall (1970) study appears applicable in that the recording of smoking rates by the subject is itself a reactive measure. Inasmuch as record keeping is a con stant variable in both groups, one would predict that the Double Satiation Group would be equivalent to the Aware ness Group on smoking rate at all intervals. This result cannot be attributed solely to the recording of smoking rates. Most assuredly, other variables are involved (e.g., the fact that the subject must expend the effort 20 to volunteer for the smoking clinic is an important variable). Experimental Hypotheses The following experimental hypotheses are advanced to answer the questions posed in the preceding section: 1. Double satiation is more effective in reducing smoking behavior than an awareness treatment (consisting of three nonspecific factors) during treatment and in follow-up. 2.- The^greater the number of follow-up telephone, contacts, the more likely will a reduction in smoking behavior (as an end of treatment result) be maintained. 3. The effect of the total number of follow-up telephone contacts interacts with the type of treatment such that the more frequent the con tact in the double satiation group, the more likely is smoking reduction to be maintained. 4. The shorter the interval between follow-up contacts (for all groups), the more likely is smoking reduction to be maintained. 5. The interval between follow-up telephone contacts interacts with the type of treatment so that the shorter the interval in the double satiation group, the more likely is a smoking reduction to be maintained. PROCEDURE Subjects A total of 87 subjects from the greater Los Angeles community were recruited via ads placed in local papers (both throw-away and commercial) in the Los Angeles Metropolitan Area (see following section). Additionally, several subjects were University of Southern California (USC) students who responded to posters placed at various locations on the USC main campus. The persons who responded to this ad (see Appendix I) ranged in age from 16 through 75. However, eleven of the subjects who responded to the ad and appeared at the initial orientation session were subsequently dropped from the analysis in that they did not appear for the treatment procedure or participate in follow-up. Design A two-by-five factorial design was employed. Subjects were randomly assigned either to Double Satiation or Awareness treatments. Additionally, subjects were again randomly assigned to one of five follow-up subgroups within each treatment. The follow-up subgroups were: 22 23 a) weekly contact, b) biweekly contact twice per week, c) biweekly contact, d) monthly contact, and e) no con tact. These frequencies of contact were identical for both the Double Satiation and Awareness groups. (For randomization procedure, see following section.) This type of design was necessitated by the hypotheses con tained in the preceding section asserting an inverse relationship between the independent variable (number of contacts) and the dependent variable (smoking rate). Instruments At the first orientation session (see following section) all subjects were administered the following instruments: a) Personal History Inventory (Marston, 1971; see Appendix II). b) Trait and State Anxiety Scale (Spielberger, 1970; see Appendix III). c) Rotter Internal-External Inventory (Rotter, 1966; see Appendix IV). d) The Marston Conflict Resolution Inventory (Marston and Barret, 1971; see Appendix V). e) The Horn Self-Testing Kit (see Appendix VI). 24 The personal history form requested information pertaining to the subject's age, sex, weight, and current smoking rate. Other information was also requested, e.g., does parent(s) or spouse smoke, occupation, etc. The anxiety scale was a very short form comprised of forty items. Items one through twenty represented the "state anxiety scale" and items twenty-one through forty represented the "trait anxiety scale." Each statement requires the subject to respond to one of four choices: For the state scale these choices ranged from "not at all" through "somewhat," "moderately so," to "very much so"; for the trait scale responses to the twenty statements gr — - range from "almost never" through "sometimes," "often,"' and "almost always." Examples from these two scales are given below: Trait Scale: 1: "I feel calm." 6: i i j feel upset." 11: "i feel self-confident 16: "i feel content." 20: "i feel pleasant." State Scale: Item No. 22: "I tire quickly." 26: "I feel rested." 25 Item No. 31: "I am inclined to take things hard." 37: "Some unimportant thoughts run through my mind and bothers me." 40: "I become tense and upset when I think about my present concerns." This scale was developed by C. D. Spielberger, 1970, and is available from the Consulting Psychologist Press in Palo Alto, California. The Rotter Internal-External instrument is a gener ally used instrument and was included in this study primarily because various investigators (e.g., Woodruff, et al. , 1965; Straits and Sechrest, 1963) report moderate correlation between external orientation and smoking. This scale is commonly used in other investigations. The Rotter is composed of twenty-nine items of which only twenty-three are scored. There are six items which are included as fillers. Representative items are: Item No. 1: a) "Children get into trouble because their parents punish them too much." b) "The trouble with most children now adays is that their parents are too easy with them." Item No. 9: a) "I have often found that what is going to happen will happen." 26 b) "Trusting to fate has never turned out as well for me as making a definite course of action." The respondent is required to choose from one of the pair of statements that accompany each item. The instruc tions stress that while the respondent may not entirely agree with any particular item, he is requested to select the one statement that is more true for him than is the other. The Conflict Resolution Inventory is a sixty item instrument developed by A. R. Marston and C. Barrett (1971). The instructions which accompany this instrument require the subject to review a given item and to indicate *> _ two things about each item: 1) The respondent is re quested to indicate what he actually does in regard to that item on a scale from one through seven, and 2) the respondent is requested to indicate what he ideally would like to do given the situation that is described. Again the response range is one through seven for each item. Representative examples from this item are: Item No. 1: A Friend of yours argues that smoking is really not that dangerous. You offer a strong counter argument. 13: After having been off cigarettes for a month, you are anxiously studying 27 for an important exam. You chew gum for awhile, but finally smoke a cigarette. 27: You have a headache and no aspirin. There is a drugstore on the corner. You stay home and just try to relax. 43: You have promised to pick up some groceries on the way home and remember as you turn in the driveway. You go on into the house. 53: You are at a party and enjoying a drink. A lot of people are smoking, and someone offers you a cigarette. You haven11 smoked for years. You refuse. 60: Someone close to you has died. You refrain from crying in public. As previously indicated, this scale requires the respondent to provide two responses to each of the sixty situations that are described by the items. The first response is on a scale from one to seven, with one being "always" and seven being "never," and indicates what the respondent actually does now. The second response, also on a scale from one to seven, with one indicating "always" 28 and seven indicating "never," requires the respondent to indicate what he would ideally like to do given the parti cular situation described. This scale may be scored in various ways. In this study the score for this scale is the sum of the differences for each of the sixty items. The last inventory (the Horn Smokers Self-Testing Kit) was included in view of its wide use throughout the nation by the American Cancer Society. This self-testing kit was developed by Dr. Horn and contains four sub-tests. A brief description of the sub-tests follow: Sub-Test 1: This sub-test is titled "Do You Want to Change Your Smoking Habits?" and contains twelve statements requiring the subject to completely agree, somewhat agree, somewhat disagree, or completely disagree with each of the twelve items. Representative items are: Item A: "Cigarette smoking might give me a serious illness." B: "If I quit smoking cigarettes, it might influence others to stop." I: "My cigarette smoking will have a harmful effect on my health." 29 Item L: "I do not like the idea of feeling depen dent on smoking." Sub-Test 2: This sub-test is titled "What Do You Think the Effects of Smoking Are?" Again, the responses available for each of the twelve items in the sub-test are essen tially identical to those in Sub-Test 1. Representative items from this sub-test are: Item A: "Cigarette smoking is not nearly as danger ous as many other health hazards." E: "Cigarette smoking is enough of a health ^ hazard for something to be done about it." H: "It would be hard for me to cut down to half the number of cigarettes I now smoke." K: "Quitting smoking helps a person to live longer." Sub-Test 3: This sub-test is titled, "Why Do You Smoke?" and is comprised of eighteen items on a five-point scale. This scale ranges from "always" through "never," with "always" receiving a weight of five and "never" receiving a weight of one. Representative items from this sub-test are: 30 Item A: E: J: M: 0: R: Sub-Test 4: This sub-test is titled, "Does the World Around You Make It Easier or Harder to Change Your Smoking Habits?" This sub-test is comprised of thirteen items, with only two possible responses except for the last item. The two responses are "true or mostly true," or "false or mostly false." However, the last item has four possible responses. Representative items from this sub-test are: Item A: "Doctors have decreased or stopped their smoking of cigarettes in the past ten years." "I smoke cigarettes in order to keep myself from slowing down." "When I have run out of cigarettes, I find it almost unbearable until I can get them." "When I feel uncomfortable or upset about something, I light up a cigarette." "I smoke cigarettes to give me a lift." "I want a cigarette most when I am comfort able and relaxed." "I found a cigarette in my mouth and didn't remember putting it-; there. " ’ sr 31 F: "Someone has recently tried to persuade me to cut down or quit smoking cigarettes." J: "It seems as though an increasing number of people object to having someone smoke near them." L: "Congressmen and other legislators are showing concern with smoking and health." M3: "They make it much more difficult than it would be otherwise." M4: "They make it somewhat more difficult than it would be otherwise. Recruitment of Subjects The following ad appeared in several local and one major commercial newspaper in the metropolitan Los Angeles area: SMOKERS The Psychology Department at the University of Southern California is providing a free smoking clinic for persons who want to stop smoking. If you are interested in obtaining this free service, please call (213) 753-3701 any time (day or night). Additionally, the News Bureau of the University of Southern California provided invaluable assistance in 32 preparing a news release on December 29, 1971, for all of the Los Angeles metropolitan news media (excluding tele vision) . This press release provided information as to the date, place, and time that the smoking clinic would be held. One newspaper (Herald Examiner) provided information as to the date and place that the clinic would be held but failed to include information regarding the time or infor mation number. Small 8 1/2 x 11 posters were placed at various locations on the USC campus advertising the clinic. These posters were humorous in content and provided a telephone number for persons to call who were interested in attending the clinic. (see Appendix VII for copy of poster.) Answering Service Each advertisement or poster provided a phone number which persons could call for additional information regarding the forthcoming smoking clinic. The phone number provided was assigned to a commercial answering service in the Los Angeles area. Rather detailed instructions for the answering service were provided. Complete instructions for the answering service are detailed below: 33 The Psychology Department of the University of Southern California (USC) will conduct a smoking clinic during the month of January 1972. Your services are requested to insure that the smoking clinic services be provided to as many persons as possible. One way of increasing this availa bility is to employ your 24-hour answering service. Ads have been placed in commercial and local papers inviting persons who are interested in the clinic to phone your office. Inasmuch as USC is using your number (which is also being used by other persons and agencies), it is requested that you employ the following procedures for the USC smoking clinic: (1) Answer all calls by stating the number that is being employed for the clinic (please do not answer the phone with this statement, "USC Smoking Clinic"). (2) The person calling will probably ask if this number is the correct one for the smoking clinic. Give an affirmative reply and indicate that this is the answering service for the USC Smoking Clinic. (3) Advise the caller that staff of the USC smoking clinic will return his/her call. You will need the following information: (a) name (b) phone number (c) address (d) date and hour of call (4) Confirm the above information with the caller and advise him/her that a USC staff member will contact him/her between 8 and 10 p.m. within 48 hours to advise him/her of clinic's first meeting. (5) A staff member from USC will make arrangements to pick up these forms each day at 6 p.m. (or at some other hour if this is inconvenient). 34 A separate form was completed for each person calling the answering service. As can be seen from the preceding, the instructions for the answering service were rather simple and unambiguous. Answering Service Callback Procedure The above forms were obtained from the answering service each day and given to the writer. The essential features of the callback procedure were: 1. Each person who called the clinic was contacted by the writer via phone to ascertain the following information: a) The degree of their interest in attending a free smoking clinic, since their original call. b) Any serious medical or psychological problems known to them at this time. (Persons attending Alcoholics Anonymous and other such self-help groups were encouraged not to attend the clinic.) 2. If the person indicated a continuing interest in attending the clinic, they were provided the following information: a) Date and time of the initial orientation meeting. a 35 b) Confirmation of their address in order that they could be sent a map of the USC campus and directions to the building and room where the initial orientation meeting would be held. c) Assurances (when requested) that severe aversive behavior modification techniques would not be employed in this smoking clinic. Orientation All persons indicating an interest in attending the smoking clinic were invited to attend an initial orienta tion session on Sunday, January 9, 1972, at either 10 a.m., 1:00 p.m., or 3:00 p.m. at Founders Hall on the USC Campus, room 133. This room is a large auditorium-classroom which will accommodate approximately 150 persons. It was not known how many people would appear in view of the wide dissemination of information regarding the services offered by the clinic to the persons in the Los Angeles area. Consequently, three orientation sessions were scheduled. For the 10 a.m. session, at which it was expected that the majority of persons attending would appear, four research assistants2 were employed to assist in the dissemination and collection of survey instruments which were administered at this session. The Research Assis tants were provided with comprehensive instructions for this orientation session after having participated in preliminary discussions and pretesting of the instruments. For details of the instructions for the Research Assis tants, see Appendix VIII. Due to the small number of individuals that were employed in the 1 p.m. and 3 p.m. orientation sessions, only the writer disseminated and collected all instruments described below. With this exception, the orientation procedure for all three sessions was identical. Rather detailed instructions regarding the orienta tion procedure may be found in Appendix IX. However, the essential features were: 1. A welcome to the USC Campus and to the Psych ology Department Smoking Clinic. 2. A brief recapitulation of previous smoking studies. 3. A brief discussion of the fact that most smoking clinics achieve some results by end 2 The writer gratefully acknowledges the assistance of Miss Beth Olsen, Miss Sandy Bell, Miss Magalie Downing, and Mr. David Haber, who served as Research Assistants during the orientation session. of treatment (Bernstein, 1970) but revert to baseline level following treatment (Marston and McFall, 1971; McFall and Hammen, In Press). All persons were advised that should they desire to continue with the clinic, they would receive a treatment that has been found to be effective in the past, and there would be no control group in terms of not receiving a treatment. (However, the specific forms of treatments were not dis closed at this orientation session.) A request that all persons desiring to continue with the clinic assist the writer in evaluating the effectiveness of the clinic by completing five paper and pencil measures (described under instruments above). A request that all persons desiring to continue with the clinic monitor their smoking behavior for the next seven days on forms supplied by the clinic (these forms were distributed by the Research Assistants and may be found in Appendix 13) . The matter of a deposit for the smoking clinic which would be returned uncashed to the person if he remained with the clinic throughout its operation was explained in detail. This 38 procedure has been found useful by McFall and Hammen, In Press); Marston and McFall (1970); and Maroney, Merskmer, and Salzberg (1970). This procedure generally prevents attrition dur ing the course of the clinic. It was stressed that the check would be returned to all partici pants irrespective of their success with the clinic, provided that they remained with the clinic during its entire operation. 8. A request that all persons indicating a desire to continue with the smoking clinic sign up for an appointment the following weekend (January 15 or 16, 1972) at a time which was convenient to them. Persons so interested were invited to sign their name on appointment sheets provided at tables in the hallway adjacent to the room where the orientation session was held. Research Assistants completed an appointment card for each person, which contained the ad dress of the USC Psychological Clinic. Following a discussion of these points, a question and answer period followed in which concerned persons dis cussed problems of weight control after being successful in quitting the cigarette habit. 39 Additionally/ persons who were under the care of a physician or therapist were advised to check with their therapist as to whether or not they should participate in this smoking clinic. The instruments (named above) were administered in the following order in each of the three sessions: a) Personal History Inventory b) Rotter Internal-External Scale c) Spielberger1s Anxiety Measure d) Marston & Barrett's 1971, Conflict Resolution Inventory e) Horn Self-Testing Kit These instruments were administered in group style with a minor modification. Persons completing a particu lar instrument could proceed to the next instrument as soon as they had finished. This procedure was followed in each of the three orientation sessions. Following a completion of all instruments, subjects desiring to continue with the clinic signed up for conven ient appointment times with the Research Assistants for the "smoking treatment." Treatment Session a) Initial Treatment: Persons attending the orien tation session described in the preceding pages who indi cated an interest in pursuing the smoking clinic were 40 advised to sign up for an appointment for a single treat ment the following weekend. There were five subjects who completed the instruments and did not appear for the initial treatment session. Subjects did not know which of either treatment they would receive. The assignment to major treatment group and sub-treatment groups was accomplished by the following procedure during the period intervening between orienta tion session and administration of treatment. By and large, all subjects who appeared at the initial orienta tion session had previously been contacted by the writer as a result of the advertisements appearing in the various papers named above. Consequently, there was information from the answering service available for each subject. In those cases where there was no information on a partic ular subject, his name was placed on a 8 1/2 x 11 sheet of paper which corresponded to the size of the sheet con taining the information received by the answering service. There were two randomization processes involved in the assignment of subjects to major treatment groups and sub-groups within each^major treatment group. This pro cedure is described below: 1. A table of random numbers contained in Kirk (19 70) was employed for the assignment of subjects to major groups. The names of the entire sample were placed in a non-ordered pile and the aforementioned table was used to assign subjects to major groups, either Double Satiation (Resnick) or Awareness treatment. The procedure was essentially as follows: A coin was tossed to deter mine whether odd numbers or even numbers would be assigned to the Double Satiation group. A table of random numbers was employed in the usual way, i.e., the first subject was assigned either to the Double Satiation or Awareness Group based on whether the number was odd or even. This procedure was followed for all subjects and resulted in an approximately even spread of subjects with forty-four in the Double Satiation Group and forty-three in the Awareness Group. 2. Subjects were then assigned to sub-groups within each major group, utilizing numbers one through five (without replacement) from Kirk's (1970) random number table. For example, the first subject in the Double Sati ation Group was assigned to sub-group 1 if that particular random number (1) appeared or sub-group 5 if that particu lar random number (5) appeared. However, no repeat in random numbers were allowed in the assignment of each block of five subjects. This assured an approximate equal number of subjects in each sub-group within each of the major treatments. To ascertain the equivalence of groups prior to the administration of treatment, t-tests were performed on each of the major groups and on the sub-groups within each major group (Hays, 1963). A significant difference was found between major group one and major group two on the age variable. Consequently, two individuals of ex treme age were transferred from one group to another to equalize these two groups. Following this exchange of subjects, a subsequent multivariate analysis of variance (MANOVA), written at the University of North Carolina (Cramer, 1970) revealed no significant difference between the two groups and all sub-groups on the following variables: a) age b) smoking rate c) years smoked d) sex Tables 1-3 present the analyses. Table 4 contains group means and standard deviations. This crucial assign ment procedure was accomplished prior to the appearance of each person at the clinic for his initial treatment. TABLE 1 MULTIVARIATE ANOVA (FOLLOW-UP) FOR THE FOLLOWING VARIABLES: SEX, AGE, DAILY SMOKING RATE, AND YEARS SMOKED* F 1.113 Degrees of Freedom 16, 226 P less than 0.344 Univariate F Tests for the Same Data Variable F(4,77) Mean Square P Less Than Sex Age Daily Smoking Rate Ye^rs Smoked 1.171 0.278 1.882 298.751 0.347 44.028 2.043 291.237 0.330 0.122 0.845 0.097 *This statistical technique was developed by the Psychometric Laboratory of North Carolina, 1970. TABLE 2 MULTIVARIATE ANOVA (MAIN EFFECT) FOR THE FOLLOWING VARIABLES: SEX, AGE, DAILY SMOKING RATE, AND YEARS SMOKED F Degrees of Freedom P less than 0.869 4,74 0.487 Univariate F Tests for the Same Data Variable F(l,77) Mean Square P Less Than Sex 0.050 0.012 0.823 Age 0.633 100.489 0.429 Daily Smoking G-rate 0.434 54.998 0.512 Years Smoked 1.720 249.235 0.194 TABLE 3 MULTIVARIATE ANOVA (INTERACTION) FOR THE FOLLOWING VARIABLES: SEX, AGE, DAILY SMOKING RATE, AND YEARS SMOKED F Degrees of Freedom P less than .376 16,226 0 .987 Univariate F Tests for the Same Data Variable F Mean Square P Less Than Sex 0.827 0.201 0.512 Age 0.211 33.429 0.932 Daily Smoking Rate 0.090 11.382 0.985 Years Smoked 0.257 36.684 0.904 TABLE 4 GRAND MEAN, MAJOR GROUP MEANS, AND SUBGROUP MEANS (WITH STANDARD DEVIATION) FOR AGE, DAILY SMOKING RATE, AND YEARS SMOKED VARIABLES Group N Age Daily [ Smoking Rate Years Smoked Stan Stan Stan dard dard dard Devi Devi Devi Mean ation Mean ation Mean ation D. S. Weekly Awareness Weekly 9 8 50 .667 49.375 11.358 10.013 28.444 28.000 9.926 16.449 29.556 30.100 11.802 10.637 D.S. Biweekly (twice a wk) 8 39.625 14.457 28.750 10 .600 18.625 8.895 Awareness (twice a week) 10 45.100 13.000 26.500 11.287 26.200 13.423 D. S. Biweekly Awareness Biweekly 7 8 42.571 44.625 16.195 13 .763 32.429 28.125 14.593 7.039 23.429 28.125 12.273 12.710 D.S. Monthly Awareness Monthly 9 9 45.778 46.000 11.189 16.039 26.889 25.556 9.981 11.534 27.444 28.444 11.348 15.773 D. S. No Contact 11 37.273 8.125 29.727 9.318 18.364 10.112 Awareness No Contact 8 41.375 11.275 29.625 10.596 21.625 10.809 C T i 47 Treatment Procedure As previously indicated, each person was assigned either to the Double Satiation (Resnick, 1968) or the Awareness treatment. The therapists for this portion of the study were three graduate counselling psychology students and one Ph.D. counselling therapist.3 Each ther apist saw an equal number of subjects and administered either the Double Satiation treatment or the Awareness treatment. The particular treatment which each person received was preassigned. Each subject appeared at the clinic at the designated time and place and was interviewed by the writer, who received either $25 in cash, money order, or check and gave the person a receipt. Addition ally, each person was given an agreement wherein this deposit was acknowledged, and each person was informed that the sum would be returned if they remained with the clinic during its two months of operation. However, should they fail to continue with the clinic, their deposit would revert to the Clinical Psychology Research Fund for future smoking clinics. Following this initial procedure, the writer had no other interaction with subjects with respect 3 The writer wishes to express his gratitude for the assistance of Dr. Diane Sundby, Mr. Gary Krupp, Mr. Ken Schultz, and Mrs. Mary Ellen Torres for their assistance in this project. 48 to the treatment procedure. The treatment procedures were conducted entirely by the four therapists. Each person was seen individually by one of the therapists. The therapist performed either a replication of the Double Satiation procedure (Resnick, 196 8) or the Awareness treatment. Below is a capsule summary of the instructions for the therapist in administering this treatment procedure. Double Satiation Instructions: Each therapist discussed the following points in this particular treat ment with each subject: a) Present smoking rate. b) Reasons (if any) for smoking. c) Reasons why smoker wants to quit at this point and time. d) Perceived reasons for inability to stop smoking previously. e) Probable excuse that subject would employ to resume smoking after successfully giving up the habit. f) Dollar cost per year to the smoker as a result of his habit. g) Discussion of the smoker's profile (Horn self testing kit) . 49 h) Instructions to double their smoking rate for seven days and cease smoking entirely. Additionally, each person was told that after they have stopped smoking should he/she encounter the desire to smoke again an effective technique to employ is gum chewing. Each person was told to wait ten minutes between desire to smoke and gum chewing. This instruction was based upon Resnick's procedure (1968). Resnick (1968, 1971) notes that the satiation instructions can be given in a couple of minutes, but a longer period (e.g, 10 minutes) provides face validity for the treatment. Note, however, that the present study varied from an exact Resnick replication. Not given in this study was the following procedure: ... Subjects in the two experimental groups were then told that the way to stop smoking was to increase smoking drastically. Disbelief was the usual response. The subject was then asked whether he ever attempted simply to cut down smoking without trying to stop completely and what happened. When the subject responded that the habit seemed to rebound even stronger, it was then suggested to him that a likely reason for this was that as each cigarette became scarcer, more time and energy were spent thinking about smoking and its attractiveness and potency increased accordingly. It was further suggested that over-smoking would lead to just the opposite effect. (p. 502) These specific instructions could not be adhered to in this study because Resnick does not make it clear how many subjects in the experimental groups expressed 50 disbelief. And there is the possibility of experimenter confounding as a result of experimenter's delivery of the instructions. The therapists in the present study reported only one instance of disbelief. On the other hand, several subjects indicated that it was a "common sense" approach to the problem of smoking. Awareness Instructions; Each therapist was provided with the following instructions for this treatment condi tion: Points (a) through (g) (see Double Satiation Instructions above) were discussed with each subject. Additionally, subjects were told: Past studies show that a critical element in quitting smoking is awareness of your smoking habit, particularly when you smoke and why you smoke. This treatment has been designed to increase your awareness of your smoking habit. Daily record keeping is also an important part of this awareness. Accuracy in keeping this record is very important in maintaining this awareness. Continue your normal smoking behavior for one week, then stop smoking com pletely. If after you have stopped smoking you have a desire to smoke, wait ten minutes then chew gum. Again, the record keeping is an important part of the treatment process. Please see Fred Richardson at the reception desk, and he will give you a supply of these forms and explain their use. You will be periodically contacted by someone from the smoking clinic. The therapists were experienced counselors, and these instructions formed the essential core of the treat ment process. Each treatment lasted for approximately 51 15 minutes. It was felt that the awareness group com prises the attention-placebo group that Bernstein (1969) advocates for evaluation of smoking clinics. Each person was seen individually by the therapist for approximately 15 minutes. However, several problems arose which pre vented the strict adherence to a 15-minute paradigm. Four persons had precipitating psychological problems which necessitated a departure from the semi-programmed treatment schedule. Two of these are omitted from all analyses. Upon conclusion of this treatment period, each person returned to the reception area where the writer again explained the use of the daily record keeping form and provided each person with a supply for seven weeks with self-addressed envelopes for return of this material to the clinic. Those persons appearing on Saturday were instructed to begin their record keeping on Sunday, January 16, 1972, and mail the first week's data into the clinic on the following Saturday, January 22, 1972, and each Saturday thereafter. Those persons receiving treat ment on Sunday were instructed to begin their daily record keeping on Monday and mail their forms in on Sunday, January 23 and each Sunday thereafter until all forms were mailed. Subjects were advised they would be phoned 52 at varying intervals. As noted above the treatment proce dure averaged approximately 15 minutes and was conducted on two consecutive days (January 15-16, 1972). The time for treatment and explanation of data forms ranged from 20-25 minutes. (see Appendix X) Follow-up Procedure A second facet of this study involved telephone follow-up of each person seen at the clinic per a prear ranged schedule which was described in the preceding section. To avoid possible confounding or contamination of the results, the writer did not participate in any of these calls. These follow-up contacts were made solely by Mrs. D. J. Scott.1 * There were several essential topics to be discussed with each person in both groups during the follow-up contacts: 1) Were they smoking? 2) What were the appar ent difficulties, if any, that prevented them from ceasing smoking entirely? 3) A discussion of the use of the daily record keeping form and its impossible utilization to re duce their smoking rate. 4) Suggestions that those cigarettes that were least meaningful, psychologically, * * However, it was found that some subjects were late in submitting data. The writer made telephone inquiries relative to this issue with such subjects. The content of these conversations was confined to subject's sub mission of data. be entirely eliminated. Otherwise, the follow-up phone contact was unstructured and included discussion of any topic initiated by the client. This telephone contact averaged five minutes for all groups. Detailed instruc tions were provided for the final follow-up contact and may be found in Appendix XI. However, the following topics were discussed with each person: 1) review of progress during clinic, 2) a discussion of general pro blems that are involved in smoking cessation, 3) ascer taining if the client was interested in attending a future smoking clinic and referral to the American Cancer Society in the event the client responded in the affirmative, 4) an expression of appreciation to the client for parti cipation in the clinic, 5) confirming with the client his present address in order that his check could be returned, 6) a request to the client that the clinic be permitted to contact him in the future to ascertain his smoking behavior at that time. Those persons remaining with the clinic throughout its operation were returned their deposits. There were a total of eight persons who did not submit data or otherwise respond to request from the writer to submit their data. These persons are not included in the analysis either of the survey data in terms of group comparison or the dependent variable (smoking rate). Moreover, per the initial agreement with all subjects, the $25 deposit of these persons was not returned but was placed in the USC Psychological Research Clinic Fund for future smoking projects. RESULTS As indicated in the Procedure Section, assignment to major treatment groups as well as assignment to sub group was based on the subject's perception of his daily smoking rate at the initial orientation meeting. However, t-tests (Hays, 196 3) revealed that the Awareness Group differed significantly from the Double Satiation Group on the dependent variable - age and years of smoking reported at orientation (P < .05). Consequently, three persons were switched from the Double Satiation Group to the Awareness Group and three persons were changed from the Awareness Group to the Double Satiation Group. These changes were necessitated by a higher mean daily smoking rate in the Double Satiation Group as com pared to the Awareness Group. Following these changes and prior to treatment, a multivariate ANOVA (Cramer, 19 70) was employed to test the equivalence of the two major treatment groups as well as the subgroups within each treatment group. It was not possible to analyze the inventories admin istered at the orientation session prior to assignment of each person to a particular treatment group. Consequently, assignments to groups were made only on the basis of age, 55 56 sex, daily smoking rate, and years smoked. As can be seen from Tables 1 - 3 (Procedure Section), there were no sig nificant difference between the major treatment groups or parallel subgroups. However, the inventories were later scored and analyzed by t-test (Winer, 1962) to ascertain the equiva lence of groups on the inventories administered. There were two analyses of the inventory data. The first analysis included all persons who completed the instru ments and appeared for treatment at the Clinic. The second analysis excluded persons who completed the orien tation session, appeared for treatment, but did not submit daily smoking rate during the follow-up phase of the Clinic. An N of 88 was involved in the first analysis. However, persons not participating in the follow-up could not be included in the final analysis. Consequently, the instrument data for each group were reanalyzed and excluded a total of 8 persons. It should be noted, how ever, that there were no significant differences between major groups and parallel subgroups on any of the survey instruments in the first analysis as well as the second analysis. In summary, the analyses clearly indicate that the groups were similar prior to administration of the treatments. It should be noted that these tables 57 reflect the reassignment of three subjects to other sub groups within the two major treatment groups. This reas signment was necessitated by the unavailability of these subjects during the follow-up phone calls. One person in the awareness treatment group that was scheduled to be contacted twice per week on a bi-weekly basis was unavail able for three calls. Consequently, this person was reas signed to the subgroup that was contacted at beginning and end of follow-up. A second person assigned to weekly follow-up phone contacts within the Awareness Group was reassigned to the biweekly follow-up group as a result of his unavaila bility. The third person that was unavailable for contact was in the Double Satiation Group and was scheduled to receive monthly follow-up contacts. However, this person could not be contacted at the scheduled time and was reassigned to one contact at beginning and end of follow- up period. Treatment and Follow-Up Results At this point, it appears necessary to repeat the hypotheses contained in Section 2: 1. Double satiation is more effective in reducing smoking behavior than an awareness treatment 58 (consisting of three nonspecific factors) during treatment and in follow-up. 2. The greater the number of follow-up telephone contacts, the more likely will a reduction in smoking behavior (as an end of treatment result) be maintained. 3. The effect of the total number of follow-up telephone contacts interacts with the type of treatment such that the more frequent the con tact in the double satiation group, the rore likely is smoking reduction to be maintained. 4. The shorter the interval between follow-up contacts (for all groups), the more likely is smoking reduction to be maintained. 5. The interval between follow-up telephone contacts interacts with the type of treatment so that the shorter the interval in the double satiation group, the more likely is a smoking reduction to be maintained. The data pertinent to these five hypotheses are contained in Table 5 through 10. Table 15 contains means and standard deviations for all groups and subgroups on smoking rate (dependent variable) at pretreatment, treat ment, and during the follow-up period. A statistical 59 test of the data in Table 5 appears superfluous in rela tion to testing hypothesis I. The "interocular" test (Edwards, 1971) clearly shows that for all groups the mean number of cigarettes smoked daily at 6-week follow-up is substantially less than the mean pre-treatment smoking level. However, for those that desire a statistical pre sentation, Table 7 displays this information. There is no significant difference between the groups at end of treatment (P < .113). Consequently, the experimental hypothesis of a lower smoking rate for the Double Satia tion Group (Resnick, 1968) is rejected. A multivariate F computer statistical program de veloped by the Psychometric Laboratory at the University of North Carolina (1971) was employed to analyze the data. Therefore, the data tables5 and Figure lA will be pre sented prior to a discussion of the results relative to the hypotheses advanced in this study. Hypothesis 1: In relation to hypothesis 1, the data in Table 5 indicate that there are no substantial differences between means at end of treatment between the major groups. Moreover, the multivariate analysis in 5 There is no standard format for multivariate MANOVA tables. This format, devised by Professor J. Kahan, USC, which resembles the usual F tables is being employed. 60 Table 6 indicates that there is no significant difference between the two groups due to treatment (P < .113). Thus, this study has produced results that are essentially similar to results of other smoking studies (Bernstein, 1969) . It would appear that people reduce or cease smoking irrespective of the treatment modalities employed. Therefore, the hypothesis that the double satiation treat ment produces superior results is rejected. It can be seen from data in Table 5 that there is a consistent decrease in mean daily smoking rate from pre treatment to end of follow-up at six weeks. Although there are crossover of "subgroups rates," the end of follow-up rate is clearly lower than the prerate (see Figures 1A through 7). Table 5A displays means and standard deviations for mean daily smoking rate for all groups on days before the follow-up contact as well as for days following the contact. It can be noted that the "before" rate is, in general, higher than the after rate. This difference is not significant (P < .345). Hypothesis 2; This hypothesis predicted a positive relationship between the number of follow-up telephone contacts and the maintenance of end of treatment results. Table 7 presents this data. The number of phone contacts does not distinguish either major groups or subgroups (P < .605). TABLE 5 MEANS, STANDARD DEVIATIONS, AND N FOR PRETREATMENT, TREATMENT, AND FOLLOW-UP DAILY SMOKING RATE Pre treat ment treat ment Follow-Up Period (weeks) N rate rate 1 2 3 4 5 6 Treatment Means Double Sati ation (D.S.) (Resnick Replication) 41 M 27.760 25.409 18.065 16.712 16.819 16.619 15.966 15.710 Awareness 39 M 25.113 17.744 12.751 13.121 13.226 13.695 12.785 12.749 Cell Means D. S. Weekly 9 M SD 23.156 11.206 15.488 11.484 13.222 10.733 10.967 7.796 12.332 10.937 11.089 10.142 9.778 7.560 9.156 6.432 Awareness 7 M 26.057 20.386 9 .171 11.786 11.171 12.271 10.900 9.414 Weekly SD 21.157 24.378 9.514 12.895 13.371 14.421 12.385 11.626 D.S. Biweekly 7 M 25.286 21.680 17.614 16.871 17.429 15.543 15.529 15.371 (twice week) SD 8.423 17.914 13.539 11.226 10.340 10.980 10.862 11.500 Awareness Bi- 9 M 24.378 15.933 11.027 10.367 11.867 13.011 11.644 13.300 Weekly (twice week) SD 12.890 10.290 10.501 8.654 8.424 11.123 11.325 11.441 TABLE 5 — continued N Pre treat ment rate treat ment rate Follow-Up Period (weeks) 1 2 3 4 5 6 D.S. Biweekly 7 M 38.657* 45.800 33 .843 28 .729 25.929 29.057 29 .443 28.857 SD 27.087 67.656 27.077 20.524 19.813 20.029 19 .008 19 .219 Awareness 8 M 24.925 17.825 15.375 15.775 15.125 13.225 12.512 12.988 Biweekly SD 11.148 7.997 9.469 9.731 7.540 6.293 6.076 7.001 D.S. Monthly 7 M 25.743 26.286 15.829 14.429 14.029 12.871 12.371 13.029 SD 10.648 13.486 14.864 14.777 14.530 12.903 13.510 15.235 Awareness 6 M 24.767 15.050 8.350 6.133 6.817 7.967 7.767 8.417 Monthly SD 7.995 9.047 5.898 4.948 4.747 5.344 5.726 5.974 D.S. No 11 M 27.455 22.364 13.709 15.118 16.082 16.300 15.018 14.627 Contact SD 8.930 8.588 6.453 5.037 5.325 5.511 8.070 9.863 Awareness No 9 M 25.511 19 .222 17.867 19.211 18.767 19.722 18.978 17.467 Contact SD 11.968 9.332 9.900 12.115 12.286 13.263 13.552 14.166 * These "high" row means and SD's reflect the inclusion of a subject with a pre treat ment daily smoking rate mean in excess of 100. This subject, is being included in the analyses in that she remained with the Clinic and submitted data. Usually persons two SD's from the mean are excluded from analysis. CTt to TABLE 5A MEANS, STANDARD DEVIATIONS, DIFFERENCES, AND WEEK SLOPE OF SMOKING RATE ON DAYS BEFORE AND AFTER FOLLOW-UP TELEPHONE CALLS Before call After call Difference Week Slope N Grand Mean Double Satiation M SD 16.223 15.04 8 -1.175 -4.833 41 Awareness M SD 15.102 14.578 -0 .524 -2.372 39 S lib group Means D.S. Weekly M 11.644 11.300 -0.344 -7.181 SD 9 .377 8.612 2.718 11.415 9 Awareness Weekly M 10.886 10.429 -0.457 -0.269 SD 12.898 10.871 4.251 6.924 7 D.S. Biweekly (twice M 17.000 15 .743 -1.257 -4.894 a week) SD 10.711 11.129 2.259 29 .933 7 Awareness Biweekly M 12.422 11.633 -0.789 -4.324 (twice a week) SD 9 .729 9 .708 3.004 11.463 9 a \ to TABLE 5A — continued Before call After call Difference Week Slope N D.S. Biweekly M 27.371 29 .443 2.071 -11.314 SD 15.774 24.6 30 10 .501 22 .694 7 Awareness Biweekly M 18.025 18.350 0 .325 -6.9 26 SD 11.463 14.677 3.873 8.487 8 D.S. Monthly M 14.214 13.143 -1.071 -6.576 SD 14.5 34 12 .923 1.790 8.313 7 Awareness Monthly M 8.250 6 .917 -1.333 1.824 SD 4.79 3 4.954 2.714 13.336 6 D.S. No Contact M 16.091 12.636 -3.455 1.288 SD 8.215 5.644 6.267 24.643 11 Awareness No Contact M 20.056 18.944 -1.111 -8.514 SD 11.19 3 10.477 2.934 25.006 9 TABLE 6 65 TEST OF MAIN TREATMENT EFFECTS SATIATION OR AWARENESS (Multivariate and Univariate F) Mean Square DF F ..T " Less Than Multivariate F Univariate F 10,59 1.657 .113 Week 1 460.219 1,68 6.069 .016 Week 2 231.113 1,68 3.711 .058 Week 3 202.012 1,68 3.221 .077 Week 4 164.020 1,68 2.513 .118 Week 5 216.977 1,68 3.001 ' .088 Week 6 165.887 1,68 1.954 .167 Before Call 62.152 1,68 0.835 .36 4 After Call 153.016 1,68 2.209 .142 After-Before 20.129 1,68 1.173 .283 Week Slope 38.262 1,68 0.113 .738 66 TABLE 7 TEST OF FOLLOW-UP EFFECT (Multivariate and Univariate F) Mean Square DF F P Less Than Multivariate F Univariate F 40,255 0.924 0.605 Week 1 157.534 4,68 2.077 0.093 Week 2 150.422 4,68 2.415 0.057 Week 3 103.472 4,68 1.650 0.172 Week 4 131.182 00 VD 2.010 0.103 Week 5 150.985 4,68 2.080 0.092 Week 6 152.555 4,68 1.797 0.140 Before Call 175.724 4,68 2.360 0.062 After Call 192.332 4,68 2.777 0.034 After-Before 19.581 4,68 1.141 0.345 Week Slope 131.375 00 VO 0.388 0.816 67 Hypothesis 3: Resnick (19 68) found that "satiation" procedures were superior to no treatment. The finding of no significant difference between stimulus satiation and nonspecific effects (see Hypothesis 1) provides informa tion on only the question of treatment differences. How ever/ the question of the degree of interaction between stimulus satiation and telephone follow-up remains unan swered. Hypothesis 3 is designed to provide information relative to this question. Table 8 provides data rela tive to the hypothesis of significant interaction between type of treatment and follow-up. There is no .significant interaction between main treatment effects and follow-up (P < .159) . Hypothesis 4: This hypothesis predicted that as the time interval increased between follow-up phone contacts, mean daily smoking rate increases, or, con versely, short time intervals between contact in follow- up maintains end of treatment gains. Inspection of the weekly subgroup means and standard deviations in Table 5 indicates that this is not the case. While the double satiation group have a higher pretreatment rate mean (23.156), its weekly counterpart in the awareness group did not differ substantially throughout follow-up. How ever, there were small crossovers between these two subgroups (see Figures 1A through 7). TABLE 8 TEST OF INTERACTION FOLLOW-UP CONTACTS AND MAIN TREATMENT (Multivariate and Univariate F) Mean Square DF F F.... Less Than Multivariate F Univariate F 40,225 1.250 .159 Week 1 133.969 4,68 1.767 .146 Week 2 90 .967 4,68 1.461 .224 Week 3 52.867 4,68 0. 843 .503. Week 4 72.683 4,68 1.113 .357 Week 5 103.000 4,68 1.425 .235 Week 6 74.416 4,68 0. 877 .483 Before Call 6 3.19 3 4,68 0.849 .499 After Call 91.292 4,68 1.318 .272 After-Before 5.912 4,68 0.344 .847 Week Slope 309 .525 4,68 0.915 .460 M E A N D A IL Y SMOKING R A T E (NUM BER O F CIGARETTES) 69 ' 301 — 25 ■ 20- 15 1 0 - AWARENESS -WEEKLY CONTACT DOUBLE SATIATION - WEEKLY CONTACT PRE TREAT- TREAT- MENT MENT 2 3 4 5 -FOLLOW-UP (WEEKS) - FIGURE 1A M E A N D A IL Y SMOKING R A TE (NUMBER O F CIGARETTES) 70 30 25- 20 15 10 - DOUBLE SATIATION — Bl WEEKLY- TWICE A WEEK FOLLOW-UP CONTACT AWARENESS Bl WEEKLY - TWICE A WEEK FOLLOW-UP CONTACT PRE- TREAT TREAT- MENT MENT - I 2 3 4 5 I- FOLLOW-UP (WEEKS) — FIGURE 2 M E A N D A IL Y SM O KING R A T E (NUMBER O F CIGARETTES) 50r 45- 40- 35- 30- 25- DOUBLE SATIATION - BI-WEEKLY CONTACT 20- 15- \ /-----AWAREK / Bl- - AWARENESS- WEEKLY CONTACT 10- PRE- TREAT MENT TREAT MENT 2 3 4 5 6 FOLLOW-UP (WEEKS)-------------I FIGURE 3 M E A N D A IL Y SM OKING R A T E (NUMBER O F CIGARETTES) 72 30 25 DOUBLE SATIATION MONTHLY CONTACT 20 AWARENESS- MONTHLY CONTACT PRE TREAT MENT TREAT MENT FOLLOW-UP (WEEKS) FIGURE 4 M E A N D A IL Y SMOKING R A TE (NUMBER O F CIGARETTES) 73 30 DOUBLE SATIATION - NO CONTACTS 25 AWARENESS - NO CONTACTS 20 PRE- TREAT- TREAT- MENT MENT FOLLOW-UP (WEEKS) FIGURE 5 M E A N D A IL Y SMOKING RATE (NUMBER O F CIGARETTES) 50r AW ARENESS DOUBLE SATIATION 45 40- 35 so- as- 20 15 10- i WEEKLY CONTACT i ----1 * BI-WEEKLY - TWICE A WEEK CONTACT * BI-WEEKLY CONTACT * K -a MONTHLY CONTACT □ a * NO CONTACT ■--- H" - a -o -o ------ PRE- TREAT- I 2 3 4 5 TREAT- MENT MENT FOLLOW-UP (W EEKS)- FIGURE 6 MEAN DAILY SMOKING RATE (NUMBER O F CIG ARETTES) 30 DOUBLE SATIATION- ALL GROUPS 25 20 AWARENESS - ALL GROUPS PRE- TREAT- TREAT- MENT MENT FOLLOW-UP (WEEKS) FIGURE 7 Hypothesis 5; This hypothesis predicted an inverse relationship between increased intervals of follow-up contact and double satiation treatment. The usual procedure in testing an interaction hypothsis is to employ ANOVA. However, Edward, Lindman, and Savage, (1963) and Edwards (1965) advocate a Bayesian approach to hypothesis testing. In looking at the evidence for this hypothesis, the writer agrees with Edwards (1971) in that the interocular test is appropriate in certain cases. It is the writer's opinion that it is not only appropriate but sufficient in testing this hypothesis. Inspection of the means (Table 5) for the weekly and bi weekly — twice a week subgroups reveal that increasing the interval between follow-up contacts for the double satiation group (holding number of contacts constant) has a detrimental effect on daily smoking rate. This group exhibits a greater tendency to revert to pretreatment rate than is shown by the other three groups. Tables 9 and 10, respectively, contain a) the number of persons who were abstinent at the end of treatment and follow-up, and b) the number of people who reduce their consumption by 50 to 99 percent of prerate at end of treatment and follow-up. It can be seen that the follow-up period tended to maintain the results found at end of treatment. TABLE 9 RELATIONSHIP BETWEEN STOPPING SMOKING AND TREATMENT CONDITION AT END OF TREATMENT AND END OF 7-WEEK FOLLOW-UP Condition End of Treatment End of Follow- Up stopped did not stop Total stopped did not stop Total Double Satiation 4 37 41 5 36 41 Awareness 4 35 39 4 35 39 Total 8 72 80 9 71 80 TABLE 10 RELATIONSHIP BETWEEN 50-99% REDUCTION IN SMOKING RATE AND TREATMENT CONDITIONS AT END OF TREATMENT AND' END OF 7-WEEK FOLLOW-UP Condition End of Treatment End of Follow-up 50-99% > 50% 50-99% > 50% reduction Reduction Total Reduction Reduction Total Double Satiation 19 22 41 18 23 41 Awareness 20 19 39 23 16 39 Total 39 41 80 41 39 80 oo 79 Figure 7 depicts the mean smoking rate of the two treatment conditions at pretreatment, treatment, and for each of the follow-up weeks. It can be seen that the shapes of the curves are the same. However, this study does not represent simply another study in the impressive, but ordinary accumulation of evidence which indicates that nearly all treatments are modestly effective. Care was taken in this study to examine the operation of nonspecific factors (Bernstein, 1969) . Moreover, care was taken to insure that subjects followed the double satiation procedure to avoid criticism (e.g., Lichtenstein, 1971) that examiner does not usually know if subject follows a prescribed treatment procedure. In the matter of insuring that subjects follow the pre scribed satiation procedure, the daily record forms were inspected for occasions of double smoking. These occasions were recorded as "instances." The instruction to double smoking rate in the stimulus satiation group resulted in fewer instances or occasions of smoking. The absolute number of cigarettes smoked during the treatment period parallel that of base rate. This is similar to the results found in the Marston and McFall (1971) study. These investigators also found that the number of smoking occasions decreased during the treatment period. Resnick 80 (1968) made it clear that subjects increased the absolute number of cigarettes smoked in the stimulus satiation conditions. It is possible that subjects in this study reduced the number of smoking occasions. DISCUSSION This smoking study has found no significant main effects between the two treatments that were administered. Resnick's (1968) double satiation procedure is not only no more effective than "nonspecific" factors, but the absolute number of persons that achieved abstinence in this study is lower than that reported by Resnick. Resnick (1968, p. 503) reports that one-third of subjects in his satiation groups were abstinent at end of treatment and at 2-week follow-up. The present study found that only one-tenth of the persons in the double satiation treatment were abstinent at the end of treatment. This is the same percentage as found in the "nonspecific" treatment group at the same period of time. Perhaps one of the major variables involved in the present study is the higher mean age and the longer smoking history of this sample. Resnick (19 6 8) dealt with a col lege population, whereas subjects in the present study were recruited from the University as well as the community at large. However, a major conclusion that can be drawn from the results of this study is that all treatment modalities are effective in reducing daily smoking rate at the end of 81 82 treatment and at the end of follow-up in comparison to pre treatment rate. Bernstein (1969) noted a similar effect of different treatment modalities. However, this study does not represent simply another study in the impressive but ordinary accumulation of evidence which indicates that nearly all treatments are modestly effective. Care was taken in this study to examine the operation of nonspecific factors (Bernstein, 1969). Moreover, care was taken to ensure that subjects followed the double satiation proce dure to avoid criticism (e.g., Lichtenstein, 1971) that experimenter does not usually know if subject follows a prescribed treatment procedure. The reduction in smoking rate for both groups is consistent with results obtained by a large number of investigators (e.g., Carlin and Armstrong, 1968; Lawson and May, 1970; Lichtenstein, Keutzer, and Himes, 1969; Ober, 1968; Schwartz and Dubitzky, 1967a, 1968; Steffy, Meichenbaum and Best, 1970; Tooley and Pratt, 1967; Wagner and Bragg, 1970; Weir, Dubitzky, and Schwartz, 1969; and Whitman, 1969.) These investigations employed treatment strategies ranging from aversive stimulation through con tingency management, contractual management, to "emotional" role playing. Many of these studies (i.e., Ober, 1968, p. 54 6; Lawson and May, 1970, p. 155) employed control or 83 attention-placebo groups. Yet the consistent result in the above studies is a reduction in smoking behavior during treatment with relapse to pretreatment rate at follow-up. The end of treatment result is also evident in the present study, but there is no evidence of relapse at follow-up. In fact, subjects continue to improve. Thus, one must agree with Bernstein (1970) that the decline in smoking behavior during treatment is largely a function of nonspecific effects. It should also be noted that various satiation techniques with follow-up produce differential results. Marrone, Merksamer, and Salzberg (1970), employing a stimulus satiation technique with telephone follow-up, did not produce the long-term effect found in the Resnick (19 68) study. However, these investigators did find a cessation of smoking in 60 percent of the subjects that were treated. As previously indicated, all groups were equivalent on these measures. The first four hypotheses were rejected. Double satiation and awareness are equally effective in reducing smoking rate. And there appears to be no significant relationship between the major treatments and frequency of telephone follow-up. These results can be seen in Figures 1A-6, where data points for each of the subgroups 84 are plotted, and in Figure 7, where data points for the major treatment groups are shown. Again reviewing Figure 7, it can be seen that, in general, all groups re duced their smoking rate below that of at end of treatment. Such results as these argue strongly for the operation of nonspecific factors that are assumed inherent in the in teraction between the experimenter and the subject. If absolute abstinence is employed as the criterion of suc cess, this study shows a poorer cure rate than other studies (e.g., Marston and McFall, 1971), but a great maintenance of end of treatment gains. It is possible that the follow-up period represent a treatment. This study as it stands constitutes a dissertation. However, there will be a subsequent follow-up of subjects in this study to determine if end of treatment results are maintained. It would appear that irrespective of treatment modality, subjects reduce their smoking behavior as a result of these nonspecific factors. The nonspecific factors that were involved in this experiment consisted only of subject's motivation to quit, encouragement by a clinic representative to eliminate cigarettes that the subject felt were unessential, and recording of smoking behavior. These results parallel those of McFall and Hammen (In Press). However, the contribution of each of 85 these nonspecific factors has not been ascertained. It is possible that daily recording of smoking behavior is primarily responsible for these results. One unanticipated finding involved the operation of these nonspecific factors with a particular treatment modality. Table 13 indicates an interaction between treatment modality and latency of follow-up. Inspection of Table 13 reveals the source of this interaction. It would appear that the increased interval between follow- up telephone contacts for the biweekly-twice a week sub group in the Double Satiation treatment tended to maintain higher daily mean smoking rates than persons in the Aware ness Group. Certain forms of satiation, with increased latency in follow-up contact are not as beneficial as regular contact and double satiation over a given period of time. Schmahl, Lichtenstein, and Harris (1972) report a similar finding in terms of frequency of follow-up and stimulus satiation: The results obtained concerning follow-up frequency are counter intuitive. The rein forcement and support offered by more frequent contact was expected to be helpful in main taining treatment gains. The data denies such an interpretation, (p. 109) This finding is especially interesting in view of the fact that all groups reduced the daily smoking rate; however, the particular combination of stimulus satiation 86 and increased interval of contact tended to attenuate the results for the biweekly-twice a week double satiation subgroup. This particular result, found here as well as in the Schmahl, et al. (1972) study, requires additional investigation. Perhaps it is the operation of the non- specific factors with a particular treatment modality that results in the least beneficial effects across subject groups. On the whole, however, this study has effectively demonstrated that a reduction in mean smoking rate is not attributable to any specific treatment modality, but rather to the operation of nonspecific factors. Bern stein's (1969) conclusion as a result of his review of the literature is applicable to this study. All treatments are effective in reducing smoking behavior. However, on the basis of the results found in this study of an attenu ated interaction between nonspecific factors and stimulus satiation as well as the result found in the Schmahl, et al. (1972) study, it would appear that further investiga tion should be directed at the interaction of treatment and nonspecific factors that are least beneficial. Exper imental results from such investigations could provide helpful guidance to future research. The effect of follow-up nonspecific factors in main taining end of treatment results requires investigation. 87 This study demonstrated the existence and operation of such factors in follow-up. The specific contribution of each factor was not ascertained. Is it the act of keeping daily smoking records that account for the maintenance of treatment gains in follow-up? Or is the follow-up tele phone call the important variable? Perhaps neither of these factors is singularly important but in combination explain the results found here. Again, the specific contribution of each of the nonspecific factors was not investigated here. Rather, the question of this existence in treatment follow-up was addressed. The implication of "nonspecific" factors in the modification of smoking behavior are numerous. Mauser (19 71) laments the failure of behavior modification in this area. Additionally, the employment of intensive, individualized treatment modalities are not only expensive but result in success rates equivalent to other less expensive treatments (cf., Azrin and Powell, 1968; Powell and Azrin, 1968). Moreover, specialized treatments do not prove to be superior to other treatments at follow-up (Bernstein, 1969; Kuetzer, et al., 1968). At follow-up relapse to base rate smoking behavior is the rule rather than the exception. It was earlier suggested in this paper that the interaction of nonspecific factors with various treatment 88 modalities receive investigation in an effort to elucidate those smoking clinic treatments that are least beneficial. It is also suggested that the demonstration of the effect of nonspecific factors in treatment and follow-up has important practical implications. These implications re volve primarily around the costs of operating smoking clinics. If the results found here are replicated, the costs of providing follow-up treatment via telephone calls appear miniscule in comparison to the costs of operating a smoking modification clinic where relapse to base rate occurs at follow-up. APPENDIX I SMOKERS The Psychology Department at the University of Southern California is providing a free smoking clinic for persons who want to stop smoking. If you are interested in obtaining this free service please call (213) 753-3701 anytime (day or night) . Ad appeared from 12-21-71 through 1-6-72. 89 APPENDIX II Personal History All information on this and all other forms are for statistical purposes only and will be kept strictly and completely confidential. 1. Name___________________________________________ __________ _____ 2. Age__________________________________ __________________________ 3. Sex: Female_____________ Male_____________________________ 4. Marital Status: Single Married Divorced Widowed____ If married; number of children If married; does spouse smoke? Yes______ No_________ 5. Highest grade completed (circle one) 1, 2, 3, 4, 5, 6, 7, 8, 9 10, 11, 12, 13, 14, 15, 16, 16+ 6. Current weight_______ lbs 7. What is your occupation______________________ 8. How long have you smoked? ____________ yrs. 9. How many cigarettes do you smoke per day?_____________________ 10. Have you tried to stop smoking before? Yes No If yes how many times 11. If vou have quit smokina. how long ago did you quit? mos 12. Do you have any medical problem(s)? Yes No If yes, what are these problem(s) 13. Did (or does) your parents smoke? Yes__________ No 90 91 APPENDIX III SELF-EVALUATION QUESTIONNAIRE Developed by C. D. Spielberger, R. L. Gorsuch and R. Lushene STAI FORM X-1 NAME------------------------ DATE----- DIRECTIONS: A number of statem ents which people have used to describe themselves are given below. Read each state- x ^ ment and then blacken in the appropriate circle to the right of 8 9 the statem ent to indicate how y o u/eel right now, that is, a t < j | g this moment. There are no right or wrong answers. Do not 5 § | n spend too much time on any one statem ent but give the answer * a ■ < a which seems to describe your present feelings best. P 5 8 8 1. I feel calm © ® ® © 2. I feel secure © ® ® © 3. I am ten se © ® ® © 4. I am regretful © ® ® ® 5. I feel a t e a s e © ® ® ® 6. I feel upset © ® ® © 7. I am presently worrying over possible m isfortunes © ® ® ® 8. I feel rested © ® ® ® 9. I feel anxious © ® ® ® 10. I feel com fortable.................................................................................................. © ® ® ® 11. I feel self-confident ......................................... © ® ® ® 12. I feel nervous ....:................................................... © ® ® © 13. I am jitte ry ........................................................................ © ® ® © 14. I feel “high strung" .............................................................................................. © ® © © 15. I am relax ed ...................................................... © ® ® © 16. I feel content ......................................................................................................... © ® ® © 17. I am w orried........................................................................................................... © ® © © 18. I feel over-excited and ra ttle d ............................................................................. © ® © © 19. I feel jo y fu l............................................................................ © ® © © 20. I feel pleasant......................................................................................................... © ® ® © CONSULTING PSYCHOLOGISTS PRESS 577 C ollege Avenue, Palo Alio, California 94306 92 SELF-EVALUATION QUESTIONNAIRE STAI FORM X-2 NAME____________________________________ DATE D IR EC TIO N S: A number of statem ents which people have used to describe*themselves are given below. Read each state m ent and then blacken in the appropriate circle to the right of the statem ent to indicate how you generally feel. There are no right or wrong answers. Do not spend too much time on any one statem ent but give the answer which seems to describe how you generally feel. 21. I feel p leasan t................................................................................................... ........ © © © ® 22. I tire quickly .......................................................................................................... . C D © © © 23. I feel like cry in g ...................................................................................................... ® © © © 24. I wish I could be as happy as others seem to b e .............................................. ® © © © 25. I am losing out on things because I can't make up my mind soon enough.... © © © © 26. I feel re s te d ........................................................................................... ................... © © © © 27. I am “calm, cool, and collected” .......................................................................... © © © © 28. I feel th a t difficulties are piling up so th at I cannot overcome them .......... © © © © *29. I worry too much over something th at really doesn’t m a tte r....................... © © © © 30. I am h a p p y ............................................................................................................... © © © © 31. I am inclined to take things h a r d ...................................................................... © © © © 32. I lack self-confidence............................................................................................. © © © © 33. I feel secure ............................................................................................................. © © © © 34. I try to avoid facing a crisis or difficulty........................................................... © © © © 35. I feel blue ................................................................................................................ © © © © 36. I am c o n te n t............................... ............................................................................. © © © © 37. Some unim portant thought runs through my m ind and bothers m e .......... © © © © 38. I take disappointments so keenly th at I can’t p u t them out of my m in d .... © © © © 39. I am a steady p e rso n .......................................................................................... ... © © © © 40. I become tense and upset when I think about my present concerns............ © © © © Copyright © 1968 by Charles D. Spietberger. Reproduction of this test or any portion thereof by any process without written permission of the Publisher is prohibited. APPENDIX IV INSTRUCTION This questionnaire is to find out how you feel about certain things. Each item consists of two (2) statements: "a" and "b". Please circle that statement which you really believe to be true. Select that statement by circling the letter "a" or "b". Since this is a measure of personal belief, there are no "right" or "wrong" answers. We want to get an idea as to how you feel about certain things. In some cases you may find that you believe both statements. Or on the other hand, you may believe neither statement. In cases of this kind, please be sure to circle the one statement that you believe is most true. Name____________________________________________ Sex_____________________________________________ Age__________ ____________________________________ 93 Children get into trouble because their parents punish them too much. The trouble with most children nowadays is that their parents are too easy with them. Many of the unhappy things in people's lives are partly due to bad luck. People's misfortunes result from the mistakes they make. One of the major reasons why we have wars is because people don't take enough interest in politics. There will always be wars, no matter how hard people try to prevent them. In the long run people get the respect they deserve in this world. Unfortunately, an individual's worth often passes unrecog nized no matter how hard he tries. The idea that teachers are unfair to students is nonsense. Most students don't realize the extent to which their grades are influenced by accidental happenings. Without the right breaks one cannot be an effective leader. Capable people who fail to become leaders have not taken advantage of their opportunities. No matter how hard you try some people just don't like you. People who can't get other to like them don't understand how to get along with others. Heredity plays the major role in determining one's personality. It is one's experience in life which determine what they're like. . I have often found that what is going to happen will happen. Trusting to fate has never turned out as well for me as making a decision to take a definite course of action. In the case of the well prepared student there is rarely if ever such a thing as an unfair test. Many times exam questions tend to be so unrelated to course work that studying is really useless. Becoming a success is a matter of hard work, luck has little or nothing to do with it. Getting a good job depends mainly on being in the right place at the right time. The average citizen can have an influence in government decisions. This world is run by the few people in power, and there is not much the little guy can do about it. 95 13. a. When I make plans, I am almost certain that I can make them work. b. It is not always wise to plan too far ahead because many things turn out to be a matter of good or bad fortune any how. 14. a. There are certain people Who are just no good, b. There is some good in everybody. 15. a. In my case getting what I want has little or nothing to do with luck. b. Many times we might just as well decide what to do by flipping a coin. 16. a. Who gets to be the boss often depends on who was lucky enough to be in the right place first, b. Getting people to do the right thing depends upon ability, luck has little or nothing to do with it. 17. a. As far as world affairs are concerned most of us are the victims of forces we can neither understand nor control, b. By taking an active part in political and social affairs the people can control world events. 18. a. Most people don't realize the extent to which their lives are controlled by accidental happenings, b. There really is no such thing as "luck". 19. a. One should always be willing to admit mistakes, b. It is usually best to cover up one's mistakes. 20. a. It is hard to know whether or not a person really likes you. b. How many friends you have depends upon how nice a person you are. 21. a. In the long run the bad things that happen to us are balanced by the good ones, b. Most misfortunes are the result of lack of ability, ignorance, laziness, or all three. 22. a. With enough effort we can wipe out political corruption, b. It is difficult for people to have much control over the things politicians do in office. 23. a. Sometimes I can't understand how teachers arrive at the grades they give, b. There is a direct connection between how hard I study and the grades I get. 24. a. A good leader expects people to decide for themselves what they should do. b. A good leader makes it clear to everybody what their jobs are. 96 25. a. Many times I feel that I have little influence over the things that happen to me. b. It is impossible for me to believe that chance or luck plays an important role in my life. 26. a. People are lonely because they don't try to be friendly, b. There's not much use in trying too hard to please people, if they like you, they like you. 27. a. There's too much emphasis on athletics in high school, b. Team sports are an excellent way to build character. 28. a. What happens to me is my own doing. b. Sometimes I feel that I don't have enough control over the direction my life is taking. 29. a. Most of the time I can't understand why politicians behave the way they do. b. In the long run the people are responsible for bad government on a national as well as on a local level. APPENDIX V Conflict Resolution Inventory INTRODUCTION The following questionnaire is part of a research project being conducted by the psychology department of the University of Southern California. We would appreciate your help by first filling out an answer sheet for the "Conflict Resolution Inven tory" and then a brief sheet of general information. Your par ticipation is entirely voluntary. All information will be kept strictly confidential. Your name is necessary only to help us analyze the data. If you feel uncomfortable about answering any questions, leave them blank. An answer sheet is provided — please do not write on the questionnaire itself, and return all the forms when you have completed them. Thank you for your assistance in this project. CONFLICT RESOLUTION INVENTORY A number of everyday situations are described on the following pages. We would like you to evaluate as honestly as possible how often in these situations you would do the thing which is underlined in each question. Even though the situation may never have happened to you, try to imagine your self in it and answer according to what you think you would do in that situation. There are no right or wrong answers. We want your own individual answers. For each question, make two separate answers. First, you should indicate how often you actually do the kind of thing underlined in the question. Circle number one if you always do that kind of thing in the situation described. Circle number seven if you never do what is underlined in that situa tion. If you sometimes do what is underlined, circle a number between one and seven depending on how often you would do it. Secondly, indicate how often you would ideally like to be able to do what is underlined in the situation described. You might want to do this all the time; in this case circle number one. Or perhaps you would prefer to do something very different in the situation described. In that case you should circle number seven, indicating that ideally you would never do what is underlined. Again, circle a number between one and seven depending on how often you would ideally like to do what is underlined. 99 EXAMPLE; You wake up too late to both eat breakfast and get to work on time; You skip breakfast. What I do What X would like to do Always____________Never___________Always________ Never < £ )2 3 4 5 6 7 1 2 3 4 © 6 7 In this situation, the person indicated he always skips break fast, but he would like to be able to go ahead and eat break fast fairly frequently, even if he would be late for work. Someone else might actually never skip breakfast, but ideally prefer to skip breakfast so that he or she can be more punctual at work. A third person might ideally want to skip breakfast in this situation just as often as he usually does. 100 1. A friend of yours argues that smoking is really not that dangerous. You offer a strong counter-argument. 2. You've received a check for your birthday. Your bank account is low. There's a sale on some attractive clothes. You spend the money on clothes. 3. You've been going to night school to begin a new professional career. Your boss promotes you and gives you a big raise. You continue with school. 4 . While working on a favorite hobby you remember an errand that you should have taken care of. You immediately stop what you are doing and take care of it. 5. You are breaking an engagement to^be married because of some unpleasant habits your fiance(e) has. You tell him (her) exactly why. 6. You're at a party and enjoying a drink. A lot of people are smoking, and someone offers you a eigarette. You haven't smoked for years. You accept and light up. 7. An accountant has described a way to pay less income tax than you are supposed to pay. You modify your report as he suggests. 8. A community hearing to discuss a law affecting your neigh borhood is scheduled on the same night you regularly attend a very pleasurable activity. You attend the hearing. 9. You are in a very serious meeting. Something strikes you funny. You contain your laughter. 10. You've been trying to improve your physical condition. As you arrive in a building the elevator door opens. You take the stairs. 11. A friend arrives unexpectedly while you're listening to ' your favorite record album. You turn it off immediately. 12. You are in bed when a tremendous earthquake hits. Although very scared, you get out of bed, and turn off the gas. 13. After having been off cigarettes for a month, you are anxiously studying for an important exam. You chew gum for a while, but finally smoke a cigarette. 101 14. You've received a check for your birthday, your bank account is low. There's a sale on some attractive clothes. You put the money in the bank. 15. You have been1 invited to a party and hear that LSD will be available. You do not attend the party. 16. You are at a potluck or smorgasbord dinner and have almost filled your plate before you have even come to the most desirable entree. You pass it by and take a seat. 17. You're at a concert and begin to feel very sleepy. You force yourself to stay awake. ”” 18. You are at a friend's house in the mid-afternoon and are told to help yourself to a tray of snacks. You're on a diet, and refuse the offer. 19. You're waiting for an overdue bus, you're carrying a pack of cigarettes even though you decided to quit the day before, you light up. 20. Your religion requires you to say a prayer aloud before a meal. You're at a dinner party with people who are not members of your religion. You say the prayer. 21. You’re taking a shower and the telephone's been ringing. You continue and let it ring. .22. Your best friend has deeply hurt your feelings and you feel like crying. You are home alone, but you keep yourself from crying. 23. An accountant has described a way to pay less income tax than you are supposed to pay. You reject his advice. 24. You have promised to pick up some groceries on the way home and remember as you turn in the driveway. You turn around and get the groceries. 25. You are in a very embarrassing situation and would like to excuse yourself. At the first chance, you leave. 26. You would like a scoop of ice cream for dessert in a res taurant where only elaborate sundaes are served. You skip dessert. 27. You have a headache and no aspirin. There is a drug store on the corner. You stay home and just try to relax. 102 2 8 . 2 9 . 3 0 . 3 1 . 3 2 . 3 3 . 3 4 . 3 5 . 3 6 . 3 7 . 3 8 . 3 9 . 4 0 . 4 1 . 4 2 . 4 3 . It is Sunday and raining heavily. You attend church anyway. In the course of an argument you become very angry and would like to shout and tell your opponent what you think of him. You wait until he is through with his point and then speak calmly. You have not slept well and feel irritable. When asked bothersome questions you respond cheerfully. You're at a friend's house in the mid-afternoon, and are told to help yourself to a tray of snacks. Though you're on a diet, you help yourself to a few. You're up late on the night before an important early appointment, and you're reading an exciting novel. You close the book and go to sleep. The car in front of you is going slowly and you would like to blast him out of the way with your horn. You follow at a safe distance until he turns off. Your employer has asked you to start working on a pile of items. It is quitting time, and you have only a few to go. You stay and finish them. You are in a very embarrassing situation and would like to excuse yourself, but you stick it out to the end. On Friday you have not completed your week's work and decide to finish on the weekend. Friends invite you to go away for the weekend. You turn down the offer in order to work. A friend of yours looks very depressed and unhappy. You're not feeling well yourself, and you tell him your troubles. You are very nervous about meeting someone and realize it would be easy to just not show up. You go anway. You have an appointment with a dentist who is usually an half hour behind schedule. You arrive at the appointed time. You are cooking a dish with wine and there is only a little left. You put the cork back and put the bottle away. You are late for an appointment because you have been enjoying the sunshine. When asked why you're late you give the real reason. You have recently met a wonderful person. You tell him (her) that you like him (her). You have promised to pick up some groceries on the way home and remember as you turn in the driveway. You go on into the house. 103 4 4 . 4 5 . 4 6 . 4 7 . 4 8 . 4 9 . 5 0 . 5 1 . 5 2 . 5 3 . 5 4 . 5 5 . 5 6 . 5 7 . One evening, after watching a couple of television shows/ you decide you have been watching too much T.V.. Suddenly a movie is announced which you have been wanting to see. You get up and turn off the set. You're caring for a young child and have promised to take him to the playground. You're feeling very tired but take him anyway. You are watching a very sexy movie and feel like touching your date. You refrain from making this move. You are in a waiting room with several other people and notice a copy of Playboy magazine which you would like to look at. You reach for a news magazine. You are very nervous about meeting someone and realize it would be easy to just not show up. So you skip the meeting. Someone close to you has died. You cry openly at the funeral. At a meeting someone offers you a cigarette. You have quit smoking. You refuse it. You notice that a cashier at a restaurant has given you more change than he should have. You return the change. You were up late the night before and it's raining. You get out of bed anyway and make it to an early appointment. You're at a party and enjoying a drink. A lot of people are smoking/ and someone offers you a cigarette. You haven't smoked for years. You refuse. You're talking to a friend. You've heard that a mutual acquaintance is getting a divorce. You don't mention it. You're up late on the night before an important early appointment, and you're reading an exciting novel. You stay up and finish the book. You've cleaned your apartment before a big party, but notice some dust on the table tops. You ignore it and go on with other preparations . ■ You have bought an expensive watch which suddenly stops running. You insist that the repair should be done free. 104 58. You're at a party on a hot summer evening and have had several glasses of cold draft beer. Feeling a little lightheaded, you drink soft drinks for the rest of the evening. 59. You're waiting for an overdue bus. You're carrying a pack of cigarettes even though you decided to quit the day before. You wait it out without smoking. 60. Someone close to you has died. You refrain from crying In public. APPENDIX VI Smoker^ Self-Testing Kit P A R T 1 : TH E T E S T S NMffi _____. ________ (Please Print) 1 2 3 i t IAS ANOEIZS COUNT! INTERAGENCT COUNCIL ON SMOKINQ AND HEALTH 111 North Hudson Avenue Pasadena, California 91101 1 * 9 - 1 ( 9 5 8 106 T trri DO YOU WANT TO CHANGE YOUR SMOKING HA M TW F or n c h cta to m a n t, c ir d a I h a num ber th a t A o m fttieth ar y o u corn p l e n t y agrat •o m a w b a l agree, aom aw h ai d lta g r ee , o r c o m p le te ly d b a p a e . Im p ortan t: A n w a r avary q u e s tio n . M fH o m r a a <boateo A CtfMatU uaottng arifM |h * aw a m i tart illN tt. I . Wj elcartlla la o t k f M b a bad eu a y to (m othara. C. I fnO c i|i t il li lawktoo la ba a a w u y ki*4 elfcatol. 0 . CofllrelllAi» ? eiiw tlto inokiAf b » thwrflRi la m . L S «*to| tjv u s ttarlam Of fNlltfl. f . If I quit t n o l^ i ( i f i n l l n it m l|M inlKxK* other* 10 Stop. 0. C ffirdfrt cmm f n u ( i to ctotb 4n| and other prim al pro^aitf. H. Ouiltirw smoklai would tfmr Hut I Km willpower. I. Hf e ifn r lli imoktot mil k m a haimful ollrct oa rnj h td tt. IT" i i c iir r it i’ r ^ t o i t o l t o i S i r othert c lo u to n * to lake up or w jtowo lawitof.________ A III Q Uil «inoklA|.Pf M « o a l tart* or oneM woeto toyrooa. L I do M l IAr the Idea of f it H * d«p«A4ent oa unoknif. H O W T O tC O flE: t . Enter ih eftu r n b o r iy o u h e v o tird a d io th eT otf I ooM ton otn I h e w a c n below , putting tho number y o u h m d r d a d to Question A ( r tu llrvoA. 10 O u ttllon B oror lino B, oic. 7 . Total ih t 3 tcorn ocroio on each lino to pot your t o u ll. Far osom pto, »h« turn o f your t c o m o v a r iu m A . E, ond I p m you your *cor< o n Hreflf! — l* m 8 . f .o n d J gives t h e ie w e o n E M m g to .o u . + + 5 " A ^ 1 H u lth + = _____ ^ F * J E u m t a + _____ + = _____ C ^ K E sthetics • * ■ + = ” B * H L M astery S c o r n a n w r y from 3 lo 12. A n y ic o te B and above is h jg ^ o n v t e w v B an d below i»J2M. Learn from Pan f w h e i yot» scores m ain. 107 Ttrri WHAT DO YOU THINK THE EFFECTS O F SMOKMQ A N D F o r w * i iW e # n in t r d r d e th e n u n in r ih s t * o w m * e d w y o u i l r o n i l y e g r * , m ild ly a p a a , m tk fly db agraa, o r stro n g ly diaagra*. Im p ortan t: A i m m w a r y qu aation . w h f w ftm ra a * x w f t Cigafitla MtoAiai b oat aaarfy at te g a to u t u m p } attar b a d tt hattrfc. f t I Om’I u n b aaoufN to ia t a w at Bm l i u n t t tint < l#if»tli HM kbi b — * i w O t o W H . _ ypa i e n r i p i . a p t n o f l M ur * •* « , it w #M i l « m1 «a Niw toooto iiop.________ 0 . It aouM ba hard f * m ta |b a m Mtoktaf c i|* rr tto i F, tM tiw ) to eigariUt I »mo*r ii nudi b u Itlalr UtoA otter Itodt to lira ■ M toy e l Ite d i u r u i Out unokkg * It n ip QOirt to c au «. f t At k m a t • ptrton o u ilt t n o l b | i l | - artllH M tef'M to racovaf lio n muck 4 at tin (b m a a i mat w o t i m t o t m i n t t i It would tM turd lor a n to cat dean to ■ lu ll IN Nmbar of c l|iitlla i to o * w aste, 1 L Tte ahola problem of c i|in t U inoUflf . a te.tetott b a w y ottur aaa. 1 i l i i m n T i a o k t d tone tneu|fi to worry about tha d lir m i tnrt td aatto 1 wnotong li wppotad la ta n * . ft (touting Motor* tetpa a panaa H j Ifcalonitr, L It aw to bt diirkutl lor a t to mala artf w to U n to l ( h m ii to my M otor* Utota. H O W TOSCO flE: I . E n iw th e A u m b * o iro tih o v e d r c to d ie th e T a ii2 q u e tio ( ia lA ih e e p # !* e batow, p u n In# ttw numtMi you Km drctod to Ouatoon A ooar Nna A . to OuHtJon 6 ovar llna B .vte. J . T otal tha 3 u x » h t a cm an a»m to n to |r t your tottoa. For t u r r e t , # n aum o f your b o t h c rm to m A , E , and I ftia a y o u your isnra on Im porunca — ton* B, F ,*n d J p m * t in n o r* on N n o n to flb r n r w * . ate. + Sooth can wary fcoM 3 to 1?.A n y acora Ban d a t e a a k M ^ ; any aoora 4 a o l b a to m b J e s- U a m from Fart I m lM iv M a o M a n a a n . 108 TtfT 1 WHY DO YOU SMOKE? Here art ittttfncntt made by aome people to doacrlbe whet they p t out of dprcttei. H o* 0 FTEN do you fed tfifs way when you araamokinf than? (Ctrda one number lor tad* *tat*m*nt.) Important: Anwwr awry question. i n'l in o tr c iiM iR n ai o r to to k n ? oqaalf Irma »lowin| down._______________________ ITH M dlini a c iiw tttT la port «f tM Mjof» fre* n o ihm WHfti ttemHy mMmi w in tof tm c tim jt t . S<nolm |ci|*(et1i*hpl<nanl*ndrel*ilA |. b. I light up a tltiiiH e eftra I freF ingrf about lo m e lh in f. _ _ _ C T f t S T f iii f 'S a out of a tir tU ts i t i a d l t almott unbt)> Jbl* until I can get D i m l ____ r r « n o » a a u le m * |le jll| w itM ut n t n bring aware ol it. C I smoke c i|* r tllti tfl tF flb liti me,tfl ptA_ mjrMll_up._ r r i r t o f lho-«istormenl ot nnoking*ei|*rr1 ti tomes from the ttrp* I U it tfl light up, L I find r ijj r itln plriswable. ]. w ir’ f t " I fad"'uncomto/tabli < H tips*! about umeirung, I l>gM up a dgintt*. K.*Tam i n i much awaia of th* li<i’itw » la a i not smoking acigarrtlr. C f light up I 'c ij j f t lli williout r u lilir q l thll hm _one twining in th# aUitiiY. II. I smoke cigarettes to give me a ‘‘lift** ft. When I im c k ra cigarette, pert o llh e enjoy- m tnl ii witching Ihesm oie as I e ihali I t 67 i want a o g ir e ttr most wtteft I M l cam- _forU bl* and r r l n t d _________________| K Whin I f ill "blue” or w « t to like ary nlndl ” oil care* and w ti li r i , I SmOfcl C igH tU H . Q. V ( d a real gnawing hunger for "a cigaretlO wtirn I h a n n 't imoked lot a whit*. O r * iovAd* m mouth didn't remember potting It thru. HOW TO SCORE: 1. Enier th en u m b ersyou h aved rd ad to the Tart 9 questions In th* spaces below , putting the number you h av ed rd a d t o Question A over line A , lo Q uestion E l over line ft, etc. 2. T otal t N S w ore* on **ch line to get your totafr. f o r exam ple, the a m i o f your wore* Peer line* A . G. and M owe* rou your acore on Stim ulation ~ lines 6 , H .and Ngivaa the ictwa o n Handling, etc, — — Total* ~Itifn ulaiion Handling Measurable Relaxation Crutch: TeosionR edurtion Craving' P ifthological A ddiction S c o r n o n vary hewn 3 to IS- A ny score 11 and above a high, any w ot* 7 and b e ta * it JfiH. Laarn from Part A what your w o r n maan. Tin 4 DOES THE WORU) M O U N D YOU M M E IT E A SF .* OR HARDER TO CHANGE YOUR SM 0K IN 6 HABITS? Indjata by dreling tha appropriate number*, whether you feat the foflowing statements era true or false. Im portan t: A n sw er «vary Q im tio n , f T feetwsbaitdecreased aTi topped totir imotmf *1 c lg vittn iw H u pn t l&ysare. austlr Iras tom e past iPyean ._________ __ _______________ I T fat rrc«M years (iNia se en to b e a w T r u le s skoal where yeo ' a n KHwrt to smoko. C. C gutlle aditHitlng mikes uNhing appear attractive to aw. 1 Schools art trying to discourage diilWea from tattling. t Doctors art tryin| to gal thtir pellnts to atop tanliag. FT"toS«^iiir7reenFr"tiJ*d toperwade aw to c e lA n ar pul Smoking ciim ltet. ____ Srths constant itfxliiton el cigarette sdrrrlitlng n a lii || Mr* lor m » to iQvil u n e h in f.___________ ________________ ST boU j GovernrntAl m d p iirr ti health w |anfiit>ons art a c tin g - — *0^1 to ditcauiate frrtplt Inna smoking.________________ L A doctor hat, al tout once, talked la aw about my smoking, IT ft m m n ihoujii ui Increasing number al people object to~~ hating t e a m s sm oke war them.______________________ It Som e cigarette coounerdili ea TV u M bm feel l i t smoking CrtenSmiMfl'enT'other kgiilatots ire shewing conceri a n tto unoking andMallh, BTThe pw plr around you. p trticuliilf those ■*» it s dose to you t t - l , relatorts, Mends, a ltk i associates), m ir mala it aatiar ar more dillkull for you Is give up smoking by « tu l they I l f erd * . Wbal about tort* people? W t v M f e u u r (bat O u r make giving up smoking or staling oil d g iitile s mere W iIIjcuII (at fig UiM it would be otfureFia? (Circle l i t number lo tha (alt . a t lha statomenl that best describes your sllualionJ 3 They make It mud) m efidilficulilhjii iVwoulJ be otherwise. 4 They make U somewhat more dilfkull than it wobld be otherwise. 5 They make it somewhat easier than ft would b e otherwise. % They make It much eatier than HwooMbe otherwise. HOW TO SCORE: f. Enter tha numbers you havt d rctod on th* Tam 4 Questions Pi th e Sp*6*S b tio w , pu lling (he n u m b * you h i * crrded t o OuttftoA A OVW lin e A , t o Question B over line B, etc. 3 . Total the 3 scores e a o m e n e e d i lins to p i your totals, f o r ewempke, tha sum o l your sc o rn ovte lines A . E, and I f lim you your score on D octors — lin n B, f , and J 0i v n the score on General C lim ne. ate. + + E + + f + + G + + General O im sta A dvertising Influence K e y G ro u p Influence” Interpersonal Support Scores can w ry from 3 to 6: fl is hitfi; 6 . h ig i middle; 4 . t o * middle: 3. tow. Laern from Perl Bsahal your sc o r n mean. 109 TOT 4 DOES THE W OftlD M O U N D YOU MAKE IT E A S E R OR HARDER TO CHANGE YOUR SMOKING HABITS? I m M a tt b y d r d in g th * app rop riate n u m b o n , w h e th er y o u foal th * foN ow tn g s ta te m e n ts a r t tru e o r fa b e . Important: Answwr bmryquartlon. trot I tha ar ar msI I r « o « W | I s H e AT&eclwi K m detftaied ar i N f H ft*ir i a n t i i| U c if x t t t n la fee f U illO y in . I T ¥ r tc M i'tta fi U eta m m I* be mmc rvies aboat whera joa a n snowed la tnwto. 6. C U m tta otfvtrtUMc a M tt ta « U a | appear rttractha la ao. 0. Sdtooti era trying (a diiceuraga d tittm f t m u b t b g . L Doctors « a trjrlng to |« t tfcelf patients b stop IT’Sointeni Kit ofcently tiied la persuade n c to c a td t n v f i l l smoking C i|tie1llt. ____________________ _ _ _ C ’The constant iapttiiofl o n iia f itt e idrrrlittflg mafcat It hard kf me la quit smelMf. _________________________ fTflolft CortirwMl ard p iiriti health aft scUttly tryini U^diicouiayr people Bow smoking. I Adoctet h a i.e tltM lo flc « .tilh td le » a b w liiq r sa w h ia f. P R m m ‘« n h ^ h ^ lwi(M lA|^iunlttr at having someone iwokf n e u them. object b K . t o w ciiM itta commercials oa TV make m fetl lifco si P C M i l n i i w 1 ^ " a U tT ii|iiU lo f» ara shewing canctm with’ ' smoking and h e a lt h .___________________ BTTha people around you. particularly those who u a d a ta b yoot ( e g . rale lives, friends, oflka associates), auy mala it easier af more difficult (of you to | i r i tip smoking by what they I lf ar da. Whet about Uitse people? Would you say that they make giving up smoking «r slaying all tf(irt(1ct more dillicull tar you than It wouldbt olhriuise? (Circle tha number lo tha b it at tha iW rment Uul bait describes your sitirstionJ T Thtfm aki Itanuck morc~tfidKrcu1'|(hanitpoulil to otherwise. 4 Thay auka it somewhat aura tfillkcuJI thaa it woDM Da otherwise. 5 They make it somewhat easier (hen It would Da otherwise. 4 They rake II muck tailor than It would ba othenrlso. HOW TO SCORE: 1. Enter Ota num bersyou h a v o c w d e d o n ih o T o n 4 questions ib (fie spaom b e ta * , putting (he number you h e w b r d e d r o O u titton A p o r t tow A , t o Ouartion B ovar llna B , ate. 2 . T e t a llh a lK D fw a a o « o n a a d ) U n o t o )t t y o u r to ia l« .F o r a x o r n p b .t tw aum o l your icoroa ovar linos A , 6 , and I g l m y o u your aecwa on D octors •* linos B ,f ,a n d J gives th e score on General O im n i. etc. G m to lC H m H l ArhwrtHtng Inlluonoa Kay Croup Inriuanca tnierparsonel Support Scot as can vary from J to 6: fl it hi#s; 6 . hiWs middSe; 4 . tow middle; 3. tow, Law n Irom Pari ■ mhos your ueraa moan Smokari S a fM e ittn g K ft This self-testing Kit wai d m k ip id for dg erctte smokers to h ttp determ ine how you fe tl about cigarette smoking, It will help you find o ut: 1. The reasons you might have for wanting to q u it smoking and how strong these reasons era. 2 . What you know about tha affects o f smoking o n health. 3 . What you pet o u t of cigarette smoking (what kind o f • smoker you are). 4 . W hether the world you lira In will be • help o r a hindrance If you were to try to change your smoking habits. This kit was developed b y Dr. Daniel Horn, Director o f th a National Clearinghouse for Smoking and Health and members of the Clearinghouse staff. The Clearinghouse was established in the Public Health Service by th e UrS. D epartm ent of Health, Education, and Welfare to try to bring under control the loll o f death and disability produced o r aggravated by cigarette smoking. It is our conviction th at if Americans take a good hard look a t th e facts about smoking cigarettes and how they feel about them , many will decide to quit. The first tw o tests ere designed to help you take this look at yourself. Tests 3 and 4 are designed to give you some insight into what kind of a smoker you are, w hat problems you are most likely to run into, if any, when you try to quit, and some guidelines o n how you m ight deal with these problems. T he purpose o f th e tests, which are aim ed a t 'Insight developm ent," is to help you understand yourself and to help you deal w ith your smoking. The first step Is to take the 4 tests in this leaflet. M ake sure you circle a num ber to answer every question. Than score yourself according to tha instructions a t the bottom of each test. D o H o u U a n t t o S t o p 111 APPENDIX VII O - O < o £ % o cO __# 3 •« o r» *? K) I f c -* : f o-» I c w J J L 0— <0 ^ a) £ £ J9 ii- <o ,c -o I cn -c - i I i y CD ^3. Ill £ § 1 3 i - APPENDIX VIII INSTRUCTIONS FOR RESEARCH ASSISTANTS A. Orientation Inasmuch as we have participated in previous discussions regarding the orientation meeting, detailed reexamination of the survey instruments are unnecessary. However, it would appear that certain areas of our earlier discussion be emphasized. 1. Do not discuss specifics of the smoking clinic with potential subjects before, during, or after the orientation session. Refer all substantive questions to Dr. Marston or Fred Richardson. 2. You will have responsibility for a specific section, number of rows, or groups of tables. Your area of responsibility will depend upon the site that is ultimately selected for the orientation session. However, your area of responsibility will be clearly defined prior to the orientation session. 3. Pass out survey, questionnaire material exactly in the order indicated by smoking clinic spokes man. 112 Thus, every person at a particular session will be responding to the same instrument at a specific time. Time (4-7 minutes) will be allocated for dissemination and collection of each instrument. This time period will vary according to the actual experience that is encountered during each session. The smoking clinic spokesman will request that ~ participants place their name (or number) on each instrument. In your area of responsibility, be sure to check each instrument when it is returned to you for this identifying information. This inspection should be made before proceeding to the next row, tables, or group. During the last fifteen minutes of the orienta tion session, proceed to your designated table/exit. This step is to ensure the availability of material for potential subjects. Do not force this material (step 5) on subjects. Rather, make it easily available. One could, for example, have a box containing the material in one hand and hold a specimen sample in the other hand. As the specimen sample is taken, replace it from the supply box in the other hand. Persons may concurrently take material from this box. APPENDIX IX PROCEDURES FOR ORIENTATION MEETING The University of Southern California and, in particular, the staff of the USC Smoking Clinic welcome you to this orientation meeting. You have taken the first step toward quitting smoking. As you all know, the Surgeon General's report which came out in 1964 indicated a definite link between smoking and numerous health problems. Nevertheless, people find it difficult to break the smoking habit. Our clinic is designed to help you stop smoking. We have conducted smoking studies ourselves and extensively reviewed the literature on smoking clinics. As a result of this thorough review, we have selected out of this tremendous amount of material two treatments that have been found to be most effective. However, the major finding of most smoking clinics is that people who are successful have 1 1 commitment." 1. Commitment: This is a term that means different things to different people. But when used in the context of smoking clinics, it usually means a willingness on the part of people to continue trying to break the smoking habit. „ „ _ People have varying degrees of commitment. However, we are asking each of you to become truly committed to giving up cigarette smoking. Again, it has been found that those persons who are committed are successful in breaking the cigarette habit. We are asking that you demonstrate to yourselves and others that you are committed by coming to one additional treatment session and participate in the follow-up. Treatment Session; We have reviewed the literature and as a result have refined our clinic to the essential things that have proven successful. This treatment is administered individually. Therefore, we cannot give you all the treatment at the same time. You can sign up for the treatment at a time that is convenient to you. These treatments will be administered next Saturday (January 15, 1972) and next Sunday (January 16, 1972) between 8:30 a.m. and 5:00 p.m. You will find sign-up sheets on tables directly across from the exits to this room. There are four sign-up sheets; one each for the morning and afternoon of Saturday and Sunday. 117 Please pick the time that is convenient for you and provide your name and other information requested on the forms. The research assistant at the table will provide you with your appointment card for your treatment session. The treatments will be administered at the time you come to the clinic. In contrast to the traditional smoking clinics, we will be keeping in touch with you at various times throughout the period that the clinic is in operation. This is a very important part of the treatment procedure. Ladies and gentlemen, almost all smoking clinics are successful; that is, people who become involved in a smoking clinic usually reduce or completely quit smoking during the period that the clinic is in operation. And, as those of you who were in previous clinics know, people find it difficult to remain off cigarettes once the clinic is over. Heretofore, the various clinics have not stayed with their clients beyond the clinic phase. Here, however, we plan to stay with you. A second aspect of this smoking clinic is daily record keeping of your smoking behavior. Research assistants distribute forms at this point. Some of you may stop smoking entirely at the end of the next treatment session; others may curtail their smoking. The goal of the smoking clinic is to assist you in breaking the habit. The record keeping tells you, as well as the clinic, how well you are progressing. It is important that you keep track of your daily smoking rate for the next week. These forms are small enough to fit inside a pack of cigarettes. We request that you make no changes in your smoking behavior between now and the treatment session. However, we request that you record the number of cigarettes smoked and the hour at which you smoked them. By now, each of you should have seven (7) of these forms (hold up form). Each form represents one day. There is space at the top of the form for your name and date. Since we are requesting that you make no changes in your smoking behavior during the next week, please record on these forms the time of day that you smoked cigarettes and the number of cigarettes smoked. Begin this record keeping tomorrow. For example, if on Monday, January 10, 1972, you smoked 2 cigarettes between 9:00 and 10:00 a.m., enter the number 2 for 9:00 a.m. This, as is each of the clinic procedures, is very important to your success in the clinic. During the time that you are smoking at your usual rate, resolve to commit yourself to staying in the clinic throughout its duration. Be sure to keep a separate record for each day. Return all these records to the clinic at the time you appear for your appoint ment next week. Follow-up: As I indicated earlier, this clinic will employ that treatment that has been found to be most effective. In addition, we will periodically contact you throughout the operation of the clinic. This follow-up has not been provided in other clinics, but we feel it is an essential part of the treatment process. This follow-up period will also include record keeping and you will be supplied with forms and an envelope at the time you come to the clinic for your treatment. This daily record keeping is a very important aspect of the treatment procedure. It serves the purpose of reminding you of your clinic commitment as well as provide you with information about the number of cigarettes you are smoking. This follow-up period is the major focus of the clinic and is designed to augment gains that are made during treatment. I would like to return to the subject of commit ment. This is a very important key to success in breaking the cigarette habit. As an external aid to help you maintain your commitment, we are asking you to bring with you a postdated personal check, cashiers check, or IOU in the amount of $25. This check or IOU will be returned to you, uncashed, at the end of the clinic (not later than April, 1972). The return of these checks, uncashed, cannot be emphasized too strongly. This clinic is free and we are not charging anyone for services. However, previous studies have found that people seem to maintain commitment with this procedure. The check will be returned to you regardless of your success at termination of the clinic. The only requirement is that you stay with the procedure and keep your smoking records. 121 If you drop out completely, your check will be used for further smoking research. The goal here is to keep you in the clinic. When you come to the clinic with your check, we will give you a receipt which clearly indicates that the check will be returned to you when the clinic terminates (not later than April, 1972). (Question Period 5-10 minutes) To assist us in evaluating the effectiveness of this clinic, we would like you to complete several instruments. Your responses to these instruments will be helpful to us in inter preting the effectiveness of this clinic. The first instrument is a personal history instrument, (Research Assistants distribute this instrument at this point), which the research assistants are passing out. This form asks for certain personal information as well as infor mation regarding your smoking habit. Please be assured that this and all other personal infor mation will be kept completely confidential. APPENDIX X Date Name Time No. Time No. 6am 6 pm 7am 7 pm Sam Spin 9am 9 pm lOam 10 pm llam 11pm noon 12 1pm lam 2 pm 2 am 3 pm 3 am 4 pm 4 am 5 pm 5 am Total: 122 APPENDIX XI INSTRUCTIONS FOR FINAL FOLLOW-UP CONTACT Inasmuch as this is the final telephone contact for this portion of the smoking clinic, it is imperative that each of the following areas be discussed. 1. Review of progress during clinic. Specifically, discuss with each person his/her smoking rate at the beginning of the clinic. Compare this with his/her present smoking rate (if still smoking). Reinforce reduction in smoking rate and/or complete cessation. Also, discuss the difficulties that the client encountered that may have contributed to any unusual variations in the subject's smoking pattern during the clinic's operation. Ask current weight. 2. Discuss general problems that are involved in smoking cessation. While this may, in some respects, relate to the preceding area, there are several general areas that can be discussed. A) Habit: Here the difficulty appears to be that persons often smoke cigarettes at particular times, e.g., driving, while drinking coffee, etc. 123 124 B) Crutch: Many persons often smoke when they are tense, experiencing a threatening situ ation, or otherwise perceive some type of stress. C) Pleasure-relaxation: Here the motivation for smoking is usually an additional relax ation such as after a job well done or while attending a cocktail party, etc. The above areas are illustrative of general areas of difficulty in breaking the cigarette habit. However, do not convey to the client that such areas are reasons for continuing to smoke. Emphasize that commitment to stop smoking places the above areas as well as other areas of difficulty in proper perspective. This perspective is intended to aid the client in further resolving to quit smoking, although this clinic is formally ending. (At this point, unsuccessful smokers may express dissatisfac tion with themselves as a result of their inability to stop smoking. Do not reinforce this negative self pers pective) . 3. Although this clinic is ending, the client may be interested in continuing with some other clinic. Inquire if the client is so interested. If so, inform him/her that the American Cancer Society has scheduled smoking clinics at the following places and times: A. April 10, 1972, at TRW - 772-1176 B. Month of May, Long Beach Community Jewish Center - 437-0791 C. Month of May, California Hospital - 627-7857 Additionally, other branch offices of the Ameri can Cancer Society may have scheduled smoking clinics in the near future. If the client is interested in obtaining additional information, he should contact the American Cancer Society Branch Office that is nearest his residence. To find the Branch Office nearest him, he should look in the white pages of the telephone book under the heading "American Cancer Society." Thank the client for his participation in the clinic. Advise him that the data submitted by participants will be extremely useful in evaluating this clinic as well as helpful in designing better smoking clinics in the future. The client may ask if there will be a final orientation session. Advise him that no final session will be held for financial reasons. Confirm present address with client (address is on check or if no check obtain present address). Advise client that his check will be returned to him and to phone the clinic at 746-2287 if he has not received his check by April 1, 1972. Advise client that this is the last call that the clinic is making in view of the clinic's cessation. However, we would like their permis sion to call them at some future time to talk with them about their smoking. REFERENCES Azrin, N. H. and Powell, J. Behavioral engineering: the reduction of smoking behavior by a conditioning appara tus and procedure. J. of Applied Behavioral Analysis, 1968, 1, 193-200. Baer, D. J. and Katkin, J. M., Jr. Limitation of smoking by sons and daughters who smoke and smoking behavior of parents. J. Genetic Psychology, 1971, 118, 293-296. Baldridge, B. J.; Kramer, M.; Whitman, R. M.; and Ornstein P. H. Smoking and dreams. Psychophysiology, 1968, 4, 372-373. Bandura, A.; Blanchard, E. B.; and Ritter, B. The Rela tive efficacy of desensitization and modeling approaches for inducing behavioral, affective, and attitudinal changes. Principles of Behavior Modification. New York Rinehart and Winston, 1969. Bernstein, D. A. Modification of smoking behavior: an evaluation review. Psych. Bull., 1969, 71, 418-440. Bernstein, D. A. The modification of smoking behavior: A search for effective variables. Behavior Res. & Therapy 1970, 8, 133-146. Carlin, A. S. and Armstrong, H. E., Jr. Aversive condi tioning: Learning or dissonance reduction. J. Consult ing Psychology, 1968, 32, 674-678. Cautela, J. R. Treatment of smoking by covert sensitiz ation. Psych. Reports, 1970, 26, 415-420. Cramer, E. M. Revised MANQVA Program. Psychometric Laboratory, University of North Carolina, September 1970 Dies, R., Honeyman, M., Reznikoff, M., & White, C. Person ality and smoking patterns in a twin population. J. Projective Techniques & Person. Assessment, 1969, TJ, 457-463. Dubitzky, M. and Schwartz, J. L. Cognitive dissonance and changes in cigarette smoking in an organized control program. J. Soc. Psych., 1969, 79, 219-225. 127 128 Edwards, W. E. Personal communication, May 1971. Edwards, W. E. Tactical note on the relationship between scientific and statistical hypothesis. Psychol. Bull., 1965, 63, 400-402. Edwards, W. E.; Lindman, H.; and Savage, L. J. Bayesian statistical inference for psychological research. Psychol. Review, 1963, 70-193-242. Elliott, R. and Tighe, T. Breaking the cigarette habit: Effects of a technique involving threatened loss of money. Psychol. Record, 1968, 18, 503-513. Evans, R. R. and Bargatta, E. F. An experiment in smoking dissuasion among university freshmen: A follow-up. Health & Social Behavior, 1970, 11, 30-36. Eysenck, H. J. Smoking, health, and personality. Basic Books: New York, 1965. Festinger, L. A Theory of Cognitive Dissonance. Stanford University Press, 1957. Forbes, G. B. Smoking beahvior and birth order. Psychol. Report, 1970, 26, 766. Frith, O. D. Smoking behavior and its relation to the smokers immediate experience. Brit. J. of Soc. & Clin. Psychol., 1971, 10, 73-78. George, T. W. Selective removal of components of tobacco smoke by filtration. National Cancer Institute Mono graph, 1968, 28, 237-248. Greene, R. D. Modification of smoking behavior of free operant conditioning methods. Psych. Record, 19 64, 14, 171-178. Hays, W. L. Statistics. New York: Holt, Rinehart, and Winston, 1963. Hjelle, L. A. and Clouser, R. Internal-external control of reinforcement in smoking behavior. Psychol. Report, 1970, 26,562. 129 Homme, L. E. Perspectives in psychology XXIV. control of coverants, the operants of the mind. Psych. Record, 1965,, 15, 501-511. Horn, D. People can be motivated to quit smoking. National Tuberculosis & Respiratory Disease Assn. Bull., 1968, 56, 2-5. James, W. H.; Woodruff, A. B.; and Werner, W. Effect of internal and external control upon changes in smoking behavior. J. Consulting Psychol., 1965, 29, 184-186. Janis, I. L. and Hoffman, D. Facilitating effects of daily contact between partners who make a decision to cut down on smoking. J. Personality & Social Psych., 1968, 9, 260-265. Jenks, R.; Schwartz, J. L.; and Dubitzky, M. Effect of the counselors approach to changing smoking behavior. J. Counsel Psych., 1969, 16, 215-221. Johnson, R. E. Smoking and the reduction of cognitive dissonance. J. Person, and Soc. Psychol., 19 68, 9, 260-265. Kanfer, F. H. Self monitoring: Methodological limitations and clinical applications. J. Consulting & Clin. Psych., 1970, 35, 148-152. Keutzer, C. S. Behavior modification of smoking: The experimental investigation of diverse techniques. Behav. Res. & Therapy, 1968a, 6, 137-157. Keutzer, C. S. Sex differences in a smoking treatment program. Diseases of the Nervous System, 1968b, 529-533. Keutzer, C. S; Lichtenstein, E.; and Mees, H. L. Modifica tion of smoking behavior: A review. Psych. Bull., 1968, 70, 520-533. Kirk, R. E. Experimental Design: Procedures for the Behavioral Sciences. Belmont, Calif. Brooks/Cole Pub- lishing Co., 1968. Lawson, D. M. and May, R. B. Three procedures for the extinction of smoking behavior. Psych. Record, 1970, 20, 151-157. 130 Lawton, M. P. A group therapy approach to giving up smoking. Applied Therapeutics, 1962, 4, 1025-1028. Lawton, M. P. Group methods in smoking withdrawal. Archives of Environ. Health, 1967, 14, 258-265. Lichtenstein, E. Modification of smoking behavior: Good designs ineffective treatments. J. Consulting Psych., 1971, 36, 163-166. Lichtenstein, E.; Keutzer, C. S.; and Himes, K. H. "Emotional" role playing and changes in smoking attitudes and behavior. Psychol. Report, 1969, 25, 379-387. Mair, J. M. M. Psychological problems and cigarette smoking. J. Psychosomatic Research, 1970, 14, 277-283. Mann, L. and Janis, I. L. A follow-up study on the long term effects of emotional role playing. J. Personality & Social Psychol., 1968, 8, 339-342. Marrone, R. L.; Merksamer, M. A.; and Salzberg, P. M. A short duration group treatment of smoking behavior by stimulus saturation. Behav. Res. & Therapy, 1970, 8, 347-352. Marston, A. R. and Barrett, C. Conflict Resolution Inventory. Unpublished. Marston, A. R. and McFall, R. M. Comparison of behavior modification approaches to smoking reduction. J. Con sulting & Clin. Psychol., 1971, 36, 153-162. Matarazzo, J. D. and Saslow, G. Psychological and related characteristics of smokers and nonsmokers. Psych. Bull., 1960, 57, 493-513. Mauser, B. Some comments on the failure of behavior therapy as a technique for modifying cigarette smoking. J. Consulting & Clin. Psychol., 1971, 36, 167-170. McFall, R. M. Effects of self monitoring on normal smoking behavior. J. Consulting & Clin. Psychol., 1970, 35, 135-142. McFall, R. M. and Hammen. Nonspecific effects in modifica tion of smoking behavior. In Press. 131 Moan, C. E. and Feick, G. L. Changes in attitudes toward smoking and communicator credibility as a function of type of communication. Psychol. Report, 1968, 23, 534. Moses, F. M. Treating smoking by discussion and hypnosis. Diseases of Nervous System, 1964, 25, 184-188. Moshy, R. J. and Halter, H. M. Reconstituted - tobacco- leaf technology: A tool for tobacco smoke modification. National Cancer Institute Monographs, 19 68, 28, 133-14 8. National Clearinghouse for Smoking and Health, Annual Reports. Ober, D. C. Modification of smoking behavior. J. Con sulting Psychol. & Clin. Psychol., 1968, 32, 534-549. Orne, M, T. From the subjects point of view, when is behavior private and when is it public: Problems of inference. J. Consulting & Clin. Psychol., 1970, 35, 143-147. Paul, G. L. Insight versus Desensitization: An Experimentj in Anxiety Reduction. Stanford: Stanford University Press, 1966. j Paul, G. L. Behavior modification research in C. M. Franks (ed.) Assessment and Status of the Behavior Therapies and Associated Developments. New York: McGraw-Hill, 1969. Platt, E. S.; Krassen, E.? and Mausner, B. Individual variation in behavioral change following role playing. Psychol. Report, 1969, 24, 155-170. Powell, J. and Azrin, N. H. The effects of shock as a punisher for cigarette smoking. J. Applied Behav. Analysis, 1968, 1, 63-71. Premack, D. Mechanisms of self control. In W. Hunt (ed.), Learning Mechanisms and Control of Smoking. New York: Aldine, 1971, In Press. Pyke, S.; Agnew, N.; and Kopperud, J. Modification of an over-learned maladaptive response through a relearning program. Behav. Res. & Therapy, 1966, 4, 197-203. 132 Rapp, G. W.; Dusza, B. T.; and Blanchet, L. Absorption and utility of Lobeline as a smoking deterrent. Amer. J. of Medical Science, 1959, 237, 387-392. Raymond, M. J. The treatment of addiction by aversive conditioning with apomorphine. Behav. 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Richardson, Frederick Lee
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The Effect Of Nonspecific Factors On The Modification Of Smoking Behaviorin Treatment Follow-Up
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