Attributional Processes in Behavior Change and ...

Journal of Consulting and Clinical Psychology l987,Vol.55,No.3.372-378

Copyright 1487 by the Arc ncan Psychological Association, [nc. 0022-006X/87/J00.75

Attributional Processes in Behavior Change and Maintenance: Smoking Cessation and Continued Abstinence Judith M. Harackiewicz Columbia University

Carol Sansone University of Utah

Lester W. Blair, Jennifer A. Epstein, and George Manderlink

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Columbia University

If individuals attribute smoking cessation to external factors, they may be less able to maintain abstinence over time. To examine the role of attributions in initial and long-term behavior change, we manipulated the externality of treatment by comparing self-help manuals with and without a drug component and by comparing the motivational orientation of three programs (intrinsic selfhelp, intrinsic gum, extrinsic gum). We examined attributions for success or failure with treatment, the effects of treatment on initial cessation and on long-term maintenance of nonsmoking, and the effects of attributions on maintenance. Subjects receiving nicotine gum were superior to the intrinsic self-help group in initial cessation but were inferior in maintaining abstinence. Subjects in the intrinsic self-help group made fewer external attributions for success and remained abstinent longer, thus providing support for the attributional mediation of treatment effects on maintenance.

ior and also that attributions influence subsequent behavior

Patients are often unable to maintain therapeutic gains after treatment has been completed (Hunt, Barnett, & Branch, 1971; Hunt & Matarazzo, 1973). For example, smoking cessation

(Judd& Kenny, 1981). Several misattribution studies (Barefoot & Girodo, 1972;

treatment programs have been reasonably effective, but recidi-

Davison & Valins, 1969; Davison, Tsujimoto. & Glaros, 1973;

vism is high (Leventhal & Cleary, 1980; Schachter, 1982). One possible solution to this problem comes from attribution the-

Storms & Nisbett, 1970) have found that external drug treatments have detrimental effects on the maintenance of behavior change, but these studies did not include independent assessments of the external attributions assumed to be the cause of

ory, which suggests that individuals who view themselves as responsible for their changed behavior will be more successful in maintaining it after treatment has been terminated (Davison & Valins, 1969; Deci & Ryan, 1985; Kopel & Arkowitz, 1975).

these results. More recently, studies have found correlations between internal attributions for behavior change and the mainte-

However, the same behavioral changes, if attributed to external factors (e.g., a drug), will be at risk once these factors are re-

nance of fluoride mouth rinsing (Lund & Kegeles, 1984) and smoking cessation (Colletti & Kopel, 1979; Fisher, Levenkron,

moved (Harackiewicz, Manderlink, & Sansone, 1984; Lepper, Greene, & Nisbett, 1973). To demonstrate that causal attributions mediate the effects of treatment on long-term mainte-

Lowe, Loro, & Green, 1982) after treatment. However, the internal attributions were not affected by the treatment programs. To date, a thorough evaluation of the mediational effects of at-

nance, we must show that treatment programs influence the at-

tributions on posttreatment behavior has not been attempted.

tributions individuals make for their success in changing behav-

When examining how attributions mediate maintenance, we must consider internal and external attributions separately because research has suggested that internal attributions can be made independently of external attributions (Solomon, 1978;

This research was supported by a grant from Merrell Dow Pharmaceuticals, Incorporated. We thank Oliver Fein, Richard Carlson, Aaron Manson, Robert Stuchell, Howard Israel, Margaret Connaghan, and Loretta Tallon for their help in conducting this research. We are grateful to Lynn Kozlowski, John Michela, Frederick Rhodewalt, and Timothy W. Smith for their helpful comments on earlier versions of this article. We also thank Steve Abell, Michael Bonner, Richard Buckley, Randi Cohen, Mitchell Earleywine, Sandy Greenstein, Les Hollo, Jennifer Kong, Yung Lee, John McGuire, Donna Meyers, Carlos Rivero, Barry Rodstein, Michael Sauerman, Mirtha Solis, Alan Steinberg, Ruth Wageman, and Lois Zorawick for their help with this project. Lester Blair is now at New York Infirmary, Beekman Downtown Hospital, 170 Williams Street, New York. Correspondence concerning this article should be addressed to Judith M. Harackiewicz, Department of Psychology, Schermerhorn Hall, Box 28, Columbia University, New York, New York 10027.

Taylor & Koivumaki, 1976). For example, individuals can realistically make both internal and external attributions for their success with treatment. These attributions might be purely external (e.g., "The drug stopped my smoking"); they might be both internal and external (e.g., "I was able to use the drug effectively"); or they might be purely internal (e.g., "I worked hard"). The elements of treatment and the method of treatment presentation can influence both internal and external attributions. Components may appear to be internally based (e.g., self-administered behavioral procedures) or externally based (e.g., a drug). Even an externally based treatment may be presented with an internal or an external orientation. For example, a drug program might emphasize the individual's role in using the

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SMOKING ATTRIBUTIONS drug or compliance with a medical regimen. Furthermore, success in treatment can also influence attribution: Individuals are more likely to attribute success to internal factors but to attribute failure to external factors (Bradley, 1978; Greenwald, 1980). This self-serving bias could have a greater impact on internal attributions than treatment because successful quitters might make high internal attributions with any treatment. Thus external attributions may be most responsive to treatment differences. Recent developments in smoking cessation research emphasize both external, pharmacological approaches and self-help


approaches based on more internal treatment components (cf. Lichtenstein, 1982). Nicotine chewing gum, a prescription drug, is intended to help smokers wean themselves from their nicotine dependence (Hughes & Miller, 1984). As an adjunct to standard clinical treatment, this gum has proven effective in smoking cessation (Jarvis, Raw, Russell, & Feyerabend, 1982). Even in a self-help context, a treatment program using nicotine gum is relatively external and may foster external attributions for success. In contrast, a self-administered behavioral program may enable smokers to quit with minimal outside help. In fact, self-help manuals have proven reasonably effective (Glasgow, Schafer, & O'Neill, 1981), although quit rates have not been as impressive as those for nicotine gum programs (e.g., Fagerstrom, 1982). In the present study, we varied the externality of treatment programs by comparing self-help programs with and without a drug component. We also compared self-help programs (across gum conditions) that varied in their motivational orientation (i.e., internal vs. external). We evaluated the effects of these treatment programs on initial smoking cessation, on subjects* attributions for their initial success or failure in quitting, and on continued abstinence. We tested whether the more external treatments had deleterious effects on maintenance and whether these effects were mediated by the attributions that subjects made for their initial success in quitting.

Method Subjects Smokers (N = 175) were recruited from a university medical center (n = 61) or a university campus health service (n = 114).' The sample was 39% male and 61% female, and the average age was 34.5 years (SD - 12.33). Self-reports indicated that, on the average, patients had been smoking for 17.4 years(SD = 11.8) and had smoked 26.6 cigarettes per day (SD = 12.8) at intake, with a nicotine content of .88 mg (SD = .37) per cigarette. Smoking history variables did not differ between treatment conditions and were not related to smoking cessation or maintenance. Men and women did not differ in their smoking history, and there were no gender differences in smoking cessation or maintenance. Patients in the medical center subsample were older (M — 39.5 years) than those in the campus health service (M = 33.11 years), they had been smoking longer (21.9 years vs. 15 years, respectively), and they smoked more cigarettes per day (29.2 vs. 25.2); for all differences, p < .05. However, there were no significant differences between the two subsamples in smoking cessation or maintenance.

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Procedure The study was conducted in two medical clinics where a smoking cessation program was offered without cost to patients. Patients interested in the program reported for an appointment with a doctor (or a nurse under the supervision of a doctor) and were randomly assigned to one of four experimental conditions: (a) intrinsic gum (n - 45), nicotine gum (Nicorette) and a self-help manual with an intrinsic motivational orientation; (b) extrinsic gum (n = 45), nicotine gum and a self-help manual with an extrinsic motivational orientation; (c) intrinsic self-help (n = 47), self-help manual only, with an intrinsic motivational orientation; and (d) control (n = 38), a short booklet oniy, with tips for stopping smoking.2 In all cases, the doctor or nurse advised the patient to stop smoking by following the guidelines in the manual. Patients in the gum conditions were taught how to use it, chewed one piece under supervision, and received a 6-week supply of 2 mg gum (six boxes of 105 pieces each). They were instructed to return for more gum when needed. The individuals who provided treatment were blind to the content of the selfhelp manuals and did not differentially affect any outcome measures. Finally, subjects were informed that their progress would be monitored for 1 year by an independent research group. Interviewers (blind to treatment condition) conducted a smoking history interview and administered several questionnaires. Patients were paid $7 for each interview.

Treatment Conditions Patients in all conditions received a manual outlining a 3-month program in which smokers would quit "cold-turkey" after a few days of preparation. In three conditions (intrinsic self-help, intrinsic gum, and extrinsic gum), the self-help manuals included a manipulation of motivational orientation, and these conditions will be referred to as the motivational treatment programs. In the control condition, the guidelines for quirting were minimal; the booklet contained only general information about smoking and offered brief tips for cessation. In the three motivational treatment programs, the guidelines were more detailed, utilizing some of the basic techniques found in existing self-help manuals (American Cancer Society, 1977; Danafler & Lichtenstein, 1978). Patients were urged to prepare for quitting by clarifying their smoking patterns and by considering their reasons for quitting. Charts were provided for recording when and why cigarettes were smoked. The manuals outlined various coping strategies for controlling smoking urges (e.g., thinking about the benefits of not smoking, finding substitute activities). The gum condition manuals described an additional coping strategy: Patients could chew nicotine gum when they felt an urge to smoke. A section on slips emphasized that if patients smoked, they should identify the causes of their relapse and use appropriate coping strategies when similar situations arose.

' Although 197 patients were originally accepted for the project, 22 failed to return for any follow-up interviews. These patients were excluded from all analyses. Dropout rates did not differ according to condition, and preliminary analyses revealed no differences between dropouts and subjects on any of the psychological measures collected at intake. 2 When this study was conducted, nicotine gum was an investigational drug, and patients with any of the following conditions were excluded from the study (prior to randomization): recent myocardial infarction, unstable angina pectoris, uncontrolled hypertension, peripheral vascular disease, peptic ulcer disease, pregnancy or lactation, difficulty in chewing, recurrent mouth sores, active temporomandibular joint disease, acute dental infection, chronic hemodialysis, or hepatitis.


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HARACKIEWICZ, SANSONE, BLAIR, EPSTEIN, MANDERLINK.

Motivational orientation manipulation. The behavioral guidelines provided in the three motivational treatment programs were identical in content but differed in emphasis. Two of the manuals (intrinsic selfhelp and intrinsic gum) focused attention on the individual's own efforts in smoking cessation, whereas the third (extrinsic gum) highlighted the doctor's prescribed program. This manipulation was intended to influence the attributions patients made for quitting in either an internal (e.g., self-determined) or an external (e.g., influenced by the doctor) direction. Subjects in both intrinsic programs were encouraged to play an active role in monitoring their smoking behavior, in deciding when to quit, and in learning which coping strategies worked best for them. Their own motivation and personal responsibility were continually emphasized, as evidenced by the key sentence, "Your determination and effort will be most important in becoming a nonsmoker." For the extrinsic gum program, the manual emphasized medical guidelines and stressed the key sentence, "Following the guidelines of this program will be most important in becoming a nonsmoker." Instructions for gum usage. Subjects were encouraged to anticipate smoking situations (e.g., work breaks) and to begin chewing the gum before smoking urges developed. They were instructed to gradually eliminate gum usage 3 months after their quit date. While they were tapering off the gum, they were to continue using behavioral and cognitive coping strategies to resist the urge to smoke (cf. Harackiewicz, Blair, Sansone, Epstein, & Stuchell, in press). The intrinsic and extrinsic gum booklets contained the same basic instructions but differed in emphasis. The intrinsic gum booklet ("Stopping Smoking on Your Own with Nicorette") stressed the patient's own responsibility in using the gum. The extrinsic gum program ("The Doctor's Program for Stopping Smoking With Nicorette") emphasized program guidelines, dictated gum usage guidelines rather than encouraging patients to become involved in deciding when to chew, and described the gum as controlling the urge to smoke.

Measures Intake. Interviewers administered the Fagerstrom (1978) Tolerance Questionnaire to assess patients' dependency on nicotine along with the Self-Motivation Inventory (Dishman, Ickes, & Morgan, 1980). We used factor analysis on the Self-Motivation Inventory and combined the 23 items that had loadings greater than .50 on the single-factor solution. Subjects also completed the Health Locus of Control scale, and we combined the five internally worded scale items (Wallston, Wallston, & DeVellis, 1978). Health locus of control was not related to smoking cessation, maintenance, or attributions and will not be discussed further. Follow-up. The first of five follow-up visits occurred approximately 6 weeks after intake. The remaining visits were scheduled at 3-month intervals after intake. Patients' self-reports of smoking behavior were used at each interview to measure smoking status. All 175 patients were interviewed 6 weeks after intake, and their current smoking status was represented in all data analyses. Those who did not return for later visits were assumed to be smoking. After 3 months, patients were only considered abstinent if they had remained so continuously. Validation of smoking status. A breath sample was collected at each visit (for carbon monoxide analysis), and saliva was collected for thiocyanate analysis at 3 and 6 months after intake. There were 166 reports of abstinence from 58 patients, and we were able to collect objective measures for 114 (69%) of them. Ninety-five percent of these reports appeared to be valid, as indicated by carbon monoxide levels (