Psychosocial Dimensions of Smoking Implications ...

Implications for the Practicing Physician of the Psychosocial Dimensions of Smoking E. B. Fisher, Jr., Donald B. Bishop, Jane Goldmuntz and Andrea Jacobs Chest 1988;93;69S-78S DOI 10.1378/chest.93.2_Supplement.69S The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/93/2_Supplement/69S

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1988by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

Downloaded from chestjournal.chestpubs.org by guest on July 11, 2011 1988, by the American College of Chest Physicians.

Implications for the Practicing the Psychosocial Dimensions E. B. Fisher, Jane

Jr.

Ph.D.;

Goldmuntz,

Donald

MA.;

SMOKING

and

B. Bishop,

Andrea

AS A SOCIAL

ACT

ORGAN

S moking

is most

often

perspectives, ior. The

two

are often

distinction

organism example smoking: psychologic

seen

health

does

soma

others

Some

of two

exclusive.

This

Nevertheless

the for

addressed

logic components more

the

biologic

of smoking,’ closely

ponents of the A key point

separation

the

smoking of this

of psyche

exposition;

noting

and

will be our and behavioral

task to com-

process. article is that

time, determined outgrowth of the biologic

and

physicians

and

events

other

health

of roles

smoking issue. In adolescence, parents’

nance

in

leaves

home

they the

smoking

Many of the social initiation of smoking young will

in the

smoking

evolves.

major and

career

play

factors that were remain important adulthood.4 continue

will

find

one’s

a the

peers.23

important in the for its mainte-

The

young

adult

who

to have

mans’

friends

who

Washington

University

in 5t.

for

smokers

so

difficult as long

several use

other

Louis.

Preparation of this paper has been supported by NIH grants CA 41703, E. B. Fisher, Jr., Principal Investigator, HL 17646, B. E. Sobel, Principal Investigator, and AM 20579, W H. Daughada Principal Investigator. tPresently at Division of Health Promotion and Education, Mmnesota Department of Health, Minneapolis.

that

and the health as one does not

years.45

a similar

factor

each

It may

be

rationalization

that proc-

a different theme, convincing each other is just too difficult a process and not

the

effort. Indeed, the adult smoker often a cigarette as having many important benefits, eg, a vehicle for relaxation, or conversely, a means for greater

mental

alertness.

The smoker of 20 cigarettes puffs an average of seven times have

a history smoker

of over inhales

anything

one

to

a day for 20 years for each cigarette

million

more else

smoking

often

except

inhalations. than

he

breathe

become

who will

and

a strongly

Thus,

or

she

does

blink.

This

conditioned

or

“overlearned” habit. The strength ofthat conditioning is evidenced by the fact that reports on the use of nicotine polacrilex in cessation programs indicate people still relapse still using nicotine

trials,

supported or

several months after quitting, polacrilex to provide them

the

strength

of the

by the

variety

of different

emotional

cues

linked

model

to explain

It assumes by

the powerful

that

the

act

the

of

smoking.

These

experienced

only

with

without may

getting

A number

have

been

friends

morning, it soon generalizes to on the phone, watching television,

a break

after

CHEST

I

93

I

The 2

I

established

FEBRUARY,


1988

and are

cravings associated

before

in the friends

an exam.

become

strong

initially with

states

then

influx of nicotine When these states

cigarettes,

together

of

of smoking. emotional

states

the

is also

physical,

For instance, Levena multiple regulation

regulates

conditioned to smoking and other substances it provides. may result. Where smoking

habit

social,

conditioning

smoker

while with

associated of condi-

smoking

to cigarettes.

psychologic models address this. thal and Cleary6 have suggested

then *From

a rationalization convince

perceives

tioning

of smoking

from

described

nicotine. While the smoking may have been with an indiridual cue in tens of thousands

of a smoker,

in addressing

determinants

pressure

worth

leads

But one has to one has to learn which evolve over

professionals can

but with quitting

almost

by a multitude offactors. As a direct complexity of the interactions among

social

multiplicity

are

as an experiment. and ultimately are processes

ess, that

the

Smoking can be viewed as a career. One doesn’t just wake up one morning smoking 30 cigarettes a day; nor wake up on another morning, once again a nonsmoker. Smoking may begin learn how to smoke how to quit. These

adult

of stimulation

that

neuropsycho-

it

social

smoking

older

is the smoking status of whom the smoker lives.

smokers

smoking is not not so dangerous

continue

biosocial

have

younger

quitting effects

our intellectual tradias opposed. However, to the

authors

in which

or as a behav-

correspond

is convenient

have

address

one

that is the human being. An important of the interaction of psyche and soma is a behavior which is maintained by strong and biologic forces and which has severe

effects.

and

from

as mutually from soma

not

smoke. Particularly important one’s spouse or others with

A BIOs0CIAL

as an addiction

distinction probably arises tion ofviewing psyche and this

OF

;t

MA.

ISM

approached

either

Ph.D.

Jacobs,

Physician of of Smoking*

talking and

smoker f Supplement

school with taking reaches 69S

the point where having a cigarette is conditioned most, if not all, of the activities in his or her daily Twenty-year times, have nities

smokers, provided

for this

cues

are

stress

conditioning

aspects

important

having themselves

to take

of important

pleasures reduction.

ubiquitous, smoker’s

inhaled with

relaxation,

link

smoking

social

ritual

makes the point that that, as an important

often

helps

define

social

in the

the

meanings

rebellion

the

or

individual’s

identity

of

images

cosmopolitan,

sexy

woman

Smoking

is also

For

many, sources

reliable

it

are

who’s

adult

or

“come

convenient

as

a long

and

a

is one of the few easily of pleasure which they

as a

of autonand For

tions

control

may

which

they

control

The

importance

budgets billion

of the in 1983

Federal heavily eludes as the

of

organism

smoking

is

also

as seen

a social in

major

tobacco

companies,

in the

United

States,

Trade Commission. marketed consumer advertising cigarette

act

the

of a

marketing almost

$2.6

according

to the

The cigarette is our product. (Marketing

and other companies’

most in-

forms ofpromotion, such sponsorship of entertain-

centage

of gross

cigarettes

than WHY

Although cigarettes, publication Smoking report,

sales

which

for other

PEOPLE

millions cigarette of the

are

consumer

WANT

TO

Surgeon

QUIT

26. 5 of cigarettes percent over As research

for

SNI0KING

currently decreased General’s

and Health in 1964. According 38 percent of men and 30 percent

over 18 smoke, as compared to 33 percent of women over 18 survey reports have indicated the total adult population has

is higher

per-

products.8

of Americans smoking has first

profit

the

smoke since the report

on

to the 1983 of women

50 percent ofmen and in 1963. In late 1987, the prevalence among fallen even further, to

In addition, the per capita consumption in the United States has decreased by 20 the 20-year period, 1963-83. has

been

unable

to identify

any

single,

to sevMany

for

rate

increased

members Parents

positive role the potential

Some

among

encourage may

decide

models for their health effects

Lower frequent

of

of

identified.

smoking.

by smoke.

respiratory in infants

In addition,

the

babies

of spontaneous

ofpregnancy

placenta, rupture

been

many

Smoking consequences risks

by

include

of smoking

a

moth-

birth weight which appears to be due to offetal growth, and a 10 to 20 percent

risk

cations

have

Other

symptoms

decide to quit smoking. has a variety ofadverse child.

metadiseases

diabetes.

after

on family

surrounded

ers, a lighter the retardation

with

or passive smoking. are also more

unborn

rea-

of specific

have genetic, for specific

smoking

to quit

mortality

those

not to smoke because of the that are involved. Examples

want to provide Others consider

the

to health

because

or those

effects

women women

higher

who factors

to smoking

potential

contrast

to quit

to quit

individuals

pregnant pregnant

abortion.

include

Other

placenta

bleeding during ofthe membranes.”2

compli-

previa,

pregnancy,

and

abruptio premature

Some individuals want to quit smoking because their habit has become too expensive. In addition to the cost ofthe

and

because

related

In

for general

want

workers

of involuntary tract infections

predominant

business

lives.

smoking

advised risks

decide

that they children.

costs.

of their

asbestos

diseases

ment events or distribution of free samples. ) Though in recent years the major tobacco companies have begun to diversify cigarettes continue to be the part

quit

strongly avoidable

continually

their

own time during the work day. Taking a break for a cigarette is still more accepted than taking a break for a few moments’ relaxation. biosocial

are often increased

The

they

through

individuals

other

some

smoking restricof the few things

and

sons,

modern,

available control.

of their

who

individuals

some employees may resist at work because smoking is one

example,

the

individuals

include

way”

a symbol

for

attempts

highly idiosyncratic. Nevertheless, for quitting are often reported.

medical risks. Individuals bolic, or occupational risk

The

smoker

motive

Individuals’

quality

adolescent

of the

so a crucial

found.

and

apparent

ofthe

are often reasons

smoking,

been

or

is a complex behavior,

readily

for not

accept the general health risks of smoking to eliminate its adverse effects on their health

the

self-concept.

assertion

Avenue

independent

smoking expressive

of smoking

and

Madison

suave,

omy

sex)

parts

has

individuals and want

to numerous,

important

motive

quitting

or

of their

relationships

(socialization, personally

Many

crucial quit eral

a million opportu-

life.

Mausner7

rich

place.

social

All ofthese and

over many

to life.

The

cigarettes, health

smoking

are

of $41 billion

per tives for cessation, medical expenses

are enormous

included,

year. it

and

the

for a two-pack-a-day

habit.

smoker

Reevaluation

to quit. pressure

are

in excess

under

50 exceed

it

once

For example,

they

were to conform,

include gaining control the addictive nature of

of the

and a realization

function

because

costs

‘

to smoke the

to cigarette If lost work

In terms of individuals’ incenis estimated that the lifetime loss of earnings attributable to

Other reasons for quitting over one’s life and combatting the

economic

costs attributable $17 billion per year.

now exceed

productivity

smoking $34, 000.

there

care

did

that lead

many

reasons

for

smoking

no longer

some

individuals

seeking social to deal with

them to relax, or because ers as sexy, accomplished,

beginning

smokers began

to smoke

acceptance stress and

advertising portrayed and independent.

time, these individuals may because of the pharmacologic

fills

to decide or felt to help smokWith

have continued to smoke effects of nicotine and

los

Smoking


Cessation

other components of the conditioning of smoking experiences.

Recognizing

the

that

fantasies

time

cigarette to many that

led

and because daily activities

smoking

of the and

hopeless.

fulfill

months

(mean

failures

before

doesn’t

to its inception,

many

decide

it’s

to quit.

Today, many social to be a nonsmoker enhanced

by

media,

communities,

choose

symbolic studies

and

to quit

in

the

worksites.

smoking

Many

because

all,

be

among

lower

among the middle low SES smokers

socioeconomic

social

groups

class. This may from nonsmoking

by middle

class

Recently,

reflect isolation of campaigns devel-

QUITTING

investigators

stage analysis DiClemente’

have

precontemplation intervention.

or concern

nor

they

are

from

likely

is not

to

the

seek

norm.

at

smoker

the

messages defenses,

stage

may

of

become habit

movement

from process.

more

action

self-reevaluation,

and

(described rely more

stage,

the

reinforcement

In the

port,

and

stimulus

the

to information of

willingness

to

smoker

continues

to

well

as

management

maintenance

that decision

chaska

and

social

management

can

add

of quitting

again

to quit,

to Prochaska a fifth they

tend

seen

in all of the

may

most

is reassurance

they

have

learned

efforts.

They

need

on

first

attempts

the

earlier and

something to be does

from

assured not

four try of the

stages.

What

that mean

their

Finally,

and come Pro-

than

to “get

during

the

mon-

actively trying to yet decided they or

minimize

emphasized during that maintenance

quitting

to be open

too hard, does not

they may simply mean that these

but

they

that

pressure. low-key

initial

the is an

than simply of the status

stage

especially the patient tests, such

must

be

Later, will

tation

of the

In the

ready

facts

and

action

quitting, quit.

the for

stage

without

too

of the may be

risks in a effective,

of

a more often

much

also

contemplation,

systematic need

they need

presen-

ask directly

individuals what

Quitters

If pushed

find another physician. This smokers are unreachable,

will

for

are

tactics.

to an expression of interest by time of feedback of results of concerning diseases related

stage, but

a career.

of precontemplation

presentations manner

in

be

that

itselfis

approached

in response or at the as spirometry,

smoking.

is important

to heavy-handed

Calm, factual and matter-of-fact

are

for help.

plans

going

support

not

only

to do

after

for

the

major

change In the

in living patterns they are trying to accomplish. maintenance stage, they will need continued support and periodic reminders to stay with their plan of action. While it “does get better,” relapse after several

months

tions,

continued

months

to one

In the

vigilance

is appropriate

after

relapsed

extended

see it

that

relapse

is the CHEST

receive

many

precursor I

93

I 2 I

the

to renewed


the

1988

support

quitting should

end

is help

of that action.

I Supplement

six

smoker

continued

stages

FEBRUARY,

tempta-

for at least

that

is not

of old

Finally,

Recalling of

face

quitting.

should

career

clinician Rather,

is common. year

has

are

it

that

in the

encouragement.

previous

perspective,

Smokers

and

cases

office).

self-liberation

stage

change rather maintenance

or

understand

who

succeeding

that

to control

to be suggesting

a practical

that

not

found

procedures

they

their

a

skills

can be done” may to make the attempt. the action

not going

they

encouragement

the

is, exhortations

of continuing of change

con-

If relapsers

a combination

to.

is not

making

in one’s

learning

also

active stage the absence

for

DiClemente’s

relapse.

to use

strategies need

and

stage:

“it

during

continue stage,

sup-

apparent. One

that

DiClemente

temptations maintenance

smokers

tinue to be emphasized, though to a lesser extent. In fact, the support offered by others for a new behavior, which is no longer quite so new, may become less

stages

want

entails

it

off your back” may help those more than those who haven’t

to

also begin to support and

stage,

reinforcement

stimulus

techniques

below). At this stage smokers on helping relationships for

understanding.

may to quit.

and

as

Prochaska and points. First of

not to smoke

confidence the final

key quit

six

of 2.6

to action

Rather,

note

That

had

the skills to implement it. from the cognitive (learning cessation) to the social (learn-

gaining before

the physician

is unclear,

open

an average

contemplation

to

more

who

for at least 15

to ask a coworker

From

smoker

however,

to quit,

make control

the

reported

finally

It is important

in which

brings

and its dangers. This openness may lead to a reevaluation

take action. During the of

environments

those own

quo.

of smoking,

contemplation,

a commitment

use

to direct emotional

to precontemplators not their desire

much

about the smoking to new information smoking,

action, and the stage of

aspects

What

a

Prochaska and process which

to contemplation

heavy-handed increase their

Once

develop

to be responsive display little

for the negative

precontemplation

but just

to

contemplation, who is in

is unlikely individuals

Such

reaction smoking

begun

years)

they

contemplation.

of the quitting process. describe a four-stage

includes precontemplation, maintenance. The smoker

five

=

is emphasized OF

conducted, on their

a cathartic

ing how

than

professionals.

STAGES

we

smoking

decision and acquiring These skills may range what to expect fullowing

in-

of the

the

simply

mass

value of being a nonsmoker. Unfortunately, now indicate smoking is considerably more

common

oped

campaigns

quit

In evaluating the different stages, DiClemente make several important

hold it more acceptable a smoker. This may

antismoking

many

dividuals

circles than

In a survey

successfully

an the

career. Dealing uS

with

relapse

will

be discussed

later

in this

article.

WAYS

OF

QUITTING:

THE

PROCESS

BY CHANNEL

MATRIX IMPLICATIONS

Smoking time,

is a chronic

developing

and

stages. Quitting developing and including roles each

FOR

regarding of these

behavior

adult

attempts.

Physicians

to

of

and

and

and

encouragement may

broader

to

for many or group With this

activity-explanation have a very constructive may be not as cessation

to

smoking

among

tutions, settings.

within the For instance, Does of patients policy for

policy

for smoking

For others,

referral-the impact

one

your

within

respiratory

employees?

The

physician

room can

also

smoking month

deliver

can

eg, nicotine

offered

by

as flyers

or

one

or several

be

involved

in some

service

in the

organizations

in

use

nicotine

a

use

cessation diate and

interventions long-term

of nicotine

polacrilex tends

impact

and be dis-

maintenance

of

offer

of a prescription

drug

which

along

has

with

other

to enhance the ofthose interventions.

instance, general practitioners’ along with a booklet on how term abstinence of4. 1 percent

nicotine Both

will

in the maintenance of smokstrides have been made in to encourage quitting. In immeFor

advice to quit delivered to do so achieved longwhile these, along with of nicotine

polacrilex,

long-term abstinence of 8.8 percent.’6 smoking cessation clinic focusing on

logic procedures such as discussed percent abstinence while the

who about

on

is a powerful

clearly implicated In the past decade, of nicotine replacement

achieved session

control,

support

section

of the replace-

Replacement course,

general,

an

with

stimulus Social

a subsequent and relapse.

to

community.

conditioning, management.

24

being interviewed on telpolacrilex to individual

public

program

1

clinics

will find that they are called at least once to react to stories on smokers’ versus nonsmok-

aversive

Nicotine been

in

role

the media. Physicians or health professionals become identified to the press as knowledgeable

may

physician

or catalyzing a cessation

cussed cessation

insti-

provide

an important

patients,

Of

to be transferred? play

The

contingency

for employees who want to quit smoking? Does it have smoking areas? Does it allow patients who do not want to be in a smoking

as

counseling

combinations, prescribing

ment,

can These

smoke

be

organizations

The following sections will discuss several processes or methods of quitting, nicotine

in workplace sold in your

it

such health

referral

What is the hosthe hospital have a Does

clinics

or voluntary

can

of different

offer

may be medical

therapist

with emphysema? smoking? Does

of quitting a number

four methods of quitting. This gives both the and the physician a wide matrix from which

to choose.

of

health-care

community, and are cigarettes

of the smoker different evision,

through the career of quitting. also catalyze promotion of non-

co-workers,

management

success

physician smokers.

on

cessation

hospitals

6) books and manuals Each of these six channels

well summarized by viewing the the provider of a wide range of services, but as a catalyst of his or

patient’s progression The physician may

front pital’s

smokers.

cessation programs range of conventional

through

to

include:

contingency or methods

smoker

available

These

handouts

is

prescription

to encourage

and

processes

to the

or methods

to quit.

3) community or workplace promotions 4) mass media 5) minimal educational programs such

circum-

any

these

individual

2)

Conventional of risks and

action,

follow-up

In turn,

local

interest

than

can encompass. as brief explanation

conditioning

channels: 1) organized

all,” and there The dimensions

it

replacement

aversive

provided

long-term

professional

would.

are

and

be adequate

hospital?

at the

individual clinician of the smoker, the

uudo

of corrective

to self-help worthwhile.

her

can’t they

quitting

polacrilex,

activities physician smoking

own

processes

decides

1) nicotine

of the

medical

several who

3) stimulus control 4) social support

diverse

relapser,

the

current

clinician’s

profession or provider clinical activities such nicotine

the

are

smoker 2)

goals.

Obviously, physicians no reason to expect that smoking

take

interest

encourage

career,

the

practice

of

the

contributions of the on the circumstances

smoking

stances, and

time, stages,

may range from is contemplating

to reassuring

to support

quitter. The will depend

physician who

the

of different

may

provoking

“precontemplator,”

stage

in a career

over

psychosocial and physical factors stages of smoking and quitting. In

smoking,

continuing

extends

too, extends over through different

“career” of a smoker, the discouraging the adolescent initiating

There

which

continuing

smoking, continuing

failed

PHYSICIANS

A 14psycho-

below achieved same program

polacrilex achieved 44 percent the psychologic procedures and

the

28 with

nicotine

ers’ rights, the dangers of smoking and pregnancy, the dangers ofpassive smoking, etc. There are a multitude of ways in which the physician can be instrumental in

polacrilex make a contribution. For instance, a psychological cessation program without gum achieved 30 percent abstinence, besting a weekly drop-in clinic

catalyzing

plus

an atmosphere

that

encourages

nonsmoking.

nicotine

polacrilex

which

2S

achieved

23 Smoking


percent Cessation

abstinence. ment and most

But the adequate

effective,

It

is

combination psychological

achieving

important

50 percent

that

nicotine

prescribed as a “magic as an adjunct to concerted should

be offered clinics,

als, such counseling

as discussed regarding

and

follow-up.

until

a clear

cessation,

should

occur

on

nicotine and

on obtaining below, proper

has

been

not

cutting

before

information

be

to

self-help

should developed down polacrilex

is available

patient.

the

to quit,

niques

use

the

manufacturer

of

been a treatment. every

of nausea. with

indicated

found

repeated

until

rates

more of 30

ofas

two

modest

plus

cessation

time

has

useful

also

with

achieving

high

after

unlikely Stimulus Some

smoking.2’ colleagues22 procedures

46

percent

absti-

offered general limiting

appeared

recently and

at two-year

to be both cardiac

patients,

polacrilex,

follow-up

in nine

rapid

smoking

in doing such

most various

rettes

or cues

It is important be

it

setting.

a

to pinpoint

specific

This

time,

enables

place,

avoiding

Seven

or averto

so, as well as other psychoas discussed below, it is

the

after

the

procedure

cue

methods

providers

are

referred

term “stimulus control.” These the number of cues for smoking,

for

quitting to by the

include: 1) and 2) “cue

ofcoffee

giving

three

normal

of their

is to wait

has

passed is

before on

conditioned unconditioned

stimulus (the cup of coffee) stimulus (the cigarette). report

much

that

of their

Contingency

some

days

this

informally,

with

friends

erally, known

should

not

gent off the

the day,

cues

have

to smoke.

family

more

The or with

be

if they

on out

long-term

reward

CHEST

I

night 93

I 2 I

establish perhaps Gen-

that

reward

Contracts

outcomes. clear

not

have

The

kids

agreeing

FEBRUARY,


1988

The

and

does

mother

those will

desirable

behavior.

a frequent,

be frequent. each

may shared

are less effective than other person. Contracts

based The

upon

period, for inthe fourth and

a professional.

undesirable

spell

arranges

contingent

quitter

contract,

effective

punish

should

table

cessation.

contracts least one

should

quitter

be

during a specified no cigarettes between

and

reward. it

the

or by written

be than

contract

the

without By quit

urges

or punishment

after

private to at

rather

but

management,

reward

behavior smoking

seventh

Pavlovian”

“

presenting

compelling

to provoke

(A until

Management

In contingency critical stance,

entails

formerly

ability

not

a cigarette.) or

in which

lost

do cues.

minutes

lighting

conditioning

as

for them to quit, they l)ut

ten

ciga-

such

selected

classic

extinction

up

cues,

rate,

three

at least

based

without

this process in we call “cue

before

select

at their

presence

for this

This

days

The smoker coffee and

feel will be most difficult a cigarette. Until they

smoking in the

generally

effective

to ten

a cup

smokers

that they without

that of

is strong. between

experiencing

altogether,

guideline

safe

Control

by the

tech-

circumstances

To help the smoker with clinics, we use a technique

participants

to be effective.24

of the

Stimulus-control

in which temptation unlearn the association

smoke

been

should be used as adjuncts to psychologprograms. Without encouragement

quit and support logical procedures

can

cues step is

For example, if coffee tea in its place during

without

continue

have

psychological

pulmonary

nicotine

smoking cessation

with

This

and external The next

a cigarette. our own

as 60 to

to six years

conditioning

to achieve

abstinence

As with

The

along

smoking.

cigarettes

coffee, endure

18 patients. sive ical

cues. drink

to tempt.

or social

situations will not

patient reports

one year after quitting, in comparison to 30 abstinence for the psychological procedures aversive smoking.22 The original rapid smoking

procedure

cigarette, for

avoiding

whether

extinction.” of

abstinence rates in More recently, less

20

to aversive

the

a single

at the

weeks or until the abstinent. Initial

follow-up

smoking

on

within

such as normal paced aversive of such a procedure, Hall and

to encourage

and

or

scheduled

abstinence

approaches

aversive

nence percent without

is often sessions

further

cessation indicated the neighborhood developed, In one test

cigarettes

for several of remaining

but

extreme

two

This

extended

percent,

and has

not widely utilized cessation entails puffing approximately

or

several

cessation and feels confident 70

the work of Lichtenstein early 1970s, rapid smoking

reliable but It usually

session,

every

ofabstinence.

likely

to

techhave

that triggers the desire to smoke. Unless the smoker is to make many radical changes in lifestyle, he or she must eventually face those

10 s of one

verge

are

temptation,

of cues

as cues for smoking. is often self-monitoring.

reason

include

ability

cue

by the

in

record and

period

can also

emotion,

Conditioning

Popularized colleagues’s

initial

that

Useful

in

may place,

to limit exposure to these is a cue, the quitter may

its representatives.

Aversive

smoker

trying is taken.

from

conditioned to serve step in stimulus control time,

the

Stimulus control the stimuli that

increase awareness of the internal that trigger the need for a cigarette.

given

patients

to reduce

desires for cigarettes. are ways of controlling

been first

by the or

instruct

be

procedures

evoke niques

the

manu-

not

extinction”

The

smoking

or, at a minimum, brief use of nicotine polacrilex

nicotine

how

polacrilex

not

to community

prescription

plan

Actual

referral

advice

The

polacrilex

pill.” Rather, it must be used efforts to quit. Prescriptions

with

cessation

of nicotine replaceintervention was

contin-

to be

or father I Supplement

large, to clear

does

not

3S

smoke of

will

probably

silverware

frequent,

at clear,

be the

more

end

and

effective

of

specific

the the

than

a new

month.

The

contract,

the

set more

of quitting we An often-quoted

percent of all undocumented

smokers figure,

back help

and since then a misnomer-no

in 1977, is actually

have

as having

been

quit

encouraged

quoted frequently. Selfone quits in a void.

through

by

This is an pamphlet

interaction Those

self-help

several

of

between who are

will

the

often

have

channels

six-month

noted

follow-up,

were

thiocyanate.

better.

out to this is that 95

quit on their own first used in an NIH

Behavior always results from the the person and the environment. viewed

left statistic

the

abstinence

“SELF-HELP”

One method point is self-help.

At

participants’

validated

The

by

percentage

abstinent,

tion those who again, outcomes

abstinent follow-up

for at least seven days have been abstinent

extended periods since their initial

ofat quit

that

least several dates. This

a comprehensive could

obtain

rates

among

heavy

and

validated, smokers

hand uuyou

relapse

forces such Such attributions

with

the

assumption

either have becomes

that

willpower

(minima:

If you

were

to question

someone

closely

who

They

need

to encourage

cigarettes

or

situations. They Most important, doing

things

AND

of

said

select

of “will RESULTS

SOCIAL

will

review

in

some

them

tempting

ENT,

their

own

program quitting

smoking

quit

date),

that included (in which cue

of cues and incentives. aversive or pharmacologic

social

cessation

20 cigarettes

per

32 cigarettes

per

day

programs

in

the

Of

nonsmokers

Intera full

contingency

regular

these,

systems,

Forty-four

per-

in the MRFIT had four-month intensive 929

throughout

repeat

buddy

procedures. men initial,

manage-

fullow-up,

of spouses,

support

program.

mained

or

the

23

percent

four-year

refollow-

up period. Continued treatment and follow-up still more to quit. The nonsmoking prevalence the four year follow-up was 40 percent.27

helped rate at

In much of our work at Washington University, we now use the Freedom from Smoking program of the American Lung Association (ALA). This program was developed in the late 1970s through ajoint committee with

representatives

from

the

and ALA staff and both a seven-session, as a self-help

agement scribed.

techniques similar For the seven-session

planned

for the

third

American

volunteers. outpatient,

alternative

help manuals. The clinic and stimulus control, self-control,

to

PROGRAMS

ces-

that are typical of what is offered First, at Washington University

a 15-session as target-date

pro-

Thoracic The program group clinic

consisting

of two

self-help manuals and contingency

self-

employ man-

to those already declinic, the quit date is

meeting

ofthe

program.

Follow-

ing the quit date, participants initiate a “plan-of-action” they have developed for coping with any temptations

STIxiuLus

of the

other

as well

power.” OF

involvement

Society includes

or cooperation. distracted from

MANAGEM

SUPPORT

environsmoking routines.

not to offer them

to ask for help need not to he

AND

section

self-management included no

of

CONTINGENCY

sation programs the community.

pants

friends

front

by a rhetoric

CONTROL,

developed techniques

in

need they

DESCRIPTION

This

their

smoke

treatment,

and with

cent of all 4, 103 smoking stopped by the end ofthe

quit simply by determination, insight, or by up my mind,” you would probably find that,

in fact, they made several changes in their ment to help them quit. People who quit need to do things. They need to change their

control along

to

a necessary condition for success. Such an analysis of relapse is unlikely to prompt renewed efforts to quit. that they “making

of stimulus techniques

and

is something

or you don’t.” Putting the two together, evidence for a nonremediable lack

range

at a for

abstinence

literature is the Multiple Risk Factor Trial (MRFIT). This program included

to

as a supposed “lack of willof failure often go hand-in-

quit vir-

educational

appreciable

ment

immutable power.”

the

months, most often study demonstrated

behavioral

gram

that they

in order undermine relapse

is,

tually all who are six- or 12-month

smoking vention

from friends or professionals myth of self-help may also by leading smokers to attribute

that

quit, relapsed, and interest. In actuality,

cause people to focus too much on vague, supposedly internal sources of change, such as determination and insight. Smokers may wait for some imagined insight

obtain help quit. The confidence

of

salivary

may have of obvious

day for at least five years; means: for 22 years). One of the more well-known

automatic. Instead, in their routines or

of

percentage of participants who had not smoked in the seven days preceding the six-month follow-up, was about 30 percent.26 This statistic takes into considera-

above, such as individual counseling from a physician or a TV show on quitting. Self-help may be a damaging myth because it may

they expect to make quitting need to instigate changes

reports

analyses

extinction,

in we

such particiand

The program components.

smoke

that

control exercises different month

cities. follow-up

macologic Most local as the

arise.

In

check Lung

addition

a buddy system The program was

The prevalence was 30 percent.

American

Association, physicians

may

techniques, are used.

to

stimulus

and relaxation evaluated in six

of not smoking at 12There was no phar-

on the veracity of the self-reports. Associations or other agencies such Cancer

include in identifying

Society,

professionals sources

4S

or American eager

of referrals Smoking


Heart

to work

with

to these Cessation

given

or similar smoking cessation programs. A versatile component of the ALA

program

self-help

version

Smoking.

includes

a cessation

in Twenty of reducing

of

Freedom

from

manual,

Days” their

Freedom

“

Smoking.”

This

tension,

includes

social

cues

obstacles

that

arise

uted

by

the

combination

attained assessed

a nonsmoking by telephone

for

cigarettes,

other

mail,

manual, there is a of Freedom from

material

for

during

coping

weight

prevalence interview one

of the materials. 28 What was most interesting

about

of year the

at nine

12 months.

The

to recruit the

months,

smokers

follow-up.

ported diminution

contrast, are

followed

prevalence

of follow-up. Association One is the

joining clinic

failed the there what

if they

data

is no point they view

self-help suggestion the

quit

course

as

in trying again, a state-of-the-art

manuals, in of continuing

continued

increase

nonsmokers

using

dom from well-produced.

contrast, effort. in

the

the

manuals

Smoking manuals People are

out after having used them on the shelffor down and quitting.

try

again

there

prevalence may

are not

be

very likely

the

may

of

a for

the

of

already the

Therefore,

it

about

how

Gordon29’#{176} present this

regard.

is under

Relapses emotional

that

we

relapse a model

occurs.

to

quitter

when may

cigarettes

helpful

a failure

slip

after

a slip

and,

to reassure

the

and

also

the

next.

of the

best

predictors

to

case. patient decrease

Instead, but also It may that

successful,

of two

of maintained

to three

abstinence

Self-efficacy

one will

has the skills be favorable

to be successful, that circumstances to the use of those skills, and thus,

that The

one will be able chief determinants

verbal

entails

the the be

is self-efficacy3’

but

to learn

smoking There

cessation. are many

reasons

smoking

or relapse

after

or in a clinic.

tion”

pertinent

leaves

that

smoking. not mere

skills. and their

Counseling

strengths, application

people

attempt

We commonly

and

fail

to cease

to quit hear

that

and to

on the

their reason

This is only an apparent problem as “low motivareason

“motivation”

low. A more robust explanation Among possible bases of better

of failure explanations

of relapse with stress,

be

negative

Relapse

beliefs

experiences

why an

is weak motivation. It renames the

but

may be needed.

the

to succeed in stopping of self-efficacy are

reassurances,

in

a person

or

in turn,

smoker

skills about

some-

of

the abstinence

is a sign ofa hopeless to quit may lead the

practice

useful

day and

and

not quit do so.

months

special occasion “just one.” This

that

should identify individuals’ encourage patients to think

for

may being This

health professionals may contribute violation effect by implicitly encourag-

here

One

effect

several

plummets as above.

opportunities

Marlatt is very

occur The

do

had

and them

time

understand

which

frequently stress.

like

have

confidence in future ability to quit. physician must encourage determination belief that mistakes can be overcome.

for failures explanation.

noted, most smokers first time they attempt

is important

to several

Overzealous abstinence

own

As was successfully

may

Free-

MAINTENANCE

thing

leads

to feel

with With

attractive to throw

be a better

results

rather than over-confident.

is at a party or some he or she can have

ing the beliefthat one Too strong an exhortation

them for a week. They may put a time, but eventually pull them at what

a

conclusion

violation

ex-smoker, becomes

long-term quitters report an average failed attempts prior to quitting.

rate

that

to

This

justifying

abstinence

who who that

of

that

is more reason

individual

not smoking, and decides

of

feel

having failed program. A second

is the

re-

schedule

even

leads

is “hopeless.”

slip,

to the

slip

at greater

to the may

turn

is hopeless.

Then, the selfconfidence violation effect unfolds

by a continuing

according

participants

case

at

There may be two reasons that data indicate a reversal of this natural history of individuals’

Such

case

of a single

one’s

An alternative

a highly structured comprehensive may perceive themselves as having

do not

program.

the

be the case where the low in self confidence,

attempts at self-help using these manuals. It may be the nature of self-help for people to try it, go back to it, try again, and gradually reach their goal. In contrast, smokers cessation

that

in

the

clinics

ofnonsmoking

slip. Having a cigarette leads to a further in self-confidence which, in turn, leads to

that

continued

the

self-confidence

smoking reduction

conclusion

which

effect,”

may occur in the affect leads to

implications

to 18 percent

cessation

violation

This negative

Distrib-

follow-up

during

a slip,

manuals

18 percent, after receipt

to have

most

literature

in the

durations the Lung pattern.

back

appeared

to cessation

In

in the

and

manuals

an “abstinence problem. some

direct

After

Critical to the too heavily the

and

for the ALA self-help program was that at the oneand three-month follow-up, the quit rate was about 12 percent. It then rose to 15 percent at six months and 19 percent

that

or

smoking.

in abandonment of the quit attempt. abstinence violation effect is weighting

maintenance. two

suggests

encouragement

lowered

the

with

gain,

of the

or

to resume

may compound the following sequence:

Smoking

which offers participants the choice smoking gradually or quitting cold

turkey. In addition to the cessation maintenance manual, “A Lifetime

prompts by peers

Marlatt

This

from

social

facilitation

is the

unexplained

are stress, and gaps crises affect. CHEST

failure in social

are

often

In

response

I 93

I

the

2

to use support

skills for coping for nonsmoking.

precipitated

I FEBRUARY,


to 1988

is

by surveys, I

Supplement

stress

and

would-be

5S

quitters

attribute

about

to interpersonal quitters, of stress also

Ashenberg, to predict

that

anxiety

life stress

programs. pattern

may

continued

relapse study

and Fish&3 found relapses. Others

current

cessation established

of smoking

In a prospective

Morgan, subsequent

hypothesized

in smoking with a firmly alleviate

80 percent

conflict.29’32

affects

of

level have success

Life stress coupled of using cigarettes to

produce

strong

temptations

to

It is tempting to think that if stress then teaching smokers skills for coping them achieve abstinence. Ashenberg and colleagues

did not differ skills. Rather, they did have relapsed.

Similarly,

have

relapse

strategies. Thus, to use stress-coping be important Work

on

the

stress

of

patterns

lapse,

may

did

almost likely to

not

of stress learned

use

any

and failure appear to

some

specific

implications

for

emphasize the events shortly

may expect to continue with This is naive. The importance

to avoid

they

who

One should to stressful

quitting

Some stressful understand the

subjects

of relapses.

has

quitting. Smokers usual after quitting.

that

temptations, were less

occurrence skills already

smokers. exposure

difficulty

found with chosen,

subjects

antecedents

counseling to minimize

in their stress-coping failing to use those skills situations in which they

Shiffman

than

causes relapse, with stress will

This may not be the found that relapsers

from smokers they reported in the specific

using strategies for coping regardless of the strategies

justify

stressors

for for

events are relationship better

instance,

a time

unavoidable. between

prepare

need after

to the

stress

coping. Also co-workers, recent quitter

by

attempting

after

cessation. If

stress

nagging. Even ress may be Learning spouses smoker willing

a new

well intentioned received by

inquiries the quitter

to

which

The support

best predictors or nature

and co-workers. or relatives who

Those smoke

social

support

among

fellow

higher

than

continued Indeed, friends

social

support

in control

smokers. offered quitters’ smoking

Those their

support

Refusing quit

level that

to maintenance. that numbers smoke may

abstinence needs

relapse

relapse

reports in front

recently

groups

of a

be

(12-month)

42

who

1apse.3

also

often

cigarette

to

report

cigarettes

to

may

Sux1,IARY

multifaceted

from been

Would-be

cigarettes subsequent person

a tremendous

AND

CONCLUSIONS

of

or re-

who

hesitating

be

nature

social, features.

the

or, at least,

smoking,

come having

by a smoker.

of smokers offering of them predicted

with a request, quitter.

The

is essential

of long-term

by buddies participants,

control group This indicates

recent research indicates and family members who

better predictor than short-term Finally, social

than group

help

smoking

has

to comply to

the

includes

its

and psychologic dimensions and It develops over time, through

for

attempts. Several repetitions ering cessation, attempting likely to precede permanent

of a sequence of considto quit, and relapsing are cessation. Those who are

such

way

of

stress. The instead of about progas nagging.

may be the quality of provided by spouse, quitters are more

were

their abstinence smokers.4#{176} In

the program, but fell to the six- or 12-month followups.4’

not ready to commit reached by low-key forceful

who have few likely to have

or conditioning. It also several unsuccessful

themselves information

exhortation.

Those

to quitting more than

who

are

ready

may be by too

to quit

may

select from among a range of approaches, including group clinics, “self-help” manuals, and physician counseling. Maintenance requires as much attention as does cessation. Cooperation from those around the quitter, or

reminders

to use skills

temptations,

and

for coping

continued

with

stressors

encouragement

from

the

physician may all encourage long-term abstinence. Owing to the multifaceted nature of smoking and quitting and the multiple approaches to cessation and its maintenance, the physician may best a catalyst for nonsmoking. If appropriate practice, ing, but

of relapse of examples

cohesion

rates

smok-

after

when. Support

emphasize and

and

phases such as experimentation is given up over time, often

“not to nag” is more commonly reported by of successful quitters. It appears that the wants to know that someone is available and to listen, but wants to be in control of where

Social

during by the

smokers

of friends are less likely to in the worksite indicates that nonsmokers are more likely

quitters and re-

and relapse is that friends, need to understand the

vulnerability and understanding,

Unmarried

in maintaining must work with

or interaction

physiologic, its career

altering

themselves

to develop

related to stress and relatives

quitter’s special needs empathy

friends, friends

programs

life as and

stressors. Since relapse is predicted by the failure to use coping skills an individual already possesses, treatment should encourage quitters to use their skills rather than teach new coping skills to handle stress. In this way, a quitter under stress will not have to add

and

to be successful quitters who

abstinence

relapse.

help case.

success.3739

ers with limited circles quit. Our own research quitters who work with

this those

may include extended patient unable to provide this may

great contributions through brief it is important to quit, encouragement referral available of interest

to

be viewed as to his or her

other

staff

or

in the community, in the patient’s

information on why to do so, timely

to materials and continued efforts and/or

u65

counselstill make

and

programs expression success. All

Smoking


Cessation

these may catalyze sive time or skills

quitting beyond

DP

without demanding excesthose commonly employed

by the physician. In catalyzing sician can also be an effective

nonsmoking, the phyproponent of community

20

facilities

of Chest

and

public

places.

Physicians’

among

its

example

policy

Fellows

and

of this

The

encouraging

in their

catalyst

American is an

22

excellent

role.

2 Pomerleau

OF.

tenance, Education,

and

Washington, 3 Evans

RI.

U.S.

LT.

Health:

prevention Psychosocial

(PHS)

strategies.

ibid

influences

on

Green

DE.

Psychological

Education,

(DHEW

Publication

Government H,

25

of the

and

8 Fisher

EB

Rev Jr.

the

Clin

for

States,

1986.

J,

factor for spontaneous National Institute

Stein

and

Services,

Smoking

(I)HEW

Publication

18

BC.

A Report

U.S.

Government

smoking

NL.

1987; I).

J

of

United

of Health

32

A risk

ofthe

and

Lexington,

costs

Ma.ssachusets:

Jr,

MAH,

DP

DC:

of smoking

as

smoking.

Toanstall

gum

and

behavioral

Cliti

Psvchol

35

Rugg

1984;

R,

StapletoEl

an

adjunct

D,

J

cessatiots:

nianuscript

ito

Harris

J, to

A

Taylor

W

general

Effect

of

38

I)ractitiOflers

39

Benowitz

N.

J

cessation.

smoking

Nicotine

relapse

gum

l)re’es3tiss.

AL,

CR,

\Vahl

N,

factor

Med

by the

Jr. Selfin

3:357-72

JK,

Simon

N,

(MRFIT).

Self-help

Vogt

TM.

V Interven-

smoking

A comparative

American

EB, procedures

Lung

study

Association.

cessation

with

J

Am

12-month Pub

Health

74: 1212-17

Marlatt

GA,

the

Gordon

JR.

maintenance SM, New

Marlatt

eds.

York:

Guilford,

1985 MM,

cessation

change.

JR,

Implications

In:

medicine:

Brunner/Mazel,

Gordoti

Condiotte

of relapse:

behavior

Behavioral

GA,

smoking

Determinants

of

Davidson

Changing

P0,

health

life-

1980.

eds.

Determinants

Lichtenstein

E.

of relapse.

Self-efficacy

J

programs.

Lichtenstein

E,

The

Antonuccio

resumption

Consult

DO,

and Clin

Association

New

relapse

Psychol

smoking

GD,

recidivism.

in 1981;

Annual

Unkicking

Presented

Seattle,

Fisher

April,

EB,

Citation

Medicine

C.

smoking.

Meeting

ZS. Morgan

Ashenberg

Rainwater

ofcigarette

Gunn

RC.

the

Western

1977

Jr. Psychological

Award

Paper,

Convention,

stress Society

of

Philadelphia,

May

Smoking

clinic

Shiffmas3

S. Relapse

analysis.

J

and

Fisher

EB,

following

Consult

Clin

Jr.

recent

l)ata

life stress.

Addictive

and

Cl).

social

Maintenance

support.

Conference

Psychosocial

Soc

Graham

S.

drawal

lt’OETI

DW

on

predictors

Behav

1971;

RW

Gibson smoking.

of

Presented

Family

at

and

Health,

Graham

5,

l)B, The

can

Lssng

Fisher ‘ear

BI),

CHEST

‘ 93

1971;

M,

Wilkinson

clinic

Jr. Employer

VR.

2

Missouri. Lando

treatment

.

FEBRUARY,


HA.

C.

population.

Five Am

smoking report St.

tE)

Louis,

Influence

of smoking.

1988

With-

5:319-37

assisted Annual

of Eastern

behavioral

J

recidivism.

behavior:

Med

Swanson

Gregory

ssoiokmg

of patterned

and

(9/83-10/84).

Association os’t the

Sci

withdrawal EB,

second

of

12:355-62

Cessation Soc

Bishop tion: Etninger

A situational

50:71-86

Morgan

SOUSC

Corporation

RA.

(.‘OheSiOaS

R,

and

cessation:

1982;

1982

Eisinger

West

smoking

Psvchol

Mozenter

cessation

1977; 67:536-44

self’

failure

1983; 8:83-7

Health

Schmahl

1980;

M.

programs:

Na-

10:476-500

R, Ordentlich

maintenance

Pub.

1979)

trial

1981;

smoking (NIH

Z, Fisher

Ockene

and

Institute,

sensitization

intervention

Prey

Faust

The habit.

Cancer

Med

and

52:574-81 summary

the

(reprinted,

covert

efficacy

cardiac

Welfare.

5, Ashenberg

Behavioral

with

2:151-66

National

1977

J

Consult

Behavior

JM.

and kicking

and

of a smoking

and

to Clin

Two-year

Interim

1977;

a nation

MD:

follow-up

41 Birchler

1977;

Consult

1984;

smoking:

Education, on

Nicotine 40

CB.

broad-

relapse

J

NL.

Psychol

Behav

L, Kurtz

risk

Minneapolis. 37

287:1782-85

RI

in smoking

Taylor

DE,

on smoking.

Davis

smoking

St Louis:

15:234-48 E,

36

53:256-58 N,

tion

Control

1983;

Jones

treatment

Maccoby training

of selfof change.

51:390-95 smoking

a

Preventing

in patients

Clin

on rapid

Hvmowitz

multiple

Health

Br Med

C,

1985;

I)r’esses

rapid

Psychol

training.

Benowitz

Consult

extinction,

GH,

The

Behav

I). C. Health

model

of

1984

1988

gum

SM,

and

Unpublished

Merriman

Hall

Stages integrative

Undirected

quitters.

chewing

JI),

an 1983;

Fondren

University;

against

CC.

Toward

Green

Behavioral 34

economic

J

Addictive

with

Clin

RT

therapy

of Health,

cessation.

and

1979 The

smokers

Jones

SM,

Bethesda,

Psychological 33

General

Washington,

J

report

cue

habit:

Human

Surgeon

and

49:648-58

36:581-85

Smoking:

effects smokers.

Consult

skill

Addictive

79-1549).

ork: 31

Hall

smoking

of Health,

I)avidson

30

Med 1977; 297:793-96 Human Development.

79-50066).

Office,

Kelly

in the

Weekly

A report

(PHS)

Psychol

EB,

Lichtenstein

for

health

disease.

I)PL,

Progress

Hughes

C,

behavioral

Research

I)epartment

styles.

Warhurton

Health: No.

Clin

of ssaccessful

Therapy

29

guide The

air, behavior.

52:372-82

disease.

Danaher

for

DC:

In: US Dept

DiClemente

Fisher

regulation

19

and

survey

Killen

health.

smoking:

Consulting

advice 17

respiratory

Services.

abortion. N Engl of Child Health and

GA,

JO,

Russell

with

of

J

Tun.stall

of rapid

follow.iip

1984

of

nicotine

M,

ofquittmng.

\Vashington 16

safety

and

7:551-65

Human

Mortality

Printing

and Compan; Prochaska

of

Psycho-

A practical

Cigarette

and

infant

G, Colditz

change

1986;

and

Susser

Government benefits

patients

cessation:

Control.

ZA,

Pregnancy

and

U.S.

A review

modification.

Cardiovascular

Morbidity

12

Oster

27

102:704-13

Washington,

Disease

Kline

U.S.

of

1983.

11

15

and

1984;

Med

Health

General.

Office,

I)ept l)C:

treatment

b’

Sachs

initiated,

Behavior

problem: risk

1970;

of smoking:

10 Centers

J

RG,

MR.

US

D,

1984;

Hall

Lowe

smoking.

28

among

Dis

Chest of

Surgeon

Printing

14

Rugg

Institutes

In:

Long-term cigarette

approach.

smoking

tional

Washington.

smoking

K. Smoking

Department

consequences

The

smoking

Respir

Rost

physician.

9 US

13

SM,

Psychosocial

88:370-405

Cigarette

Am

78-581).

in behavioral

1980;

JS.

disease. the

Hall

No.

1977

PD.

theory

Bulletin,

7 Mausner

(ADM)

Successful

1979

on Smoking

MRP

for dependent

recosnmendations.

26

smoking.

Research

Office,

Cleary

research

logical

in

Welfare,

No.

Printing

Leventhal

the

factors

and

smoky

of smoking

2:109-12

digest:

cigarette

warm,

40:92-8

Rodrigues

behavioral

smoking

Health,

6

HA.

79-5O(6).

Office,

adolescents:

24

Health,

ibid 5

1977;

Lando

pulmonary

mainof

A reI)ort

No.

and

93:37S-55S

l)ept

Printing

in children

and

Kozlowski

US

Publication

Government

Smoking

determinants

and

1988;

establishment.

In:

Smoking

(DHEW

l)C:

in the

of smoking.

Welfare,

General

Chest

factors

cessation

Behav

Psvchol

dependence.

Behavioral

and

Surgeon

4

Nicotine

E,

smoking, modification

1973;

treatment

cigarette

REFERENCES

J.

the

45:361-66

23 1 Henningfield

rapid

in

Psvchol

Lichtenstein

spectrum

College

nonsmoking

offices

Clin

smoking 21

of

placebo

Consult

or voluntary agency programs as well as institutional and governmental policies to limit smoking in health care

Cotnparison

attention

Supplement

Pub

eliminathe

Amen-

1984 of

J

year

J

Consult

group

Clin

flS

Psychol 42

1984;

Mermelstein Social

J

52:1080-86

43

R, Cohen support

Counseling

S, Lichtenstein

and Clin

smoking

Psychol

1986;

cessation

E,

Baen and

JS,

Kamarck

maintenance.

T

Morgan

GD,

Ashenberg

smoking

and

the

1988

social

ZS,

Fisher

environment.

EB,

Jr.

J

Consult

Abstinence Clin

from Psychol

(in press)

54:447-5i3

78S

Smoking


Cessation

Implications for the Practicing Physician of the Psychosocial Dimensions of Smoking E. B. Fisher, Jr., Donald B. Bishop, Jane Goldmuntz and Andrea Jacobs Chest 1988;93; 69S-78S DOI 10.1378/chest.93.2_Supplement.69S This information is current as of July 11, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/93/2_Supplement/69S Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.
