Addletire Behaviors. Vol 4. pp. 331 to 338 © Pergamon Press Ltd 1979. Printed in Great Britain
SMOKING,
0306-4603/79/I 101-0331 $02.00/0
SEAT-BELTS, AND ABOUT HEALTH
BELIEFS
J. RICHARD EISER, STEPHEN R. SUTTON Institute of Psychiatry, University of London
and MALLORY WOBER Independent Broadcasting Authority, London
Abstract--Questionnaires concerned with cigarette smoking and seat-belt use were completed by 378 respondents who were taking part in a survey of audience reactions to 1 week's television programmes. Controlling for sex, age, and social class, self-reported seat-belt use was lower among smokers than non-smokers (P < 0.01). Smokers tended to hold less negative beliefs about the consequences of smoking than did non-smokers. Notably, only 49.5% of smokers (as against 88.7% of never-smokers) believed smoking to be "really as dangerous as people say", and 13.8% of smokers (as against 29.2% of never-smokers) realized that smoking caused more deaths than road accidents. Similarly, non-wearers of seat-belts were more sceptical of the benefits of seat-belt use (51.6% of non-wearers believed "seat-belts really make driving much safer" compared with 92.2% of wearers). Respondents who asserted that people have the right to put their own health at risk, as opposed to a moral responsibility not to risk their health, were more likely to smoke and less likely to wear seat-belts. It is concluded that both smoking and the non-use of seat-belts may partly reflect more general attitudes about safeguarding health, as well as more specific beliefs which may be susceptible to informational influence.
Cigarette smoking and driving without seat-belts involve clear and generally acknowledged risks. Studies of American adults (Helsing & Comstock, 1977; Manheimer et al., 1966) and adolescents (Williams, 1973) show that the two kinds of behaviour have some association with each other, as well as with other behaviours which imply reduced concern for one's health. The reason for such associations, however, remains unclear. A common research strategy has been to attempt to distinguish smokers and nonwearers of seat-belts from the rest of the population in terms of demographic, educational and personality characteristics. Smoking tends to be associated with lower socioeconomic status and educational attainment (Bynner, 1969; Lee, 1976), as is the non-use of seat-belts (Fhfiner & Hane, 1973; Manheimer & Mellinger, 1964). Users of seat-belts (Manheimer et al., 1966) and non-smokers (Jacobs et al., 1966) are also reported to be lower on the personality trait of impulsivity. An alternative strategy, favoured in the present report, places less emphasis on showing that smokers (or non-wearers of seat-belts) are different kinds of people, and assumes instead that they make different decisions concerning their behaviour and its consequences. This may involve a lower estimation of the health risks involved and/or less concern with protecting oneself from illness or injury. For example, Eiser & Sutton (1977) found that smokers who were less interested in attending an anti-smoking clinic were less likely to believe that attendance would improve their chances of giving up smoking. Thus, even when a person chooses to behave "unhealthily", this choice may nonetheless be "rational" from a subjective point of view, granted the beliefs and values on which it is premised. An understanding of such beliefs and values is therefore essential to any psychological explanation of such behaviour. The present study therefore attempts to explore:-(a) whether in terms of self-reports, the association between smoking and the non-use of seat-belts can be confirmed on a British sample of known demographic composition; 331
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J. RICHARD EISER, STEPHEN R. SUTTON and MALLORY WOBER
(b) whether any gross differences are discernible between smokers and non-smokers, and between wearers and non-wearers of seat-belts, in terms of their beliefs concerning the health risks involved; (c) how beliefs and attitudes concerning smoking and seat-belt use relate to each other; (d) whether behavioural and attitudinal differences regarding smoking and seat-belt use relate more generally to whether individuals feel they have a general obligation to protect their health, as opposed to a right to put their own health at risk if they so choose. In addition, the timing of this study provided an opportunity to assess some reactions of smokers and non-smokers to the unsuccessful launch of cigarettes containing tobacco substitutes in the United Kingdom.
METHOD During the week beginning 24th October 1977, 837 programme appreciation diaries were sent by the Independent Broadcasting Authority to a representative sample of the London Area, aged 18 yr and over, all of whom had responded previously to a similar survey in the area. Each respondent was asked to record his or her impressions of television programmes viewed during the week beginning 31st October 1977. Attached to each diary was a separate duplicated questionnaire (one double-sided page), the rationale for which was a programme concerned with stopping smoking, broadcast on Sunday 23rd October on the independent television network. A total of 532 (63.6~o) diaries were returned, of which 378 (45.2~o) were accompanied by usable questionnaires. Of those completing the questionnaire, 46~o were male and 54~o female. Subjects were also classified by age (18-34yr, 32.0~o; 35-54yr, 43.1~o; 55 yr and over, 24.9~o) and by social class (ABC1, i.e. professional, non-manual, 42.9~o; Cz i.e. skilled manual, 36.0~o; DE, i.e. semi-skilled, unskilled manual, 21.2~). After a question asking subjects if they had seen the programme, the questionnaire contained the following questions relevant to our analysis. 1. "Are you a smoker?" (Responses enabled subjects to be classified as smokers, 28.8~o, never-smokers, 44.4~o, and ex-smokers 26.7~--an under-representation of smokers and over-representation of ex-smokers compared with the general population of the United Kingdom; Lee, 1976). Questions 2-5 were for smokers only. 2. "About how many cigarettes do you usually smoke in a day?" 3. "Do you want to stop smoking?" (Yes definitely/Possibly, but not just yet/No definitely not) 4. "At present are you trying to stop or reduce your smoking?" (Yes I'm trying to stop completely/Yes, I'm trying to cut down to ... cigarettes per day/No) 5. "Have you tried the new cigarettes with tobacco substitutes?" (Yes I like them/Yes, but I don't like them/No) The remaining questions were for all subjects. 6. "Do you think that most smokers could stop smoking if they really wanted to?" (Yes/No) 7. "Do you think that most smokers would feel fitter if they stopped smoking?" (Yes/No) 8. "Do you agree with this statement: If you've been smoking for more than about 10 yr, there's no point in stopping, as any damage has probably been done already?" (Yes/No) 9. "Do you believe that smoking is really as dangerous as people say'?" (Yes/No) 10. "Do you think that the government should try to persuade people not to smoke?" (Yes/No) 11. "Do you think that the new cigarettes with tobacco substitutes are likely to prove safer than ordinary cigarettes?" (Yes/No)
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12. "Which do you think kills more people in Britain today; smoking or road accidents?" (Smoking/Road Accidents/Both about equal) 13. "Do you usually wear a seat-belt when you travel by car?" (Yes/No/I never travel by car) 14. " D o you believe that seat-belts really make driving much safer?" (Yes/No) 15. "Do you think the government should make the wearing of seat-belts compulsory?" (Yes/No) Finally, subjects were asked to indicate which of the following two statements came closer to the Way they generally felt: 16. (a) "If people want to do things which can cause sickness or injury to themselves, they have every right to do so". (b) "People have a moral responsibility to avoid doing things which can cause sickness or injury to themselves". The data were analysed by G o o d m a n ' s ECTA program which fits log-linear models to multivariate contingency tables so as to yield values of Z2 (strictly, the log-likelihood X2 statistic) analogous to F-values for main effects and interactions in an analysis of variance (Bishop et al., 1975). RESULTS (a) Association between smoking and demographic factors The sex, age and social class composition of the groups of smokers, never-smokers and ex-smokers was first examined. Smoking was significantly associated with sex (Z2 = 36.7, d.f. = 2, P < 0.001) controlling for age and social class, with 40.5~o of men being smokers and 28.3~o of men having never smoked, compared with 19.0~o and 68.0~o respectively among women. Smoking was also significantly associated with age (X2 = 10.6, d.f. = 4, P < 0.05) controlling for sex and social class. Fewer of the oldest subjects smoked, and more had given up (from young to old, percentages of smokers were 29.8, 31.9 and 22.3, and ex-smokers, 18.2, 27.0, 37.2). There was no simple association between smoking and social class, but the interactive effect on smoking of sex and social class was significant (Z2 = 10.1, d.f. = 4, P < 0.05). Among men, the largest proportion of smokers and the smallest proportion of ex-smokers were in classes DE, whereas the reverse was true among women. (b) Associations with demographic factors on questions for smokers only A total of 98 smokers completed questions 2-5 (a further 11 smoked only pipes and cigars and were excluded from analyses of these questions). The mean daily cigarette consumption was 19.0 overall, 20.6 for men and 16.6 for women (F = 4.1, d.f. = 1, 67, P < 0.05 by analysis of variance). The age and social class effects were non-significant. On question 3, 42.9~o said they definitely wanted to stop smoking, 39.8~o said they possibly did, and 17.3~o said they definitely did not. Age had a significant effect (Z2 = 12.3, d.f. = 4, P < 0.02) controlling for sex and social class, with the percentages of those saying they possibly wanted to stop decreasing with age (50.0, 41.7, 12.5). The oldest group tended either definitely to want to stop (56.3~o) or definitely to not want to (31.3~o). Question 4 showed no effects due to demographic factors. Responses to question 5 are discussed in section "h" below. (c) Associations with demographic factors on other questions Next we inspected subjects' responses to other questions for associations with sex, age or social class. In view of difficulties of interpretation, and the possibility that more complex effects might merely reflect peculiarities of our sample, we did not look for higher-order associations (i.e., interactions) between two or more of the demographic factors and the questionnaire responses. Sex had a significant effect, controlling for
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J. RICHARD EISER, STEPHEN R. SUTTON and MALLORY WOBER
age and social class, on items 7 and 9. More women than men thought smokers would feel fitter if they stopped smoking (95.6~ vs 90.2~o, Z: = 4.4, d.f. = 1, P < 0.05), and believed smoking to be really dangerous (81.5~o vs 68.8~o, Z2 = 8.0, d.f. = 1, P < 0.01). Both these associations, however, are nonsignificant when controlling for smoking status. There were no significant associations with age, controlling for sex and social class. Social class had an effect on items 7, 8 and 12 controlling for sex and age, with the percentage thinking smokers would be fitter if they stopped being 93.2, 97.1 and 86.2 in classes ABC1, C2, and DE respectively (Z2 = 7.6, d.f. = 2, P < 0.05); the percentages accepting the "damage done already" argument were 6.2, 14.7 and 25.0 respectively (X2 = 17.4, d.f. = 2, P < 0.001). On question 12, the percentages identifying smoking as the greater cause of death decreased with lower social class (32.1, 22.1, 11.2), whilst the percentages saying "both about equal" increased (29.6, 30.9, 48.7; Z2 = 16.9, d.f. = 4, P < 0.01). On all these three items, the effect of controlling also for smoking status is to raise the values of Z2 (to 8.9, 17.6 and 18.0 respectively). There was also a significant class effect on item 13 (see section "f" below). (d) Associations with smoking status, controlling for demographic factors Smokers, never-smokers and ex-smokers were then compared in terms of their responses on items from 6 onwards (see Table 1). Controlling for sex, age and social class, smokers were significantly less likely to think that most smokers could stop smoking, more likely to question the benefits of stopping and the dangers of continuing, less supportive of anti-smoking campaigns, more sceptical of cigarettes with tobacco substitutes, more likely to say they drove without seat-belts, and more assertive of their right to put their health at risk. However, they did not differ significantly from non-smokers on the two attitudinal items relating to seat-belt use (14 and 15).
(e) Associations with believing smoking dangerous Subjects were then divided on the basis of their responses to question 9 ("Do you believe that smoking is really as dangerous as people say?") and compared in terms of their responses on other items, controlling for sex, age, social class and smoking status. Those who said "Yes" to this question were more likely than those who said " N o " to believe that smokers would feel fitter if they stopped (97.6~ vs 79.3~, Z2 = 22.0, d.f. = 1, P < 0.001), to support government anti-smoking campaigns (71.7~o vs 20.7~o, Z2 = 59.5, d.f. = 1, P < 0.001) to claim they wore seat-belts (51.1~o vs 33.3~o, excluding those who never travelled by car, Z2 = 7.2, d.f. = 1, P < 0.01), to believe that seat-belts
Table 1. Percentage agreement with questionnaire items overall, and by s m o k i n g status. Effects of s m o k i n g status assessed by log-likelihood X2, controlling for sex, age and social class
Question 6. Smokers could stop. 7. Smokers would be fitter. 8. D a m a g e done already. 9. Smoking really dangerous. 10. G o v ' t should persuade not to smoke. 11. Tobacco substitutes safer. 12. More deaths from smoking. F r o m road accidents. Both about equal. 13. Wear seat-belt. N o t wear. Never travel by car. 14. Seat-belts make driving safer. 15. Seat-belts should be compulsory. 16. (a) Right to risk health. (b) Responsibility to avoid risk. *P < 0.05, **P < 0.01, ***P < 0.001.
Overall
Smokers
Never smokers
Ex-smokers
)f2
d.f.
85.7 93.1 13.2 75.7 59.3 33.9 24.1 41.8 34.1 44.2 50.3 5.6 72.2 43.1 42.6 57.4
74.3 87.2 18.3 49.5 44.0 23.9 13.8 49.5 36.7 29.4 67.0 3.7 65.1 40.4 58.7 41.3
89.9 97.0 13.7 88.7 64.3 41.1 29.2 36.9 33.9 52.4 39.9 7.7 75.0 44.0 33.3 66.7
91.1 93.1 6.9 82.2 67.3 32.7 26.7 41.6 31.7 46.5 49.5 4.0 75.2 44.6 40.6 59.4
14.4"** 8.3* 7.3* 51.8"** 11.6"* 9.9** 12.8"
2 2 2 2 2 2 4
17.2"*
4
4.1 2.0 18.0"**
2 2 2
Smoking and seat-belts beliefs
335
made driving safer (79.0~ vs 51.1~o, X2 = 18.1, d.f. = 1, P < 0.01), and to believe seatbelts should be compulsory (49.3~o vs 23.9~, X2 = 18.7, d.f. = 1, P < 0.001). They were less likely to accept the "damage done already" argument (9.8~ vs 23.9~, X 2 = "7.8, d.f. = 1, P < 0.01). They were more likely to believe that smoking caused more deaths than road accidents (31.1~o vs 2.2~) and less likely to say that road accidents caused more deaths (31.8~ vs 72.8~o, Z2 = 47.4, d.f. = 2, P < 0.001). If smokers, they were more likely to say they definitely wanted to stop (60.0~o vs 25.0~o) and less likely to say they definitely did not (4.0~o vs 31.3~o, ;(2 = 17.2, d.f. = 2, P < 0.001). There was also a significant association with question 16 (see section "g" below). (f) Seat-belt use The claimed use of seat belts was significantly associated with social class, controlling for sex and age (;(2 = 19.9, d.f. = 4, P < 0.001) with higher classes claiming to use them more (ABCI, 53.7~o; C2, 39.0~o; DE, 33.7~o). However, with those who said they never travelled by car excluded, this effect is non-significant (ABCt, 55.4~o; C2 40.5~; DE, 39.1~o; X2 = 9.1, d.f. = 4, P < 0.1). Excluding these same subjects, and controlling for sex, age and social class, wearers of seat-belts were significantly more likely to believe that seat-belts made driving safer than were non-wearers (92.2~o vs 51.6~/~ ;(2 = 73.2, d.f. = 1, P < 0.001), and that seat-belt use should be made compulsory (53.9~o vs 30.0~, ;(2 = 21.0, d.f. = 1, P < 0.001). There was also a significant association with question 16 (see below). Controlling for demographic factors and smoking status there was no significant association between seat-belt use and estimates of the relative dangers of smoking and road accidents. (g) Associations with perceived right to put own health at risk The final question (16) asked subjects to choose between a statement (a) asserting people's right to put their own health at risk, and another (b) asserting their moral responsibility to protect their own health. As already mentioned, more smokers than non-smokers chose the first statement. Controlling for sex, age, social class and smoking status, those choosing the first statement were less likely to think that smokers would be fitter if they stopped than those choosing the second statement (88.2~ vs 96.8~, ;(2 = 10.9, d.f. = 1, P < 0.001) that smoking was really dangerous (66.5~ vs 82.5~, ;(2 = 5.0, d.f. = 1, P < 0.05), and that the government should try to persuade people not to smoke (46.0~o vs 69.1~o, Z2 = 20.6, d.f. = 1, P < 0.001). They were less likely to think smoking caused more deaths than road accidents (19.9~ vs 27.2~) and more likely to think road accidents caused more deaths (50.3~ vs 35.5~o, ;(2 = 6.4, d.f. = 2, P < 0.05). They were less likely to wear seat-belts (35.4~ vs 50.7~/~ excluding those who said they never travelled by car, ;(2 = 9.5, d.f. = 2, P < 0.01), and less likely to say seat-belt use should be made compulsory (29.8~o vs 53.0~/~ ;(2 = 26.9, d.f. = 1, P < 0.001). (h) Tobacco substitutes Of the 98 cigarette smokers, 51.0~ had tried cigarettes containing tobacco substitutes, but disliked them, 9.2~o had tried and liked them, and 39.8~o had not tried them. These percentages were not significantly affected by age or social class. For women, the percentages were 59.0, 12.8 and 28.2 respectively and for men, 45.8, 6.8 and 47.5. In other words, controlling for age and social class, women were more likely than men to have tried tobacco substitute cigarettes (71.8~ vs 52.6~o, ;(2 = 4.4, d.f. = 1, P < 0.05). Considering only those who had tried them, however, women were not significantly more likely than men to have found them acceptable (17.9~ vs 12.9~o, Z 2 = 1.4, d.f. = 1, NS). Controlling for sex, age and social class, those who said they liked them tended to be lighter smokers (average consumption 14.3) than those who had tried but disliked them (19.3) or not tried them (19.8), but this difference was non-significant. As already reported (Table 1, question 11), smokers were more doubtful of the extra safety of tobacco substitutes than non-smokers. Responses to this question were not significantly
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J. RICHARD EISER, STEPHEN R. SUTTON and MALLORY WOBER
associated with age, sex, or social class, either among smokers only, or for the total sample. There was a nonsignificant association between trying or liking the substitute cigarettes and believing them to be safer. Of those who had tried but disliked them, 18.0% thought they were safer, compared with 44.4% of those who liked them, and 20.5% of those who had not tried them (;(2 = 2.6, d.f. = 2, NS, controlling for sex, age and social class). DISCUSSION These data testify both to the generality and specificity of health attitudes and behaviour. Consistent with previous American research, we found an association between smoking and the non-use of seat-belts, with less than a third of the smokers claiming that they wore seat-belts, as compared with about half the non-smokers. This association does not appear to be a spurious one attributable to social class (even though both behaviours were somewhat class-related) since it remains highly significant after controlling for the effects of demographic factors. In addition, both behaviours were associated with the beliefs that individuals have a right to put their own health at risk, as opposed to having an obligation to avoid risks to health. Such a general attitude is interesting, in that it may allow the individual to admit that a given behaviour, such as smoking, is dangerous, but still resist the suggestion that he should therefore give it up. It also reflects a radically different outlook from the values implicit in many attempts at health education. Nonetheless, those who assert their right to risk their health tend also to view the behaviours in which they indulge (either smoking or driving without seat-belts) as involving less serious risks. We observed a consistency between individuals' specific behaviours and their relative estimates of the dangers involved. Those who drove without seat-belts were less inclined to accept that seat-belts made driving safer, and smokers were more inclined to underestimate the danger of smoking. Also smokers held significantly more negative views about government anti-smoking campaigns (though not about seat-belt legislation) whilst non-wearers of seat-belts were significantly more opposed to seat-belt legislation (though not to anti-smoking campaigns). Smokers and non-smokers did not differ significantly in their beliefs about the safety benefits of seat-belts. The belief that smoking was "really dangerous" significantly predicted seat-belt use although less strongly than it predicted not smoking. Among smokers, this same belief was associated with a more definite wish to stop. These results are broadly consistent with a "rational" decision-making model of health behaviour. Simply stated, people are less likely to do things which they believe are dangerous to their health, especially when they attach importance to protecting their health; similarly, when people engage in "unhealthy" behaviour, it is likely that they will have a lower estimate of the risks involved, and/or will attach less importance to such risks. The design of this study does not permit us to distinguish people's reasons from their rationalizations (though, in time, what starts as a rationalization for past behaviour may become a reason for present and future behaviour). With smoking (though not the seat-belt issue) an important aspect is the person's perception of his ability to abstain from the admittedly dangerous behaviour, and, as in previous research (Eiser et al., 1977), we found differences between smokers and non-smokers in their perceptions of the difficulty of giving up smoking. We have argued elsewhere (Eiser, 1978; Eiser et al., 1978) that smokers who see themselves as "addicted" may be both making a subjectively valid inference from earlier failed attempts at giving up, and also providing themselves with a rationalization for not attempting seriously to stop again. Either way, smokers who feel thay cannot easily stop may be prepared to accept that smoking is dangerous, and, it could be argued, put their health at risk not unwittingly but unwillingly (e.g. McKennell & Thomas, 1967). If this is so, simply telling such smokers the "facts" is unlikely to change their behaviour. Our data suggest a slightly different picture. Over 80% of the smokers in our sample said they definitely or possibly wished to stop. Yet even within such a sample, half
Smoking and seat-belts beliefs
337
the smokers did not believe smoking to be "really as dangerous as people say". Also, three smokers out of four said they thought that most smokers could stop smoking if they really wanted to. A striking instance where subjects' beliefs were incorrect in fact is the comparison between the number of deaths from smoking and road accidents. Under 14~o of smokers realized that smoking caused more deaths, and the corresponding percentage of non-smokers, though double that for smokers, is still low enough to suggest that this might be a theme worth reviving in health education campaigns. Less dramatic, but possibly more directly relevant to their decision to stop or continue smoking, is the preparedness of a minority of smokers to accept the "damage done already" argument. It is especially noteworthy that subjects of lower social class tended to believe smoking was less dangerous, even after controlling for whether or not they were smokers. At the same time, there was no significant association between social class and our "health rights" question (16). It is a common experience that groups of higher social status tend to be more likely to change their behaviour in response to health campaigns. Our findings suggest that such differences may be partly attributable to the fact that lower social class groups remain comparatively poorly informed of the health consequences of their behaviour, rather than necessarily "poorly motivated". The data regarding tobacco substitute cigarettes are consistent with the evidence that a large number of smokers did in fact try the new cigarettes after they were first launched in Britain on July 1st, 1978. It has been estimated that about 33% of smokers bought a pack of substitute cigarettes in the following 5 weeks (Van Rossum, 1978), and many more may have tried one from someone else's pack. In our sample, 59 out of 98 cigarette smokers had tried the new cigarettes but only 9 said they liked them. It cannot of course be assumed that the 50 who disliked them were all objecting to the substitute material per se, rather than to the reduction in nicotine and/or tar. However, if what was responsible for the products's failure was indeed the "campaign of vilification" (Van Rossum, 1978) by governmental agencies such as the Health Education Council (whose own campaign did not start till August 18th, by which time sales were already falling), one might have expected a lower rate of trying but a higher rate of liking. There are suggestions in our data that the substitute cigarettes were tried more by women, and liked somewhat more by lighter smokers. The tendency for those who liked them to believe them to be safer raises the question of what might have happened if the manufacturers had been allowed to claim that they had produced a "safer cigarette". It is almost a truism that the problem with health education is not that of convincing people that certain behaviours are dangerous to health, but persuading them to act upon their beliefs. Without minimizing the latter problem, our data suggest that there may be a number of important areas where many people underestimate the relevant dangers. This implies that there may still be room for improvement as a result of better directed and designed informational campaigns. However, the finding that smokers and non-wearers of seat-belts not only underestimate the risks of their behaviour, but also assert their right to put their own health at risk, implies a more fundamental divergence of values between health educators and their primary targets, which may be less easy to overcome. REFERENCES Bishop, Y. M. M., Fienberg S. E., & Holland P. W. Discrete Multivariate Analysis: Theory and Practice. Cambridge, MA: M.I.T. Press, 1975. Bynner, J. M. The Young Smoker. Government Social Survey SS383. London: HMSO, 1969. Eiser, J. R. Discrepancy, dissonance and the 'dissonant' smoker. International Journal of the Addictions, 1978, 13, 1295-1305. Eiser, J. R., & Sutton, S. R. Smoking as a subjectively rational choice. Addictive Behaviors, 1977, 2, 129-134. Eiser, J. R., Sutton, S. R., & Wober, M. Smokers, non-smokers and the attribution of addiction. British Journal of Social and Clinical Psychology, 1977, 16, 329-336. Fh~iner, G., & Hane, M. Seat-belts: Factors influencing their use. A Literature Survey. Accident Analysis and Prevention, 1973, 5, 27-43. Helsing, K. S., & Comstock, G. W. What kinds of people do not use seat-belts? American Journal of Public Health, 1977, 67, 1043-1050.
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Jacobs, M. A., Anderson, L. S., Champagne, E., Karush, N., Richman, S. J., & Knapp, P. H. Orality, impulsivity and cigarette smoking in men: Further findings in support of a theory. Journal of Nervous and Mental Disease, 1966, 143, 207 219. Lee, P. N. (Ed.) Statistics of Smoking in the United Kingdom. London: Tobacco Research Council, 1976. Manheimer, D. I., & Mellinger, G. D. A survey of seat belt ownership in six California communities. Traffic Safety Research Review, 1964, 8, 3 9. Manheimer, D. I., Mellinger, G. D., & Crossley, H. M. A follow-up study of seat-belt usage. Traffic Safety Research Review, 1966, 10, 2-13. McKennell, A. C., & Thomas, R. K. Adults" and Adolescents" Smoking Habits and Attitudes. Government Social Survey, SS353/B. London: HMSO, 1967. Van Rossum, R. The great substitute disaster. The Grocer, September 16, 1978, 1~,. Williams, A. F. Personality and other characteristics associated with cigarette smoking among young teenagers. Journal of Health and Social Behaviour, 1973, 14, 374-380.
SMOKING,
0306-4603/79/I 101-0331 $02.00/0
SEAT-BELTS, AND ABOUT HEALTH
BELIEFS
J. RICHARD EISER, STEPHEN R. SUTTON Institute of Psychiatry, University of London
and MALLORY WOBER Independent Broadcasting Authority, London
Abstract--Questionnaires concerned with cigarette smoking and seat-belt use were completed by 378 respondents who were taking part in a survey of audience reactions to 1 week's television programmes. Controlling for sex, age, and social class, self-reported seat-belt use was lower among smokers than non-smokers (P < 0.01). Smokers tended to hold less negative beliefs about the consequences of smoking than did non-smokers. Notably, only 49.5% of smokers (as against 88.7% of never-smokers) believed smoking to be "really as dangerous as people say", and 13.8% of smokers (as against 29.2% of never-smokers) realized that smoking caused more deaths than road accidents. Similarly, non-wearers of seat-belts were more sceptical of the benefits of seat-belt use (51.6% of non-wearers believed "seat-belts really make driving much safer" compared with 92.2% of wearers). Respondents who asserted that people have the right to put their own health at risk, as opposed to a moral responsibility not to risk their health, were more likely to smoke and less likely to wear seat-belts. It is concluded that both smoking and the non-use of seat-belts may partly reflect more general attitudes about safeguarding health, as well as more specific beliefs which may be susceptible to informational influence.
Cigarette smoking and driving without seat-belts involve clear and generally acknowledged risks. Studies of American adults (Helsing & Comstock, 1977; Manheimer et al., 1966) and adolescents (Williams, 1973) show that the two kinds of behaviour have some association with each other, as well as with other behaviours which imply reduced concern for one's health. The reason for such associations, however, remains unclear. A common research strategy has been to attempt to distinguish smokers and nonwearers of seat-belts from the rest of the population in terms of demographic, educational and personality characteristics. Smoking tends to be associated with lower socioeconomic status and educational attainment (Bynner, 1969; Lee, 1976), as is the non-use of seat-belts (Fhfiner & Hane, 1973; Manheimer & Mellinger, 1964). Users of seat-belts (Manheimer et al., 1966) and non-smokers (Jacobs et al., 1966) are also reported to be lower on the personality trait of impulsivity. An alternative strategy, favoured in the present report, places less emphasis on showing that smokers (or non-wearers of seat-belts) are different kinds of people, and assumes instead that they make different decisions concerning their behaviour and its consequences. This may involve a lower estimation of the health risks involved and/or less concern with protecting oneself from illness or injury. For example, Eiser & Sutton (1977) found that smokers who were less interested in attending an anti-smoking clinic were less likely to believe that attendance would improve their chances of giving up smoking. Thus, even when a person chooses to behave "unhealthily", this choice may nonetheless be "rational" from a subjective point of view, granted the beliefs and values on which it is premised. An understanding of such beliefs and values is therefore essential to any psychological explanation of such behaviour. The present study therefore attempts to explore:-(a) whether in terms of self-reports, the association between smoking and the non-use of seat-belts can be confirmed on a British sample of known demographic composition; 331
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J. RICHARD EISER, STEPHEN R. SUTTON and MALLORY WOBER
(b) whether any gross differences are discernible between smokers and non-smokers, and between wearers and non-wearers of seat-belts, in terms of their beliefs concerning the health risks involved; (c) how beliefs and attitudes concerning smoking and seat-belt use relate to each other; (d) whether behavioural and attitudinal differences regarding smoking and seat-belt use relate more generally to whether individuals feel they have a general obligation to protect their health, as opposed to a right to put their own health at risk if they so choose. In addition, the timing of this study provided an opportunity to assess some reactions of smokers and non-smokers to the unsuccessful launch of cigarettes containing tobacco substitutes in the United Kingdom.
METHOD During the week beginning 24th October 1977, 837 programme appreciation diaries were sent by the Independent Broadcasting Authority to a representative sample of the London Area, aged 18 yr and over, all of whom had responded previously to a similar survey in the area. Each respondent was asked to record his or her impressions of television programmes viewed during the week beginning 31st October 1977. Attached to each diary was a separate duplicated questionnaire (one double-sided page), the rationale for which was a programme concerned with stopping smoking, broadcast on Sunday 23rd October on the independent television network. A total of 532 (63.6~o) diaries were returned, of which 378 (45.2~o) were accompanied by usable questionnaires. Of those completing the questionnaire, 46~o were male and 54~o female. Subjects were also classified by age (18-34yr, 32.0~o; 35-54yr, 43.1~o; 55 yr and over, 24.9~o) and by social class (ABC1, i.e. professional, non-manual, 42.9~o; Cz i.e. skilled manual, 36.0~o; DE, i.e. semi-skilled, unskilled manual, 21.2~). After a question asking subjects if they had seen the programme, the questionnaire contained the following questions relevant to our analysis. 1. "Are you a smoker?" (Responses enabled subjects to be classified as smokers, 28.8~o, never-smokers, 44.4~o, and ex-smokers 26.7~--an under-representation of smokers and over-representation of ex-smokers compared with the general population of the United Kingdom; Lee, 1976). Questions 2-5 were for smokers only. 2. "About how many cigarettes do you usually smoke in a day?" 3. "Do you want to stop smoking?" (Yes definitely/Possibly, but not just yet/No definitely not) 4. "At present are you trying to stop or reduce your smoking?" (Yes I'm trying to stop completely/Yes, I'm trying to cut down to ... cigarettes per day/No) 5. "Have you tried the new cigarettes with tobacco substitutes?" (Yes I like them/Yes, but I don't like them/No) The remaining questions were for all subjects. 6. "Do you think that most smokers could stop smoking if they really wanted to?" (Yes/No) 7. "Do you think that most smokers would feel fitter if they stopped smoking?" (Yes/No) 8. "Do you agree with this statement: If you've been smoking for more than about 10 yr, there's no point in stopping, as any damage has probably been done already?" (Yes/No) 9. "Do you believe that smoking is really as dangerous as people say'?" (Yes/No) 10. "Do you think that the government should try to persuade people not to smoke?" (Yes/No) 11. "Do you think that the new cigarettes with tobacco substitutes are likely to prove safer than ordinary cigarettes?" (Yes/No)
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12. "Which do you think kills more people in Britain today; smoking or road accidents?" (Smoking/Road Accidents/Both about equal) 13. "Do you usually wear a seat-belt when you travel by car?" (Yes/No/I never travel by car) 14. " D o you believe that seat-belts really make driving much safer?" (Yes/No) 15. "Do you think the government should make the wearing of seat-belts compulsory?" (Yes/No) Finally, subjects were asked to indicate which of the following two statements came closer to the Way they generally felt: 16. (a) "If people want to do things which can cause sickness or injury to themselves, they have every right to do so". (b) "People have a moral responsibility to avoid doing things which can cause sickness or injury to themselves". The data were analysed by G o o d m a n ' s ECTA program which fits log-linear models to multivariate contingency tables so as to yield values of Z2 (strictly, the log-likelihood X2 statistic) analogous to F-values for main effects and interactions in an analysis of variance (Bishop et al., 1975). RESULTS (a) Association between smoking and demographic factors The sex, age and social class composition of the groups of smokers, never-smokers and ex-smokers was first examined. Smoking was significantly associated with sex (Z2 = 36.7, d.f. = 2, P < 0.001) controlling for age and social class, with 40.5~o of men being smokers and 28.3~o of men having never smoked, compared with 19.0~o and 68.0~o respectively among women. Smoking was also significantly associated with age (X2 = 10.6, d.f. = 4, P < 0.05) controlling for sex and social class. Fewer of the oldest subjects smoked, and more had given up (from young to old, percentages of smokers were 29.8, 31.9 and 22.3, and ex-smokers, 18.2, 27.0, 37.2). There was no simple association between smoking and social class, but the interactive effect on smoking of sex and social class was significant (Z2 = 10.1, d.f. = 4, P < 0.05). Among men, the largest proportion of smokers and the smallest proportion of ex-smokers were in classes DE, whereas the reverse was true among women. (b) Associations with demographic factors on questions for smokers only A total of 98 smokers completed questions 2-5 (a further 11 smoked only pipes and cigars and were excluded from analyses of these questions). The mean daily cigarette consumption was 19.0 overall, 20.6 for men and 16.6 for women (F = 4.1, d.f. = 1, 67, P < 0.05 by analysis of variance). The age and social class effects were non-significant. On question 3, 42.9~o said they definitely wanted to stop smoking, 39.8~o said they possibly did, and 17.3~o said they definitely did not. Age had a significant effect (Z2 = 12.3, d.f. = 4, P < 0.02) controlling for sex and social class, with the percentages of those saying they possibly wanted to stop decreasing with age (50.0, 41.7, 12.5). The oldest group tended either definitely to want to stop (56.3~o) or definitely to not want to (31.3~o). Question 4 showed no effects due to demographic factors. Responses to question 5 are discussed in section "h" below. (c) Associations with demographic factors on other questions Next we inspected subjects' responses to other questions for associations with sex, age or social class. In view of difficulties of interpretation, and the possibility that more complex effects might merely reflect peculiarities of our sample, we did not look for higher-order associations (i.e., interactions) between two or more of the demographic factors and the questionnaire responses. Sex had a significant effect, controlling for
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J. RICHARD EISER, STEPHEN R. SUTTON and MALLORY WOBER
age and social class, on items 7 and 9. More women than men thought smokers would feel fitter if they stopped smoking (95.6~ vs 90.2~o, Z: = 4.4, d.f. = 1, P < 0.05), and believed smoking to be really dangerous (81.5~o vs 68.8~o, Z2 = 8.0, d.f. = 1, P < 0.01). Both these associations, however, are nonsignificant when controlling for smoking status. There were no significant associations with age, controlling for sex and social class. Social class had an effect on items 7, 8 and 12 controlling for sex and age, with the percentage thinking smokers would be fitter if they stopped being 93.2, 97.1 and 86.2 in classes ABC1, C2, and DE respectively (Z2 = 7.6, d.f. = 2, P < 0.05); the percentages accepting the "damage done already" argument were 6.2, 14.7 and 25.0 respectively (X2 = 17.4, d.f. = 2, P < 0.001). On question 12, the percentages identifying smoking as the greater cause of death decreased with lower social class (32.1, 22.1, 11.2), whilst the percentages saying "both about equal" increased (29.6, 30.9, 48.7; Z2 = 16.9, d.f. = 4, P < 0.01). On all these three items, the effect of controlling also for smoking status is to raise the values of Z2 (to 8.9, 17.6 and 18.0 respectively). There was also a significant class effect on item 13 (see section "f" below). (d) Associations with smoking status, controlling for demographic factors Smokers, never-smokers and ex-smokers were then compared in terms of their responses on items from 6 onwards (see Table 1). Controlling for sex, age and social class, smokers were significantly less likely to think that most smokers could stop smoking, more likely to question the benefits of stopping and the dangers of continuing, less supportive of anti-smoking campaigns, more sceptical of cigarettes with tobacco substitutes, more likely to say they drove without seat-belts, and more assertive of their right to put their health at risk. However, they did not differ significantly from non-smokers on the two attitudinal items relating to seat-belt use (14 and 15).
(e) Associations with believing smoking dangerous Subjects were then divided on the basis of their responses to question 9 ("Do you believe that smoking is really as dangerous as people say?") and compared in terms of their responses on other items, controlling for sex, age, social class and smoking status. Those who said "Yes" to this question were more likely than those who said " N o " to believe that smokers would feel fitter if they stopped (97.6~ vs 79.3~, Z2 = 22.0, d.f. = 1, P < 0.001), to support government anti-smoking campaigns (71.7~o vs 20.7~o, Z2 = 59.5, d.f. = 1, P < 0.001) to claim they wore seat-belts (51.1~o vs 33.3~o, excluding those who never travelled by car, Z2 = 7.2, d.f. = 1, P < 0.01), to believe that seat-belts
Table 1. Percentage agreement with questionnaire items overall, and by s m o k i n g status. Effects of s m o k i n g status assessed by log-likelihood X2, controlling for sex, age and social class
Question 6. Smokers could stop. 7. Smokers would be fitter. 8. D a m a g e done already. 9. Smoking really dangerous. 10. G o v ' t should persuade not to smoke. 11. Tobacco substitutes safer. 12. More deaths from smoking. F r o m road accidents. Both about equal. 13. Wear seat-belt. N o t wear. Never travel by car. 14. Seat-belts make driving safer. 15. Seat-belts should be compulsory. 16. (a) Right to risk health. (b) Responsibility to avoid risk. *P < 0.05, **P < 0.01, ***P < 0.001.
Overall
Smokers
Never smokers
Ex-smokers
)f2
d.f.
85.7 93.1 13.2 75.7 59.3 33.9 24.1 41.8 34.1 44.2 50.3 5.6 72.2 43.1 42.6 57.4
74.3 87.2 18.3 49.5 44.0 23.9 13.8 49.5 36.7 29.4 67.0 3.7 65.1 40.4 58.7 41.3
89.9 97.0 13.7 88.7 64.3 41.1 29.2 36.9 33.9 52.4 39.9 7.7 75.0 44.0 33.3 66.7
91.1 93.1 6.9 82.2 67.3 32.7 26.7 41.6 31.7 46.5 49.5 4.0 75.2 44.6 40.6 59.4
14.4"** 8.3* 7.3* 51.8"** 11.6"* 9.9** 12.8"
2 2 2 2 2 2 4
17.2"*
4
4.1 2.0 18.0"**
2 2 2
Smoking and seat-belts beliefs
335
made driving safer (79.0~ vs 51.1~o, X2 = 18.1, d.f. = 1, P < 0.01), and to believe seatbelts should be compulsory (49.3~o vs 23.9~, X2 = 18.7, d.f. = 1, P < 0.001). They were less likely to accept the "damage done already" argument (9.8~ vs 23.9~, X 2 = "7.8, d.f. = 1, P < 0.01). They were more likely to believe that smoking caused more deaths than road accidents (31.1~o vs 2.2~) and less likely to say that road accidents caused more deaths (31.8~ vs 72.8~o, Z2 = 47.4, d.f. = 2, P < 0.001). If smokers, they were more likely to say they definitely wanted to stop (60.0~o vs 25.0~o) and less likely to say they definitely did not (4.0~o vs 31.3~o, ;(2 = 17.2, d.f. = 2, P < 0.001). There was also a significant association with question 16 (see section "g" below). (f) Seat-belt use The claimed use of seat belts was significantly associated with social class, controlling for sex and age (;(2 = 19.9, d.f. = 4, P < 0.001) with higher classes claiming to use them more (ABCI, 53.7~o; C2, 39.0~o; DE, 33.7~o). However, with those who said they never travelled by car excluded, this effect is non-significant (ABCt, 55.4~o; C2 40.5~; DE, 39.1~o; X2 = 9.1, d.f. = 4, P < 0.1). Excluding these same subjects, and controlling for sex, age and social class, wearers of seat-belts were significantly more likely to believe that seat-belts made driving safer than were non-wearers (92.2~o vs 51.6~/~ ;(2 = 73.2, d.f. = 1, P < 0.001), and that seat-belt use should be made compulsory (53.9~o vs 30.0~, ;(2 = 21.0, d.f. = 1, P < 0.001). There was also a significant association with question 16 (see below). Controlling for demographic factors and smoking status there was no significant association between seat-belt use and estimates of the relative dangers of smoking and road accidents. (g) Associations with perceived right to put own health at risk The final question (16) asked subjects to choose between a statement (a) asserting people's right to put their own health at risk, and another (b) asserting their moral responsibility to protect their own health. As already mentioned, more smokers than non-smokers chose the first statement. Controlling for sex, age, social class and smoking status, those choosing the first statement were less likely to think that smokers would be fitter if they stopped than those choosing the second statement (88.2~ vs 96.8~, ;(2 = 10.9, d.f. = 1, P < 0.001) that smoking was really dangerous (66.5~ vs 82.5~, ;(2 = 5.0, d.f. = 1, P < 0.05), and that the government should try to persuade people not to smoke (46.0~o vs 69.1~o, Z2 = 20.6, d.f. = 1, P < 0.001). They were less likely to think smoking caused more deaths than road accidents (19.9~ vs 27.2~) and more likely to think road accidents caused more deaths (50.3~ vs 35.5~o, ;(2 = 6.4, d.f. = 2, P < 0.05). They were less likely to wear seat-belts (35.4~ vs 50.7~/~ excluding those who said they never travelled by car, ;(2 = 9.5, d.f. = 2, P < 0.01), and less likely to say seat-belt use should be made compulsory (29.8~o vs 53.0~/~ ;(2 = 26.9, d.f. = 1, P < 0.001). (h) Tobacco substitutes Of the 98 cigarette smokers, 51.0~ had tried cigarettes containing tobacco substitutes, but disliked them, 9.2~o had tried and liked them, and 39.8~o had not tried them. These percentages were not significantly affected by age or social class. For women, the percentages were 59.0, 12.8 and 28.2 respectively and for men, 45.8, 6.8 and 47.5. In other words, controlling for age and social class, women were more likely than men to have tried tobacco substitute cigarettes (71.8~ vs 52.6~o, ;(2 = 4.4, d.f. = 1, P < 0.05). Considering only those who had tried them, however, women were not significantly more likely than men to have found them acceptable (17.9~ vs 12.9~o, Z 2 = 1.4, d.f. = 1, NS). Controlling for sex, age and social class, those who said they liked them tended to be lighter smokers (average consumption 14.3) than those who had tried but disliked them (19.3) or not tried them (19.8), but this difference was non-significant. As already reported (Table 1, question 11), smokers were more doubtful of the extra safety of tobacco substitutes than non-smokers. Responses to this question were not significantly
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J. RICHARD EISER, STEPHEN R. SUTTON and MALLORY WOBER
associated with age, sex, or social class, either among smokers only, or for the total sample. There was a nonsignificant association between trying or liking the substitute cigarettes and believing them to be safer. Of those who had tried but disliked them, 18.0% thought they were safer, compared with 44.4% of those who liked them, and 20.5% of those who had not tried them (;(2 = 2.6, d.f. = 2, NS, controlling for sex, age and social class). DISCUSSION These data testify both to the generality and specificity of health attitudes and behaviour. Consistent with previous American research, we found an association between smoking and the non-use of seat-belts, with less than a third of the smokers claiming that they wore seat-belts, as compared with about half the non-smokers. This association does not appear to be a spurious one attributable to social class (even though both behaviours were somewhat class-related) since it remains highly significant after controlling for the effects of demographic factors. In addition, both behaviours were associated with the beliefs that individuals have a right to put their own health at risk, as opposed to having an obligation to avoid risks to health. Such a general attitude is interesting, in that it may allow the individual to admit that a given behaviour, such as smoking, is dangerous, but still resist the suggestion that he should therefore give it up. It also reflects a radically different outlook from the values implicit in many attempts at health education. Nonetheless, those who assert their right to risk their health tend also to view the behaviours in which they indulge (either smoking or driving without seat-belts) as involving less serious risks. We observed a consistency between individuals' specific behaviours and their relative estimates of the dangers involved. Those who drove without seat-belts were less inclined to accept that seat-belts made driving safer, and smokers were more inclined to underestimate the danger of smoking. Also smokers held significantly more negative views about government anti-smoking campaigns (though not about seat-belt legislation) whilst non-wearers of seat-belts were significantly more opposed to seat-belt legislation (though not to anti-smoking campaigns). Smokers and non-smokers did not differ significantly in their beliefs about the safety benefits of seat-belts. The belief that smoking was "really dangerous" significantly predicted seat-belt use although less strongly than it predicted not smoking. Among smokers, this same belief was associated with a more definite wish to stop. These results are broadly consistent with a "rational" decision-making model of health behaviour. Simply stated, people are less likely to do things which they believe are dangerous to their health, especially when they attach importance to protecting their health; similarly, when people engage in "unhealthy" behaviour, it is likely that they will have a lower estimate of the risks involved, and/or will attach less importance to such risks. The design of this study does not permit us to distinguish people's reasons from their rationalizations (though, in time, what starts as a rationalization for past behaviour may become a reason for present and future behaviour). With smoking (though not the seat-belt issue) an important aspect is the person's perception of his ability to abstain from the admittedly dangerous behaviour, and, as in previous research (Eiser et al., 1977), we found differences between smokers and non-smokers in their perceptions of the difficulty of giving up smoking. We have argued elsewhere (Eiser, 1978; Eiser et al., 1978) that smokers who see themselves as "addicted" may be both making a subjectively valid inference from earlier failed attempts at giving up, and also providing themselves with a rationalization for not attempting seriously to stop again. Either way, smokers who feel thay cannot easily stop may be prepared to accept that smoking is dangerous, and, it could be argued, put their health at risk not unwittingly but unwillingly (e.g. McKennell & Thomas, 1967). If this is so, simply telling such smokers the "facts" is unlikely to change their behaviour. Our data suggest a slightly different picture. Over 80% of the smokers in our sample said they definitely or possibly wished to stop. Yet even within such a sample, half
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the smokers did not believe smoking to be "really as dangerous as people say". Also, three smokers out of four said they thought that most smokers could stop smoking if they really wanted to. A striking instance where subjects' beliefs were incorrect in fact is the comparison between the number of deaths from smoking and road accidents. Under 14~o of smokers realized that smoking caused more deaths, and the corresponding percentage of non-smokers, though double that for smokers, is still low enough to suggest that this might be a theme worth reviving in health education campaigns. Less dramatic, but possibly more directly relevant to their decision to stop or continue smoking, is the preparedness of a minority of smokers to accept the "damage done already" argument. It is especially noteworthy that subjects of lower social class tended to believe smoking was less dangerous, even after controlling for whether or not they were smokers. At the same time, there was no significant association between social class and our "health rights" question (16). It is a common experience that groups of higher social status tend to be more likely to change their behaviour in response to health campaigns. Our findings suggest that such differences may be partly attributable to the fact that lower social class groups remain comparatively poorly informed of the health consequences of their behaviour, rather than necessarily "poorly motivated". The data regarding tobacco substitute cigarettes are consistent with the evidence that a large number of smokers did in fact try the new cigarettes after they were first launched in Britain on July 1st, 1978. It has been estimated that about 33% of smokers bought a pack of substitute cigarettes in the following 5 weeks (Van Rossum, 1978), and many more may have tried one from someone else's pack. In our sample, 59 out of 98 cigarette smokers had tried the new cigarettes but only 9 said they liked them. It cannot of course be assumed that the 50 who disliked them were all objecting to the substitute material per se, rather than to the reduction in nicotine and/or tar. However, if what was responsible for the products's failure was indeed the "campaign of vilification" (Van Rossum, 1978) by governmental agencies such as the Health Education Council (whose own campaign did not start till August 18th, by which time sales were already falling), one might have expected a lower rate of trying but a higher rate of liking. There are suggestions in our data that the substitute cigarettes were tried more by women, and liked somewhat more by lighter smokers. The tendency for those who liked them to believe them to be safer raises the question of what might have happened if the manufacturers had been allowed to claim that they had produced a "safer cigarette". It is almost a truism that the problem with health education is not that of convincing people that certain behaviours are dangerous to health, but persuading them to act upon their beliefs. Without minimizing the latter problem, our data suggest that there may be a number of important areas where many people underestimate the relevant dangers. This implies that there may still be room for improvement as a result of better directed and designed informational campaigns. However, the finding that smokers and non-wearers of seat-belts not only underestimate the risks of their behaviour, but also assert their right to put their own health at risk, implies a more fundamental divergence of values between health educators and their primary targets, which may be less easy to overcome. REFERENCES Bishop, Y. M. M., Fienberg S. E., & Holland P. W. Discrete Multivariate Analysis: Theory and Practice. Cambridge, MA: M.I.T. Press, 1975. Bynner, J. M. The Young Smoker. Government Social Survey SS383. London: HMSO, 1969. Eiser, J. R. Discrepancy, dissonance and the 'dissonant' smoker. International Journal of the Addictions, 1978, 13, 1295-1305. Eiser, J. R., & Sutton, S. R. Smoking as a subjectively rational choice. Addictive Behaviors, 1977, 2, 129-134. Eiser, J. R., Sutton, S. R., & Wober, M. Smokers, non-smokers and the attribution of addiction. British Journal of Social and Clinical Psychology, 1977, 16, 329-336. Fh~iner, G., & Hane, M. Seat-belts: Factors influencing their use. A Literature Survey. Accident Analysis and Prevention, 1973, 5, 27-43. Helsing, K. S., & Comstock, G. W. What kinds of people do not use seat-belts? American Journal of Public Health, 1977, 67, 1043-1050.
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Jacobs, M. A., Anderson, L. S., Champagne, E., Karush, N., Richman, S. J., & Knapp, P. H. Orality, impulsivity and cigarette smoking in men: Further findings in support of a theory. Journal of Nervous and Mental Disease, 1966, 143, 207 219. Lee, P. N. (Ed.) Statistics of Smoking in the United Kingdom. London: Tobacco Research Council, 1976. Manheimer, D. I., & Mellinger, G. D. A survey of seat belt ownership in six California communities. Traffic Safety Research Review, 1964, 8, 3 9. Manheimer, D. I., Mellinger, G. D., & Crossley, H. M. A follow-up study of seat-belt usage. Traffic Safety Research Review, 1966, 10, 2-13. McKennell, A. C., & Thomas, R. K. Adults" and Adolescents" Smoking Habits and Attitudes. Government Social Survey, SS353/B. London: HMSO, 1967. Van Rossum, R. The great substitute disaster. The Grocer, September 16, 1978, 1~,. Williams, A. F. Personality and other characteristics associated with cigarette smoking among young teenagers. Journal of Health and Social Behaviour, 1973, 14, 374-380.
