The process of cessation

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SMOKING AND ALCOHOL USE
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further drinking behaviour. However, it has been suggested that it is not the actual
effects of alcohol use that promote drinking but the expected effects (George and Marlatt
1983). Therefore, because a small amount of alcohol may have positive effects people
assume that these positive effects will continue with increased use. This perspective is in
line with the social learning model of addictive behaviours and emphasizes the role of
reinforcement and cognitions.
Social predictors of alcohol initiation and maintenance
Many of the social factors that relate to smoking behaviour are also predictive of alcohol
consumption. For example, parental drinking is predictive of problem drinking in
children. According to a disease model of addictions it could be argued that this reflects
the genetic predisposition to develop an addictive behaviour. However, parental drinking
may be influential through ‘social hereditary factors’, with children being exposed to
drinking behaviour and learning this behaviour from their parents (Orford and Velleman
1991). In addition, peer group alcohol use and abuse also predicts drinking behaviour as
does being someone who is sensation seeking, with a tendency to be aggressive and
having a history of getting into trouble with authority. Johnston and White (2003) used
the theory of planned behaviour (see Chapter 2) to predict binge drinking in students.
However, given the social nature of binge drinking they focused on the role of norms.
Using a longitudinal design, 289 undergraduate students completed a questionnaire
concerning their beliefs with follow-up collected about reported binge drinking. The
results showed an important role for norms particularly if the norms were of a
behaviourally relevant reference group that the student reported a strong identification
with.
STAGE 3: THE CESSATION OF AN ADDICTIVE BEHAVIOUR
Because of the potential health consequences of both smoking and alcohol consumption, research has examined different means to help smokers and drinkers quit their
behaviour. Cessation of an addictive behaviour can be examined in terms of the processes
involved in cessation and the interventions designed to motivate individuals to quit their
behaviour.
The process of cessation
Traditionally, smoking cessation was viewed as a dichotomy: an individual either smoked
or did not. Individuals were categorized as either smokers, ex-smokers or non-smokers.
This perspective was in line with a biomedical model of addictions and emphasized the
‘all or nothing nature’ of smoking behaviour. In addition, alcoholics were encouraged
to abstain and to become non-drinkers. However, early attempts at promoting total
abstinence were relatively unsuccessful and research now often emphasizes cessation as
a process. In particular, Prochaska and DiClemente (1984; see Chapter 2) adapted their
stages of change model to examine cessation of addictive behaviours. This model
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114 HEALTH PSYCHOLOGY
highlighted the processes involved in the transition from a smoker to a non-smoker and
from a drinker to a non-drinker. They argued that cessation involves a shift across five
basic stages:
1 precontemplation: defined as not seriously considering quitting;
2 contemplation: having some thoughts about quitting;
3 preparation: seriously considering quitting;
4 action: initial behaviour change;
5 maintenance: maintaining behaviour change for a period of time.
Prochaska and DiClemente maintain that individuals do not progress through these
stages in a straightforward and linear fashion but may switch backwards and forwards
(e.g. from precontemplation to contemplation and back to precontemplation again).
They call this ‘the revolving door’ schema and emphasize the dynamic nature of cessation. This model of change has been tested to provide evidence for the different stages for
smokers and outpatient alcoholics (DiClemente and Prochaska 1982; 1985; DiClemente
and Hughes 1990), and for the relationship between stage of change for smoking cessation and self-efficacy (DiClemente 1986). In addition, DiClemente et al. (1991) examined
the relationship between stage of change and attempts to quit smoking and actual
cessation at one- and six-month follow-ups. The authors categorized smokers into either
precontemplators or contemplators and examined their smoking behaviour at follow-up.
They further classified the contemplators into either contemplators (those who were
smoking, seriously considering quitting within the next six months, but not within the
next 30 days) or those in the preparation stage (those who were seriously considering
quitting smoking within the next 30 days). The results showed that those in the preparation stage of change were more likely to have made a quit attempt at both one and six
months, that they had made more quit attempts, and were more likely to be not smoking
at the follow-ups. This study is described in detail in Focus on research 5.1, page 115.
Research has also used the health beliefs and structured models outlined in Chapter 2
to examine the predictors of both intentions to stop smoking and successful smoking
cessation. For example, individual cognitions such as perceptions of susceptibility,
past cessation attempts and perceived behavioural control have been shown to relate
to reductions in smoking behaviour (Giannetti et al. 1985; Cummings et al. 1988; Godin
et al. 1992). In addition, the theory of planned behaviour (TPB) has been used as a
framework to explore smoking cessation in a range of populations, including those
following a worksite ban (Borland et al. 1991), pregnant women and the general
population (Godin et al. 1992).
Along these lines, one study examined the usefulness of the TPB at predicting intention to quit smoking and making a quit attempt in a group of smokers attending health
promotion clinics in primary care (Norman et al. 1999). The results showed that the best
predictors of intentions to quit were perceived behavioural control (i.e. ‘How much
control do you feel you have over not smoking over the next six months?’) and perceived
susceptibility (i.e. ‘How likely do you think it might be that you will develop any of the
following problems in the future if you continue to smoke?’). At follow-up, the best
predictors of making a quit attempt were intentions at baseline (i.e. ‘How likely is it that
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