Clinical Methods in Smoking Cessation: Description and Evaluation of a Stop Smoking Clinic TEMPLE HARRUP, BRUCE A. HANSEN, MA,
Abstract: This study reports the results of the Kaiser-Permanente Stop Smoking Clinic and describes the philosophy and methods employed by the clinic in treating addictive smoking behavior. Of the 1,128 clients who registered for the group program, 57 per
The growing acceptance of the idea that cigarettes can be used addictively is reflected in recent literature. 1-6 The minimal effectiveness of interventions which do not reflect the addictive aspects of smoking behavior may have contributed to an underlying pessimism and sense of impotence in clinical approaches to the problem. This study describes an attempt to understand addictive smoking behavior from a phenomenologic perspective. It is hoped that this description of clinical procedures and issues will be read jointly with the theoretical position on which these methods are based.7
AND
KRIKOR SOGHIKIAN, MD, MPH
cent are abstinent six months after quitting smoking and 47 per cent are abstinent at one year. The clinic methods used are described in detail. They attempt to relate smoking behavior to the larger phenomenon of
addiction. (Am J Public Health 69:1226-1231.)
The Kaiser-Permanente Stop Smoking Clinic is part of the Northern California region of Kaiser-Permanente Medical Care Program, a health maintenance organization serving over a million members. The clinic is an educational program that uses group counseling in a flexible, eclectic fashion designed to meet a variety of individual needs, including a directive, didactic component, provided by the group leader and a group-support counseling component. It has two major goals: cessation of cigarette smoking, and cessation of the desire to smoke.
The clinic presently covers an eight-week period with 13 90-minute meetings. Groups meet twice weekly for the first nine meetings and once weekly for the remaining four meetings. Group reunions are held at three months, six months, and twelve months after quitting. Groups have an average of ten members. The clinic has employed a total of eight counselors since 1973. They have all been ex-smokers; six quit smoking while enrolled in clinic groups. All leaders have an extensive background in drug counseling or psychology and have undergone an extensive training period before leading groups. Since 1973, over 1,100 clients, more than 80 per cent of whom are Kaiser Foundation Health Plan members, have registered for the group program which is presently offered at five San Francisco Bay Area medical centers. Potential clients are made aware of the clinic's existence by physician referral, by word of mouth, by pamphlet distribution, and by the health plan newsletter. Each participant has taken the initiative to call for information, make an appointment, attend an initial interview session, and pay a nominal fee* before joining a group. This population varies in age from 19 to 73 years with an average of 41 years; 43 per cent of the clients are male, 57 per cent female. They have smoked an average of 32 cigarettes daily for 22 years, and the average age at onset of smoking was 19 years.
From the Stop Smoking Clinic, Kaiser-Permanente Medical Care Group, Northern California Region. Address reprint requests to Ms. Temple Harrup, Stop Smoking Clinic, Kaiser-Permanente Medical Center, 3779 Piedmont Avenue, Oakland, CA 94611. This paper, submitted to the Journal January 2, 1979, was revised and accepted for publication June 26, 1979.
*Group members are charged an enrollment fee to defray a portion of the clinic costs. From 1973 to 1977, a fee of $15 to $42.50 for health plan members and of $30 to $85 for non-members was charged.
Description of Program
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HARRUP ET AL
Procedures of the Stop Smoking Clinic Initial Interview Session The group leader conducts a half-hour initial interview with each prospective group member. Clients have filled out a profile sheet which provides demographic data, smoking history, motivational structure, health status, and information about other drug involvement. Using the profile sheet as a guide, the group leader attempts to explore with the client his/her level of commitment, degree of addictive involvement and quality of life. Although the client may not feel secure about the ability to stop smoking, a personal desire to do so is necessary. Inadequate motivation levels are reflected in the client's response to a variety of smoking-related subjects such as: * Was the decision to contact the clinic self-motivated, or was it at the request of a physician or concerned family member? * Does the client relate how he feels about quitting only in negative terms? * Does the client also express negative feeling regarding smoking and positive feeling about quitting? * Is the client's awareness of the nature of the cigarette involvement functioning on a naive level? e.g., "'If I can stay off for one day, I'll have it licked." The group leader must also be sensitive to any indication of addictive behavior in other areas which can increase substance substitution once cessation has occurred. Often, the client's closest associates, such as a spouse, are smokers with whom the smoking experience is shared. Obviously, this makes it more difficult for the client to maintain abstinence.8-14 The interview provides a confidential consultation where important life events and changes may be discussed. During the discussion, the group leader attempts to ascertain the general quality of the client's life indicated by disclosures related to the areas of work, interpersonal relationships, and physical and psychological well-being. Inadequate life satisfaction caused by deficits in these areas make renunciation of gratification gained from addictive tobacco use difficult.15 A subjective appraisal based on the client's responses is made and shared with the client, enabling him to make a more informed decision regarding smoking and what might be involved in eliminating this behavior. The interview is brought to a close at this point for those who will not become members of a group. Self-help materials with telephone or return visit follow-up are provided for those clients who feel their problem is minimal and does not warrant the intensive group experience. Clients who have never attempted to quit or control their smoking are often encouraged to have this experience with the aid of self-help materials before making a decision to join the group program. Clients in a state of crisis-impending divorce, recent death in the family, severe emotional or psychologic problems-are encouraged to quit at a time when they are less likely to be overwhelmed by the upheaval brought about from cessation combined with their other difficulties. These clients are often advised to seek additional sources of support. AJPH December 1979, Vol. 69, No. 12
The program goal of maintaining cessation permanently is emphasized, rather than the more immediate goal of
"quitting smoking." The addictive nature of tobacco smoking is stressed, as is the fact that clinic rmethods are derived from this perspective. The date assigned for the group to stop smoking is given. All references to occurrences after the appointed date are prefaced with such phrases as: "After you quit" or "When you don't smoke," with absolute and positive assurance that this event will occur. The interview should be regarded as initial treatment as well as a process during which the most appropriate treatment mode is selected.
Cessation of Cigatette Smoking (Meetings 1-8) A group sense that a common negative condition exists can be fostered at the initial meeting by encouraging the disclosure of individual histories and feelings regarding smoking. Common experiences are important factors in the unification of individuals into a cohesive group. Ambivalent feelings, which are best expressed as the fear of what will result from not smoking vs. the fear of what will result from smoking, are frequently revealed in group discussion. Clients often fear that without cigarettes they will be unable to cope with daily life situations. This in turn creates an expectation and fear of failure. The process of sharing these common experiences and feelings facilitates group cohesion, strengthens the sense of having a common goal, and reinforces the hope of succeeding as a group when they have failed as individuals. Concepts of motivation are didactically presented to the group at the second meeting. The group is informed that the positive, internalized motivations of looking forward to the benefits of cessation, caring about themselves, and wanting to improve their lives are more efficacious than negative, external motivations such as trying to respond to fear of ill health or to comply with pressure from others. To be successful, smokers must first believe that it is possible to quit smoking. The group leader, by communicating without equivocation faith in the client's ability to succeed, helps to foster a belief in this possibility. Anticipating the quitting date by encouraging clients to frequently repeat, "In days, I am going to stop . . . ," strengthens the belief, intention, and expectation that upon the arrival of the given date, they will, in fact, stop smoking. As group members have discussed their reasons for being in the group, the leader can use their statements as illustrations of the various motivations to quit and encourage those which lead toward gaining health and freedom instead of those which convey a sense of suffering and loss. On both work and leisure days, for each cigarette smoked, the group members are asked to record: 1) time, 2) circumstance, 3) emotional state, 4) level of craving, 5) the identified cue which aroused craving, 6) expected gratification, and 7) experienced gratification. The results are usually discussed during the third meeting. Cues tend to fall into two categories: situational, such as drinking coffee, someone else lighting up, transition periods between activities, or at established points in habit pat1227
STOP SMOKING CLINIC
terns; emotional, such as boredom, anger, anxiety, or feelings of joy, self-satisfaction, and reward. The situational cues are more easily identified and, after cessation, more easily dissociated from the smoking experience. Soon after quitting, the ex-smoker is able to participate in those events which previously functioned as situational cues without craving a cigarette as long as the event is frequently encountered, e.g., coffee drinking. The emotional cues are more difficult to identify. Clients report that any intensely felt emotion is accompanied by craving. Some group members recognize a relation between smoking and emotional states to the extent that they can identify the particular affects (differing with each individual) which they, to varying degrees, experience as craving states. They also report experiencing emotional situations with a total lack of affective response accompanied with a marked increase in the need to smoke (craving),7 e.g., "When I get mad, I need a cigarette to calm down." A functional use of cigarettes becomes more obvious to clients who acknowledge smoking as a way to avoid conflict, to buffer unpleasant affects, and to provide a source of satisfaction in daily life. This relation to cigarettes is often brought to the client's awareness more acutely after cessation. Theoretical and practical information on addictive process related to cigarette smoking is presented to the group at the fourth meeting. The group leader reviews a handout describing the addictive process as the creation of an artificial "basic need" which causes the user to cyclically alternate between states of craving and gratification.'6 The significance of craving as more dominant and necessary for the functioning of the addictive cycle is pointed out. It is stressed that to become free necessitates letting go or relinquishing not simply the cigarettes and actual smoking behavior, but the desire to smoke itself. Most smokers experience those situations wherein they believe it is impossible to smoke with a minimum or absence of craving. Thus, it is suggested that in order to avoid craving, one's entire existence must be viewed as a situation in which it is simply not possible to smoke, e.g.: "'Imagine being shipwrecked on a small desert island where there are no cigarettes and no possibility of getting any." Understanding, accepting, and internalizing the view that cigarettes no longer exist is perhaps the most important concept to be accepted by clients who intend to stop smoking. It should be introduced and reinforced with a variety of examples and analogies which repeat the concept in as many ways and as often as is necessary to become a rigidly adhered to belief. Alfred Lindesmith's work on addiction'7 is reviewed to acquaint the group with basic concepts and processes of addictive behavior. Clients relate this information to their own experiences and thereby free themselves from the false concepts of causality linking neurosis, character disorder, feelings of weakness and of helplessness with the addictive state and instead strengthen their belief that freedom from addiction is possible. The assigned date to stop smoking falls on the fifth session. During the meeting, the group is instructed to leave the room and smoke their last cigarettes together. Home and work telephone numbers of the members and leader are dis1 228
tributed, and each person is assigned one group member to phone daily. "Care packages" containing sugarless gum, cloves and cinnamon sticks, balloons, sunflower seeds, and other items are distributed. Group members review a previous assignment to allocate their time until the next scheduled meeting. Using the records of their smoking patterns, the members are able to anticipate those events which function as cues to smoke, and can plan alternative responses. The process of sharing individual schedules serves as a behavioral rehearsal of nonsmoking responses to cue situations. The group anticipate their emotional reactions to not smoking. The possibility of feeling overcome by disorientation, panic, grief, a sense of loss, anxiety, frustration, anger and boredom is considered, and the leader suggests specific coping behaviors should this occur. Another strategy to minimize the unpleasantness of quitting is to disrupt habit patterns and daily routines. The group reassembles for its sixth meeting after having abstained for two days, and members share experiences of having lived through this period without smoking cigarettes. The general tenor of the meeting is often characterized by near hysteria, as stories of triumph over the previously anticipated difficulties are exchanged. People proudly tell how they responded assertively in situations in which they would otherwise have remained passive and smoked. Episodes of disorientation are humorously related. Mixed with the sense of achievement and growing confidence are signs of grieving. People feel on the verge of tears and report breaking down and crying for no reason.'8 A diversity of psychological and physical symptoms which have been experienced are shared. The theme of common suffering intensifies group cohesion and identity. The realization that smoking may have masked deeper problems increases with the awareness that these unresolved issues must now be handled without cigarettes. The leader gives support, encouragement, and praise but reminds the group again that quitting smoking is the first step and that now the focus must be on the long-range goal of remaining a nonsmoker permanently. Four days after quitting, the group meets for breakfast (seventh meeting). Conversation continues along the themes of the last session. The feeling of having "'weathered a storm" together promotes personal disclosures which are now less restricted to the subject of smoking, and encompasses each person's total life situation as it has been affected by the termination of smoking. As the euphoria of successfully quitting diminishes, members often experience the acute awareness of problems in the life situation. The sense of loss increases and relates less specifically to cigarettes. By the eighth meeting, clients yearn for "something" which cannot be identified and tend toward bored passivity and depression. Reports of angry outbursts triggered by insignificant events or even feelings of rage toward everyone are common. Above all, they believe that suffering would be eliminated if one, just one, cigarette could be smoked! Clients are advised not to allow themselves to think about, yearn for, or in any way entertain the remotest possiAJPH December 1979, Vol. 69, No. 12
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bility of smoking. The very act of imagining any set of circumstances, no matter how unlikely, which would lend permission to "having just one" will eventually lead to relapse. The leader carefully reviews Lindesmith's summary of factors which facilitate relapse: * The neutralization of the miseries of addiction which are remote consequences compared to the immediate satisfactory ones; * The rationalizations of the abstainer that life without the drug is dull; * The knowledge or beliefs acquired from direct personal experience of the marvelous potency and versatility of the drug; * The attraction exercised by associations within the drug-using subculture;** * The changed perceptions of the addict which lead him to respond to virtually all distress as though it were withdrawal distress to be banished by a fix.'9 Ultimately, the danger of relapse is proportional to the degree of withdrawal discomfort experienced vs. the degree of gratification attained by other means. Clients are informed that it is possible to shift addictive involvement from one substance to another and advised to develop an awareness of their behavior when using food, alcohol, or other drugs as replacements for cigarettes. Nutritional information is given to the group; however, alcohol and other drug-abuse counseling usually occurs on an individual basis. Unless the problem area in question is both severe and long-standing, clients usually regain their equilibrium within six months of cessation. Adopting New Supportive Behaviors (Meetings 9-13) Maintaining cessation tends to be a more diverse and individual experience for the group than was the process of quitting (meetings 1-8). Personality styles, sex roles, and quality of life become major factors in determining vulnerability to relapse. In many cases, cigarette addiction has facilitated the maintenance of an unhappy status quo or enhanced an ability to endure unpleasantness. For many people, the cessation of smoking automatically brings about a more intense, acute experiencing of emotion and reevaluation of the life situation.20 The group leader, although supporting the attempts at positive change, also counsels moderation in areas where sudden, impulsive action might bring about major life crises, such as leaving home or quitting a job. Group members are encouraged to engage in activities which are new sources of pleasure and satisfaction. The most helpful activity in which the client can engage is exercise.2' Group members lend each other encouragement in adopting a regular, vigorous exercise program as a permanent alternative to certain gratifications formerly attained by smoking. Each member was given a copy of Your Perfect Right,22 a manual on assertiveness training, which identifies and dis-
**The availability and social acceptance of cigarettes make this a particularly difficult problem for the recovered smoker.
AJPH December 1979, Vol. 69, No. 12
tinguishes between behaviors which are nonassertive, assertive, and aggressive. After cessation, the focus of discussion turns to the development of active coping as a replacement for the nonassertive behaviors that previously accompanied smoking. Direct, assertive behaviors are now encouraged to resolve difficult life situations in contrast to passive avoidance behaviors that were previously facilitated by smoking: avoiding conflict, reducing awareness of negative emotional states, passively enduring unpleasantness. The former smoker often feels compelled to choose between direct, assertive coping strategies or a return to smoking. The experiences of individual group members can provide models in which actions and events are described, accompanying feelings are expressed, desired changes are specified, and the positive consequences that will result from these changes are cited. Behavior thus becomes less passive, more assertive, and results in an experience of acting on the environment to improve one's lot rather than facilitating one's ability to passively endure unpleasantness. Variable factors such as sex roles, self esteem, and quality of life affect the client's capability for assuming more assertive behaviors. Reunions
Group reunions are held at approximately three, six, and 12 months after cessation. Reunions allow the groups to remain in contact and provide continuing support during the first year of abstinence. Reunions also provide an opportunity to integrate the impact quitting smoking has had on the physical and mental quality of their lives.
Evaluation Designation of smoking status of all persons who had registered for the group program was based on an independent follow-up telephone evaluation conducted one year after quitting. Attendance at regularly scheduled reunions contributed to the validity of the client's own report. Clients who had relapsed seemed to readopt the image of "smoker" and did not try to maintain the false belief that they had quit. The percentages of clients not smoking over time for the 1,128 persons who registered during the study period 1973 to 1977 from the time of quitting are described in Table 1. Of the original sample of 1,128 clients, 134 persons (12 per cent) never attended or dropped out before attending six meetings, and 262 persons (23 per cent) did not attend two-thirds of the meetings. Resumption of smoking over time for 1,128 registered clients by sex is shown in Figure 1. Throughout 1974, the clinic conducted a total of 15 groups (157 clients) with a one-year follow-up which showed 71 clients not smoking, 77 clients smoking, and 7 clients unknown. A two-year follow-up of these groups was conducted in 1977 which showed 44 clients not smoking, 67 clients smoking, and 46 clients unknown. We have not compared the two-year follow-up with the overall clinic one-year follow-up because of the relatively high rate of unknowns in the two-year evaluation. 1 229
STOP SMOKING CLINIC TABLE 1-Smoking Status for Stop Smoking Program Measured from Date of Cessation 2 Mo.
48 Hr.
All registered clients Not smoking* Smokingt Unknownt Total Clients Attending 6 or More Meetings'* Not smoking
6 Mo.
12 Mo.
No.
%
No.
%
No.
%
No.
%
1018 69 41 1128
90 6
78 46 6 100
640 414 74
77
47 46 7
1128
57 37 6 100
533 518
100
881 185 62 1128
1128
100
962 32 0 994
97 3 0 100
848 133 13 994
85 14 1 100
611 331 52 994
62 33 5 100
506 430 58 994
51 43 6 100
848 18 0 866
98 2 0 100
785 74 7 866
91 8 1 100
569 254 43 866
66 29 5 100
471 350 45 866
54 41 5 100
Smoking Unknown Total Clients Attending 2/3 or More Meetings** Not smoking Smoking Unknown Total
4
*No regular tobacco consumption. Isolated smoking instance or episode recorded for month or months in which behavior occurred.
tTobacco regularly smoked, including occasional smoking, smoking at parties only, smoking one cigarette every three months. tClients could not be located. Deceased clients dropped from evaluation. Clients who joined second group in same year were evaluated as part of second group. "These categories correlate attendance with success.
Discussion The relapse curve steeply declines during the first three months, then gradually levels between three months and one year after quitting. Hunt and Matarazzo23 and Hunt with Bespalec24 showed that 20 per cent to 30 per cent of persons abstemious at the completion of treatment were not smoking one year later. Other reviews of smoking cessation programs and evaluations of their effectiveness25-36 have uniformly pointed toward discouragingly low abstinence rates. Hunt, Barnett, and Branch reported a marked similarity in the relapse curves from 84 studies of smoking cessation interventions. Participants in smoking cessation programs relapsed within one year at the same rate (approximately 80 100
l
I
,80 0
60
o 0
$ 40 o
- 200
Men
II 2 days
N = 1128 1
2
4
6
1 8
1 10
12
Time after quitting, months FIGURE 1-Resumption of Smoking Over Time by Sex for AU Registered Stop Smoking Clients 1230
ed.30' 32, 33, 38-42
Because the majority of our clients are members of a prepaid health plan and were willing to pay a fee to join a group support program and attend an initial interview session, these factors may bias the sample of persons who entered group treatment and should be kept in mind in any attempt to generalize from these results. A finding of the clinic was that clients' decisions to give up cigarettes are often motivated by a broader personal commitment to improve the quality of their lives in general rather than a response to fear of adverse health consequences. This description of group treatment is concerned with those persons for whom a knowledge of the issues and problems of addictive behavior and the support of a group program are major factors in their ability to remain abstinent.
REFERENCES
N = 485
----Women N = 643
Total
per cent) as heroin addicts and at a slightly higher rate than alcoholics. In most reported studies, men are cited as significantly more successful than women. In our study, 49 per cent of all registered male clients were abstinent at one year, whereas 46 per cent of their female counterparts were still not smoking. The group leader's concem for the many issues facing women today are thought to contribute to the relatively better response by female clients than is generally report-
1. Jaffe JH: Cigarette smoking as an addiction, In: Steinfeld J, et al, (eds). Proceedings, Third World Conference. Smoking and Health, vol. 2. Health Consequences, Education, Cessation Activities, and Governmental Action. New York City, New York, June 2-5, 1975. 2. Russell MA: The smoking habit and its classification. Practitioner 212:791-800, 1974. 3. Australian Council on Smoking and Health. Special supplement on smoking and health. Med J Aust 2:1-4, 1975. 4. Solomon, RL, Corbit JD: An opponent-process theory of moti-
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5. 6. 7.
8. 9. 10. 11.
12. 13. 14. 15. 16. 17.
18. 19.
20. 21. 22. 23.
vation: II. cigarette addiction. J Abnorm Psychol 81:158-171, 1973. Solomon RL, Corbit JD: An opponent-process theory of motivation: I. temporal dynamics of affect. Psychol Rev 81:119-145, 1974. Hill D: Report on the third world conference on smoking and health. Cancer Forum 6:299-302, 1975. Harrup T: Addictive processes in tobacco use, In: Progress in Smoking Cessation. Proceedings, International Conference on Smoking Cessation, New York City. June 21-23, 1978. New York, American Cancer Society, 1979. Erickson LGW, Cramer JA: Smoking behavior development and modification: an empirical application of three social psychological theories. J Appl Soc Psychol 6:369-386, 1976. Schwartz JL, Dubitzky M: Psycho-social factors in cigarette smoking and cessation. Institute for Health Research, Berkeley, California, 1968. Jenks R, Schwartz JL, Dubitzky M: Effect of the counselor's approach to changing smoking behavior. J Counsel Psychol 16:215-221, 1969. Jacobs MA, Spilken, AZ, Norman MM, et al: Interaction of personality and treatment conditions associated with success in a smoking control program. Psychosom Med 33:545-556, 1971. Schwartz JL, Dubitzky M: Smoking behavior and attempts to discontinue smoking. Bull NY Acad Med 44:1536-1545, 1968. Graham S, Gibson RW: Cessation of patterned behavior: withdrawal from smoking. Soc Sci Med 5:319-337, 1971. Schwartz JL, Dubitzky M: Maximizing success in smoking cessation methods. Am J Public Health 59:1392-1399, 1969. Bozzetti LP: Group psychotherapy with addicted smokers. Psychother Psychosom 20:172-175, 1972. Reinert, RE: General observations on drug habituation. Bull Menninger Clin 34:195-204, 1970. Lindesmith A: Addiction and Opiates. Chicago, Aldine Press, 1968. Tamerin JS: The psychodynamics of quitting smoking in a group. Am J Psychiatry 129:589-595, 1972. Lindesmith A: Cure and relapse, In: Addiction and Opiates. Chicago, Aldine Press, 1968, pp. 129-155. Sarbin TR, Nucci LP: Self-reconstitution processes: a proposal for reorganizing the conduct of confirmed smokers. J Abnorm Psychol 81:182-195, 1973. Christen AG, Cooper KH: Strategic withdrawal from cigarette smoking. CA 29:96-107, 1979. Alberti RE, Emmons ML: Your Perfect Right: A Guide to Assertive Behavior, 3rd ed. San Luis Obispo, California, Impact Publishers, 1978. Hunt W, Matarazzo J: Habit mechanisms in smoking, In: Hunt W: (ed), Learning Mechanism in Smoking. Chicago, Aldine Press, 1970, pp. 65-95.
I
24. Hunt WA, Bespalec, DA: An evaluation of current methods of modifying smoking behavior. J Clin Psychol 30:431-438, 1974. 25. Schwartz JL: A critical review and evaluation of smoking control methods. Public Health Rep 84:483-506, 1969. 26. Bernstein DA: Modification of smoking behavior: an evaluative review. Psychol Bull 71:418-440, 1969. 27. Mausner B: Some comments on the failure of behavior therapy as a technique for modifying cigarette smoking. Consult Clin Psychol 36: 167-170, 1971. 28. Keutzer CS, Lichtenstein F, Mees HL: Modification of smoking behavior: a review. Psychol Bull 70:520-533, 1968. 29. Bradshaw PW: The problem of cigarette smoking and its control. Int J Addict 8:353-371, 1973. 30. West D, Graham S, Swanson M, Wilkinson G: Five-year followup of a smoking withdrawal clinic population. Am J Public Health 67:536-544, 1977. 31. Schewchuk LA: Special report. Smoking cessation program of the American Health Foundation. Prev Med 5:454-474, 1976. 32. Guilford JS: Sex differences between successful and unsuccessful abstainers from smoking, In: Zagona S: (ed), Studies and Issues in Smoking Behavior. National Research Conference on Smoking and Behavior, 2d, University of Arizona, 1966. Tucson, University of Arizona Press, 1967, pp. 95-102. 33. Guilford JS: Group treatment versus individual initiative in the cessation of smoking. J Appl Psychol 56:162-167, 1972. 34. Lawton MP: Group methods in smoking withdrawal. Arch Environ Health 14:258-265, 1967. 35. Thompson EL: Smoking education programs, 1960-1976. Am J Public Health 68:250-257, 1978. 36. Lichtenstein E, Keutzer CS: Experimental investigation of diverse techniques to modify smoking: a follow-up report. Behav Res Ther 7:139-140, 1969. 37. Hunt WA, Barnett LW, Branch LG: Relapse rates in addiction programs. J Clin Psychol 27:455-456, 1971. 38. Bothwell PW: The epidemiology of cigarette smoking in rural school children. Med Officer 102:125-132, 1959. 39. Haenszel W, Shimkin MB, Miller HP: Tobacco Smoking Patterns in the United States. U.S. Public Health Monograph #45, Public Health Service Publication #463, Washington, DC: Gov Printing Office, 1956. 40. Eisinger RA: Psychosocial predictors of smoking recidivism. J Health Soc Behav 12:355-362, 1971. 41. Delarue NC: A study in smoking withdrawal: the Toronto smoking withdrawal centre-description of activities. Can J Public Health 64:S5-19, 1973. 42. Berglund E: A Follow-up Study of 13 Norwegian Tobacco Withdrawal Clinics: The Five-Day Plan, The Final Report. Oslo: Norwegian Cancer Society, 1969.
Post-Doctoral Fellowships in Ethics for 1980-81 Offered
The Hastings Center, Institute of Society, Ethics and the Life Sciences, is offering three one-year resident post-doctoral fellowships for the study of ethics and the life sciences for the academic year 1980-81. The program is interdisciplinary in nature, is open to applicants from all fields, and requires an advanced doctoral or professional degree (or its equivalent). Application deadline is January 1, 1980. Request brochure from B. Baya, Post-Doctoral Fellowship Program, The Hastings Center, 360 Broadway, Hastings-on-Hudson, NY 10706, 914/478-0500.
AJPH December 1979, Vol. 69, No. 12
1231
Abstract: This study reports the results of the Kaiser-Permanente Stop Smoking Clinic and describes the philosophy and methods employed by the clinic in treating addictive smoking behavior. Of the 1,128 clients who registered for the group program, 57 per
The growing acceptance of the idea that cigarettes can be used addictively is reflected in recent literature. 1-6 The minimal effectiveness of interventions which do not reflect the addictive aspects of smoking behavior may have contributed to an underlying pessimism and sense of impotence in clinical approaches to the problem. This study describes an attempt to understand addictive smoking behavior from a phenomenologic perspective. It is hoped that this description of clinical procedures and issues will be read jointly with the theoretical position on which these methods are based.7
AND
KRIKOR SOGHIKIAN, MD, MPH
cent are abstinent six months after quitting smoking and 47 per cent are abstinent at one year. The clinic methods used are described in detail. They attempt to relate smoking behavior to the larger phenomenon of
addiction. (Am J Public Health 69:1226-1231.)
The Kaiser-Permanente Stop Smoking Clinic is part of the Northern California region of Kaiser-Permanente Medical Care Program, a health maintenance organization serving over a million members. The clinic is an educational program that uses group counseling in a flexible, eclectic fashion designed to meet a variety of individual needs, including a directive, didactic component, provided by the group leader and a group-support counseling component. It has two major goals: cessation of cigarette smoking, and cessation of the desire to smoke.
The clinic presently covers an eight-week period with 13 90-minute meetings. Groups meet twice weekly for the first nine meetings and once weekly for the remaining four meetings. Group reunions are held at three months, six months, and twelve months after quitting. Groups have an average of ten members. The clinic has employed a total of eight counselors since 1973. They have all been ex-smokers; six quit smoking while enrolled in clinic groups. All leaders have an extensive background in drug counseling or psychology and have undergone an extensive training period before leading groups. Since 1973, over 1,100 clients, more than 80 per cent of whom are Kaiser Foundation Health Plan members, have registered for the group program which is presently offered at five San Francisco Bay Area medical centers. Potential clients are made aware of the clinic's existence by physician referral, by word of mouth, by pamphlet distribution, and by the health plan newsletter. Each participant has taken the initiative to call for information, make an appointment, attend an initial interview session, and pay a nominal fee* before joining a group. This population varies in age from 19 to 73 years with an average of 41 years; 43 per cent of the clients are male, 57 per cent female. They have smoked an average of 32 cigarettes daily for 22 years, and the average age at onset of smoking was 19 years.
From the Stop Smoking Clinic, Kaiser-Permanente Medical Care Group, Northern California Region. Address reprint requests to Ms. Temple Harrup, Stop Smoking Clinic, Kaiser-Permanente Medical Center, 3779 Piedmont Avenue, Oakland, CA 94611. This paper, submitted to the Journal January 2, 1979, was revised and accepted for publication June 26, 1979.
*Group members are charged an enrollment fee to defray a portion of the clinic costs. From 1973 to 1977, a fee of $15 to $42.50 for health plan members and of $30 to $85 for non-members was charged.
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Procedures of the Stop Smoking Clinic Initial Interview Session The group leader conducts a half-hour initial interview with each prospective group member. Clients have filled out a profile sheet which provides demographic data, smoking history, motivational structure, health status, and information about other drug involvement. Using the profile sheet as a guide, the group leader attempts to explore with the client his/her level of commitment, degree of addictive involvement and quality of life. Although the client may not feel secure about the ability to stop smoking, a personal desire to do so is necessary. Inadequate motivation levels are reflected in the client's response to a variety of smoking-related subjects such as: * Was the decision to contact the clinic self-motivated, or was it at the request of a physician or concerned family member? * Does the client relate how he feels about quitting only in negative terms? * Does the client also express negative feeling regarding smoking and positive feeling about quitting? * Is the client's awareness of the nature of the cigarette involvement functioning on a naive level? e.g., "'If I can stay off for one day, I'll have it licked." The group leader must also be sensitive to any indication of addictive behavior in other areas which can increase substance substitution once cessation has occurred. Often, the client's closest associates, such as a spouse, are smokers with whom the smoking experience is shared. Obviously, this makes it more difficult for the client to maintain abstinence.8-14 The interview provides a confidential consultation where important life events and changes may be discussed. During the discussion, the group leader attempts to ascertain the general quality of the client's life indicated by disclosures related to the areas of work, interpersonal relationships, and physical and psychological well-being. Inadequate life satisfaction caused by deficits in these areas make renunciation of gratification gained from addictive tobacco use difficult.15 A subjective appraisal based on the client's responses is made and shared with the client, enabling him to make a more informed decision regarding smoking and what might be involved in eliminating this behavior. The interview is brought to a close at this point for those who will not become members of a group. Self-help materials with telephone or return visit follow-up are provided for those clients who feel their problem is minimal and does not warrant the intensive group experience. Clients who have never attempted to quit or control their smoking are often encouraged to have this experience with the aid of self-help materials before making a decision to join the group program. Clients in a state of crisis-impending divorce, recent death in the family, severe emotional or psychologic problems-are encouraged to quit at a time when they are less likely to be overwhelmed by the upheaval brought about from cessation combined with their other difficulties. These clients are often advised to seek additional sources of support. AJPH December 1979, Vol. 69, No. 12
The program goal of maintaining cessation permanently is emphasized, rather than the more immediate goal of
"quitting smoking." The addictive nature of tobacco smoking is stressed, as is the fact that clinic rmethods are derived from this perspective. The date assigned for the group to stop smoking is given. All references to occurrences after the appointed date are prefaced with such phrases as: "After you quit" or "When you don't smoke," with absolute and positive assurance that this event will occur. The interview should be regarded as initial treatment as well as a process during which the most appropriate treatment mode is selected.
Cessation of Cigatette Smoking (Meetings 1-8) A group sense that a common negative condition exists can be fostered at the initial meeting by encouraging the disclosure of individual histories and feelings regarding smoking. Common experiences are important factors in the unification of individuals into a cohesive group. Ambivalent feelings, which are best expressed as the fear of what will result from not smoking vs. the fear of what will result from smoking, are frequently revealed in group discussion. Clients often fear that without cigarettes they will be unable to cope with daily life situations. This in turn creates an expectation and fear of failure. The process of sharing these common experiences and feelings facilitates group cohesion, strengthens the sense of having a common goal, and reinforces the hope of succeeding as a group when they have failed as individuals. Concepts of motivation are didactically presented to the group at the second meeting. The group is informed that the positive, internalized motivations of looking forward to the benefits of cessation, caring about themselves, and wanting to improve their lives are more efficacious than negative, external motivations such as trying to respond to fear of ill health or to comply with pressure from others. To be successful, smokers must first believe that it is possible to quit smoking. The group leader, by communicating without equivocation faith in the client's ability to succeed, helps to foster a belief in this possibility. Anticipating the quitting date by encouraging clients to frequently repeat, "In days, I am going to stop . . . ," strengthens the belief, intention, and expectation that upon the arrival of the given date, they will, in fact, stop smoking. As group members have discussed their reasons for being in the group, the leader can use their statements as illustrations of the various motivations to quit and encourage those which lead toward gaining health and freedom instead of those which convey a sense of suffering and loss. On both work and leisure days, for each cigarette smoked, the group members are asked to record: 1) time, 2) circumstance, 3) emotional state, 4) level of craving, 5) the identified cue which aroused craving, 6) expected gratification, and 7) experienced gratification. The results are usually discussed during the third meeting. Cues tend to fall into two categories: situational, such as drinking coffee, someone else lighting up, transition periods between activities, or at established points in habit pat1227
STOP SMOKING CLINIC
terns; emotional, such as boredom, anger, anxiety, or feelings of joy, self-satisfaction, and reward. The situational cues are more easily identified and, after cessation, more easily dissociated from the smoking experience. Soon after quitting, the ex-smoker is able to participate in those events which previously functioned as situational cues without craving a cigarette as long as the event is frequently encountered, e.g., coffee drinking. The emotional cues are more difficult to identify. Clients report that any intensely felt emotion is accompanied by craving. Some group members recognize a relation between smoking and emotional states to the extent that they can identify the particular affects (differing with each individual) which they, to varying degrees, experience as craving states. They also report experiencing emotional situations with a total lack of affective response accompanied with a marked increase in the need to smoke (craving),7 e.g., "When I get mad, I need a cigarette to calm down." A functional use of cigarettes becomes more obvious to clients who acknowledge smoking as a way to avoid conflict, to buffer unpleasant affects, and to provide a source of satisfaction in daily life. This relation to cigarettes is often brought to the client's awareness more acutely after cessation. Theoretical and practical information on addictive process related to cigarette smoking is presented to the group at the fourth meeting. The group leader reviews a handout describing the addictive process as the creation of an artificial "basic need" which causes the user to cyclically alternate between states of craving and gratification.'6 The significance of craving as more dominant and necessary for the functioning of the addictive cycle is pointed out. It is stressed that to become free necessitates letting go or relinquishing not simply the cigarettes and actual smoking behavior, but the desire to smoke itself. Most smokers experience those situations wherein they believe it is impossible to smoke with a minimum or absence of craving. Thus, it is suggested that in order to avoid craving, one's entire existence must be viewed as a situation in which it is simply not possible to smoke, e.g.: "'Imagine being shipwrecked on a small desert island where there are no cigarettes and no possibility of getting any." Understanding, accepting, and internalizing the view that cigarettes no longer exist is perhaps the most important concept to be accepted by clients who intend to stop smoking. It should be introduced and reinforced with a variety of examples and analogies which repeat the concept in as many ways and as often as is necessary to become a rigidly adhered to belief. Alfred Lindesmith's work on addiction'7 is reviewed to acquaint the group with basic concepts and processes of addictive behavior. Clients relate this information to their own experiences and thereby free themselves from the false concepts of causality linking neurosis, character disorder, feelings of weakness and of helplessness with the addictive state and instead strengthen their belief that freedom from addiction is possible. The assigned date to stop smoking falls on the fifth session. During the meeting, the group is instructed to leave the room and smoke their last cigarettes together. Home and work telephone numbers of the members and leader are dis1 228
tributed, and each person is assigned one group member to phone daily. "Care packages" containing sugarless gum, cloves and cinnamon sticks, balloons, sunflower seeds, and other items are distributed. Group members review a previous assignment to allocate their time until the next scheduled meeting. Using the records of their smoking patterns, the members are able to anticipate those events which function as cues to smoke, and can plan alternative responses. The process of sharing individual schedules serves as a behavioral rehearsal of nonsmoking responses to cue situations. The group anticipate their emotional reactions to not smoking. The possibility of feeling overcome by disorientation, panic, grief, a sense of loss, anxiety, frustration, anger and boredom is considered, and the leader suggests specific coping behaviors should this occur. Another strategy to minimize the unpleasantness of quitting is to disrupt habit patterns and daily routines. The group reassembles for its sixth meeting after having abstained for two days, and members share experiences of having lived through this period without smoking cigarettes. The general tenor of the meeting is often characterized by near hysteria, as stories of triumph over the previously anticipated difficulties are exchanged. People proudly tell how they responded assertively in situations in which they would otherwise have remained passive and smoked. Episodes of disorientation are humorously related. Mixed with the sense of achievement and growing confidence are signs of grieving. People feel on the verge of tears and report breaking down and crying for no reason.'8 A diversity of psychological and physical symptoms which have been experienced are shared. The theme of common suffering intensifies group cohesion and identity. The realization that smoking may have masked deeper problems increases with the awareness that these unresolved issues must now be handled without cigarettes. The leader gives support, encouragement, and praise but reminds the group again that quitting smoking is the first step and that now the focus must be on the long-range goal of remaining a nonsmoker permanently. Four days after quitting, the group meets for breakfast (seventh meeting). Conversation continues along the themes of the last session. The feeling of having "'weathered a storm" together promotes personal disclosures which are now less restricted to the subject of smoking, and encompasses each person's total life situation as it has been affected by the termination of smoking. As the euphoria of successfully quitting diminishes, members often experience the acute awareness of problems in the life situation. The sense of loss increases and relates less specifically to cigarettes. By the eighth meeting, clients yearn for "something" which cannot be identified and tend toward bored passivity and depression. Reports of angry outbursts triggered by insignificant events or even feelings of rage toward everyone are common. Above all, they believe that suffering would be eliminated if one, just one, cigarette could be smoked! Clients are advised not to allow themselves to think about, yearn for, or in any way entertain the remotest possiAJPH December 1979, Vol. 69, No. 12
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bility of smoking. The very act of imagining any set of circumstances, no matter how unlikely, which would lend permission to "having just one" will eventually lead to relapse. The leader carefully reviews Lindesmith's summary of factors which facilitate relapse: * The neutralization of the miseries of addiction which are remote consequences compared to the immediate satisfactory ones; * The rationalizations of the abstainer that life without the drug is dull; * The knowledge or beliefs acquired from direct personal experience of the marvelous potency and versatility of the drug; * The attraction exercised by associations within the drug-using subculture;** * The changed perceptions of the addict which lead him to respond to virtually all distress as though it were withdrawal distress to be banished by a fix.'9 Ultimately, the danger of relapse is proportional to the degree of withdrawal discomfort experienced vs. the degree of gratification attained by other means. Clients are informed that it is possible to shift addictive involvement from one substance to another and advised to develop an awareness of their behavior when using food, alcohol, or other drugs as replacements for cigarettes. Nutritional information is given to the group; however, alcohol and other drug-abuse counseling usually occurs on an individual basis. Unless the problem area in question is both severe and long-standing, clients usually regain their equilibrium within six months of cessation. Adopting New Supportive Behaviors (Meetings 9-13) Maintaining cessation tends to be a more diverse and individual experience for the group than was the process of quitting (meetings 1-8). Personality styles, sex roles, and quality of life become major factors in determining vulnerability to relapse. In many cases, cigarette addiction has facilitated the maintenance of an unhappy status quo or enhanced an ability to endure unpleasantness. For many people, the cessation of smoking automatically brings about a more intense, acute experiencing of emotion and reevaluation of the life situation.20 The group leader, although supporting the attempts at positive change, also counsels moderation in areas where sudden, impulsive action might bring about major life crises, such as leaving home or quitting a job. Group members are encouraged to engage in activities which are new sources of pleasure and satisfaction. The most helpful activity in which the client can engage is exercise.2' Group members lend each other encouragement in adopting a regular, vigorous exercise program as a permanent alternative to certain gratifications formerly attained by smoking. Each member was given a copy of Your Perfect Right,22 a manual on assertiveness training, which identifies and dis-
**The availability and social acceptance of cigarettes make this a particularly difficult problem for the recovered smoker.
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tinguishes between behaviors which are nonassertive, assertive, and aggressive. After cessation, the focus of discussion turns to the development of active coping as a replacement for the nonassertive behaviors that previously accompanied smoking. Direct, assertive behaviors are now encouraged to resolve difficult life situations in contrast to passive avoidance behaviors that were previously facilitated by smoking: avoiding conflict, reducing awareness of negative emotional states, passively enduring unpleasantness. The former smoker often feels compelled to choose between direct, assertive coping strategies or a return to smoking. The experiences of individual group members can provide models in which actions and events are described, accompanying feelings are expressed, desired changes are specified, and the positive consequences that will result from these changes are cited. Behavior thus becomes less passive, more assertive, and results in an experience of acting on the environment to improve one's lot rather than facilitating one's ability to passively endure unpleasantness. Variable factors such as sex roles, self esteem, and quality of life affect the client's capability for assuming more assertive behaviors. Reunions
Group reunions are held at approximately three, six, and 12 months after cessation. Reunions allow the groups to remain in contact and provide continuing support during the first year of abstinence. Reunions also provide an opportunity to integrate the impact quitting smoking has had on the physical and mental quality of their lives.
Evaluation Designation of smoking status of all persons who had registered for the group program was based on an independent follow-up telephone evaluation conducted one year after quitting. Attendance at regularly scheduled reunions contributed to the validity of the client's own report. Clients who had relapsed seemed to readopt the image of "smoker" and did not try to maintain the false belief that they had quit. The percentages of clients not smoking over time for the 1,128 persons who registered during the study period 1973 to 1977 from the time of quitting are described in Table 1. Of the original sample of 1,128 clients, 134 persons (12 per cent) never attended or dropped out before attending six meetings, and 262 persons (23 per cent) did not attend two-thirds of the meetings. Resumption of smoking over time for 1,128 registered clients by sex is shown in Figure 1. Throughout 1974, the clinic conducted a total of 15 groups (157 clients) with a one-year follow-up which showed 71 clients not smoking, 77 clients smoking, and 7 clients unknown. A two-year follow-up of these groups was conducted in 1977 which showed 44 clients not smoking, 67 clients smoking, and 46 clients unknown. We have not compared the two-year follow-up with the overall clinic one-year follow-up because of the relatively high rate of unknowns in the two-year evaluation. 1 229
STOP SMOKING CLINIC TABLE 1-Smoking Status for Stop Smoking Program Measured from Date of Cessation 2 Mo.
48 Hr.
All registered clients Not smoking* Smokingt Unknownt Total Clients Attending 6 or More Meetings'* Not smoking
6 Mo.
12 Mo.
No.
%
No.
%
No.
%
No.
%
1018 69 41 1128
90 6
78 46 6 100
640 414 74
77
47 46 7
1128
57 37 6 100
533 518
100
881 185 62 1128
1128
100
962 32 0 994
97 3 0 100
848 133 13 994
85 14 1 100
611 331 52 994
62 33 5 100
506 430 58 994
51 43 6 100
848 18 0 866
98 2 0 100
785 74 7 866
91 8 1 100
569 254 43 866
66 29 5 100
471 350 45 866
54 41 5 100
Smoking Unknown Total Clients Attending 2/3 or More Meetings** Not smoking Smoking Unknown Total
4
*No regular tobacco consumption. Isolated smoking instance or episode recorded for month or months in which behavior occurred.
tTobacco regularly smoked, including occasional smoking, smoking at parties only, smoking one cigarette every three months. tClients could not be located. Deceased clients dropped from evaluation. Clients who joined second group in same year were evaluated as part of second group. "These categories correlate attendance with success.
Discussion The relapse curve steeply declines during the first three months, then gradually levels between three months and one year after quitting. Hunt and Matarazzo23 and Hunt with Bespalec24 showed that 20 per cent to 30 per cent of persons abstemious at the completion of treatment were not smoking one year later. Other reviews of smoking cessation programs and evaluations of their effectiveness25-36 have uniformly pointed toward discouragingly low abstinence rates. Hunt, Barnett, and Branch reported a marked similarity in the relapse curves from 84 studies of smoking cessation interventions. Participants in smoking cessation programs relapsed within one year at the same rate (approximately 80 100
l
I
,80 0
60
o 0
$ 40 o
- 200
Men
II 2 days
N = 1128 1
2
4
6
1 8
1 10
12
Time after quitting, months FIGURE 1-Resumption of Smoking Over Time by Sex for AU Registered Stop Smoking Clients 1230
ed.30' 32, 33, 38-42
Because the majority of our clients are members of a prepaid health plan and were willing to pay a fee to join a group support program and attend an initial interview session, these factors may bias the sample of persons who entered group treatment and should be kept in mind in any attempt to generalize from these results. A finding of the clinic was that clients' decisions to give up cigarettes are often motivated by a broader personal commitment to improve the quality of their lives in general rather than a response to fear of adverse health consequences. This description of group treatment is concerned with those persons for whom a knowledge of the issues and problems of addictive behavior and the support of a group program are major factors in their ability to remain abstinent.
REFERENCES
N = 485
----Women N = 643
Total
per cent) as heroin addicts and at a slightly higher rate than alcoholics. In most reported studies, men are cited as significantly more successful than women. In our study, 49 per cent of all registered male clients were abstinent at one year, whereas 46 per cent of their female counterparts were still not smoking. The group leader's concem for the many issues facing women today are thought to contribute to the relatively better response by female clients than is generally report-
1. Jaffe JH: Cigarette smoking as an addiction, In: Steinfeld J, et al, (eds). Proceedings, Third World Conference. Smoking and Health, vol. 2. Health Consequences, Education, Cessation Activities, and Governmental Action. New York City, New York, June 2-5, 1975. 2. Russell MA: The smoking habit and its classification. Practitioner 212:791-800, 1974. 3. Australian Council on Smoking and Health. Special supplement on smoking and health. Med J Aust 2:1-4, 1975. 4. Solomon, RL, Corbit JD: An opponent-process theory of moti-
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5. 6. 7.
8. 9. 10. 11.
12. 13. 14. 15. 16. 17.
18. 19.
20. 21. 22. 23.
vation: II. cigarette addiction. J Abnorm Psychol 81:158-171, 1973. Solomon RL, Corbit JD: An opponent-process theory of motivation: I. temporal dynamics of affect. Psychol Rev 81:119-145, 1974. Hill D: Report on the third world conference on smoking and health. Cancer Forum 6:299-302, 1975. Harrup T: Addictive processes in tobacco use, In: Progress in Smoking Cessation. Proceedings, International Conference on Smoking Cessation, New York City. June 21-23, 1978. New York, American Cancer Society, 1979. Erickson LGW, Cramer JA: Smoking behavior development and modification: an empirical application of three social psychological theories. J Appl Soc Psychol 6:369-386, 1976. Schwartz JL, Dubitzky M: Psycho-social factors in cigarette smoking and cessation. Institute for Health Research, Berkeley, California, 1968. Jenks R, Schwartz JL, Dubitzky M: Effect of the counselor's approach to changing smoking behavior. J Counsel Psychol 16:215-221, 1969. Jacobs MA, Spilken, AZ, Norman MM, et al: Interaction of personality and treatment conditions associated with success in a smoking control program. Psychosom Med 33:545-556, 1971. Schwartz JL, Dubitzky M: Smoking behavior and attempts to discontinue smoking. Bull NY Acad Med 44:1536-1545, 1968. Graham S, Gibson RW: Cessation of patterned behavior: withdrawal from smoking. Soc Sci Med 5:319-337, 1971. Schwartz JL, Dubitzky M: Maximizing success in smoking cessation methods. Am J Public Health 59:1392-1399, 1969. Bozzetti LP: Group psychotherapy with addicted smokers. Psychother Psychosom 20:172-175, 1972. Reinert, RE: General observations on drug habituation. Bull Menninger Clin 34:195-204, 1970. Lindesmith A: Addiction and Opiates. Chicago, Aldine Press, 1968. Tamerin JS: The psychodynamics of quitting smoking in a group. Am J Psychiatry 129:589-595, 1972. Lindesmith A: Cure and relapse, In: Addiction and Opiates. Chicago, Aldine Press, 1968, pp. 129-155. Sarbin TR, Nucci LP: Self-reconstitution processes: a proposal for reorganizing the conduct of confirmed smokers. J Abnorm Psychol 81:182-195, 1973. Christen AG, Cooper KH: Strategic withdrawal from cigarette smoking. CA 29:96-107, 1979. Alberti RE, Emmons ML: Your Perfect Right: A Guide to Assertive Behavior, 3rd ed. San Luis Obispo, California, Impact Publishers, 1978. Hunt W, Matarazzo J: Habit mechanisms in smoking, In: Hunt W: (ed), Learning Mechanism in Smoking. Chicago, Aldine Press, 1970, pp. 65-95.
I
24. Hunt WA, Bespalec, DA: An evaluation of current methods of modifying smoking behavior. J Clin Psychol 30:431-438, 1974. 25. Schwartz JL: A critical review and evaluation of smoking control methods. Public Health Rep 84:483-506, 1969. 26. Bernstein DA: Modification of smoking behavior: an evaluative review. Psychol Bull 71:418-440, 1969. 27. Mausner B: Some comments on the failure of behavior therapy as a technique for modifying cigarette smoking. Consult Clin Psychol 36: 167-170, 1971. 28. Keutzer CS, Lichtenstein F, Mees HL: Modification of smoking behavior: a review. Psychol Bull 70:520-533, 1968. 29. Bradshaw PW: The problem of cigarette smoking and its control. Int J Addict 8:353-371, 1973. 30. West D, Graham S, Swanson M, Wilkinson G: Five-year followup of a smoking withdrawal clinic population. Am J Public Health 67:536-544, 1977. 31. Schewchuk LA: Special report. Smoking cessation program of the American Health Foundation. Prev Med 5:454-474, 1976. 32. Guilford JS: Sex differences between successful and unsuccessful abstainers from smoking, In: Zagona S: (ed), Studies and Issues in Smoking Behavior. National Research Conference on Smoking and Behavior, 2d, University of Arizona, 1966. Tucson, University of Arizona Press, 1967, pp. 95-102. 33. Guilford JS: Group treatment versus individual initiative in the cessation of smoking. J Appl Psychol 56:162-167, 1972. 34. Lawton MP: Group methods in smoking withdrawal. Arch Environ Health 14:258-265, 1967. 35. Thompson EL: Smoking education programs, 1960-1976. Am J Public Health 68:250-257, 1978. 36. Lichtenstein E, Keutzer CS: Experimental investigation of diverse techniques to modify smoking: a follow-up report. Behav Res Ther 7:139-140, 1969. 37. Hunt WA, Barnett LW, Branch LG: Relapse rates in addiction programs. J Clin Psychol 27:455-456, 1971. 38. Bothwell PW: The epidemiology of cigarette smoking in rural school children. Med Officer 102:125-132, 1959. 39. Haenszel W, Shimkin MB, Miller HP: Tobacco Smoking Patterns in the United States. U.S. Public Health Monograph #45, Public Health Service Publication #463, Washington, DC: Gov Printing Office, 1956. 40. Eisinger RA: Psychosocial predictors of smoking recidivism. J Health Soc Behav 12:355-362, 1971. 41. Delarue NC: A study in smoking withdrawal: the Toronto smoking withdrawal centre-description of activities. Can J Public Health 64:S5-19, 1973. 42. Berglund E: A Follow-up Study of 13 Norwegian Tobacco Withdrawal Clinics: The Five-Day Plan, The Final Report. Oslo: Norwegian Cancer Society, 1969.
Post-Doctoral Fellowships in Ethics for 1980-81 Offered
The Hastings Center, Institute of Society, Ethics and the Life Sciences, is offering three one-year resident post-doctoral fellowships for the study of ethics and the life sciences for the academic year 1980-81. The program is interdisciplinary in nature, is open to applicants from all fields, and requires an advanced doctoral or professional degree (or its equivalent). Application deadline is January 1, 1980. Request brochure from B. Baya, Post-Doctoral Fellowship Program, The Hastings Center, 360 Broadway, Hastings-on-Hudson, NY 10706, 914/478-0500.
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