ORIGINAL ARTICLE

Applying Lessons Learned from Obsessions:Metacognitive Processes in Smoking Cessation

Elizabeth Nosen Æ Sheila R. Woody

Published online: 29 December 2007

� Springer Science+Business Media, LLC 2009

Abstract Cognitive theories of obsessions propose that

unwanted thoughts become frequent, intense and persistent

when people interpret them in personally meaningful ways

and attempt to control them through thought suppression. The

present study examined the generalizability of this model to

another form of unwanted, actively resisted intrusion––nico-

tine cravings. In this investigation, 180 individuals attempting

to quit smoking completed several online questionnaires. In

line with cognitive theories, individuals who appraised their

cravings as more catastrophic and personally significant

experienced more severe craving-related thoughts and were

more likely to be smoking one month later; these effects

remained after accounting for several established predictors of

cessation difficulty. Contrary to expectation, tendency to

suppress unwanted thoughts was not a significant factor.

Overall, findings complement existing work on the role of

anxiety sensitivity in smoking behaviour and implicate per-

sonally meaningful appraisals of smoking-related thoughts,

images and impulses in cessation difficulty.

Keywords Obsessions � Metacognition � Appraisals �Thought suppression � Smoking cessation �Nicotine dependence

Introduction

Researchers have identified a strong cognitive component

to nicotine cravings, characterized by a thought, thought

process, or an expectation of the consequences of smoking

(Shadel et al. 2001). Smokers are more likely to lapse after

experiencing intense, persistent and distressing cravings

(Shiffman et al. 1997a; Shiffman et al. 1996; Shiffman

et al. 1997b). As such, identifying factors that influence the

severity of smoking-related thoughts, images and impulses

is critical for understanding and preventing cessation

relapse. Recent research from the study of obsessions may

provide a fresh perspective on this issue.

For some time, anxiety researchers have been investigat-

ing the development of another type of distressing and

recurrent cognitive phenomenon—obsessions. Current cog-

nitive models of obsessive–compulsive disorder propose that

metacognition plays a pivotal role in determining how

problematic unwanted thoughts become: individuals who

interpret their thoughts as meaning something overly

important tend to be more disturbed by unwanted thoughts

and tend to experience more frequent, intense and persistent

intrusions (Clark et al. 2000; Rachman 1997, 1998; Sal-

kovskis 1985). In addition, some individuals attempt to avoid

the discomfort associated with unwanted thoughts by sup-

pressing them. Unfortunately, this strategy can paradoxically

make the thoughts recur with greater frequency, which in

theory, propels an escalating cycle of recurrence, over-

interpretation and distress (Abramowitz et al. 2001; Purdon

1999; Rachman 1997, 1998; Salkovskis 1985; Wegner et al.

1987). These models have been gaining empirical support in

recent years and have led to the development of new inter-

ventions designed to reduce the persistence and distress

associated with obsessions (Abramowitz et al. 2007; Clark

et al. 2000; Clark et al. 2003; Purdon and Clark 1994a,

1994b; Rachman 2003; Teachman et al. 2006).

The key element in these theories is appraisal of the

meaning of an intrusive thought, irrespective of thought

content. As such, the same processes that are proposed to

occur for obsessions may also occur for other types of

E. Nosen (&) � S. R. Woody

Department of Psychology, University of British Columbia,

2136 West Mall, Vancouver, BC, Canada V6T 1Z4

e-mail: lnosen@psych.ubc.ca

123

Cogn Ther Res (2009) 33:241–254

DOI 10.1007/s10608-007-9180-8

unwanted, distressing and actively resisted thoughts, like

the craving-related thoughts experienced by people trying

to quit smoking. To the extent that this is true, personally

meaningful interpretations of cravings and use of thought

suppression may promote the development of more fre-

quent, intense and persistent cravings, which may in turn

increase risk for future smoking behaviour. The present

study represents an initial investigation of this hypothesis.

Maladaptive Interpretations of Unwanted

Intrusive Thoughts

The Obsessive Compulsive Cognitions Working Group

(OCCWG) has highlighted three types of appraisals that

are important in obsessions: overestimation of the personal

significance of the thought (e.g., this thought means I am a

bad person), ‘‘thought–action fusion’’ or flawed beliefs

about the perceived consequences of having an unwanted

intrusive thought (e.g., having this thought means I will

undoubtedly act on it), and an unrealistic desire to maintain

perfect thought control (e.g., I must control this thought)

(OCCWG 1997, 2001, 2003). Research on obsessive

thoughts suggests that these personally meaningful inter-

pretations of unwanted thoughts encourage negative self-

evaluation, are associated with intrusion frequency, con-

trollability and discomfort with thought recurrence and

prospectively predict obsessive–compulsive symptoms

(Abramowitz et al. 2007; Clark et al. 2000; Clark et al.

2003; Purdon 2001; Purdon and Clark 1994a, b; Teachman

et al. 2006). In other forms of psychopathology, the ten-

dency to assume equivalence between thoughts and action

(i.e., ‘‘thought–action fusion’’) has been found at elevated

levels in individuals with depression, generalized anxiety,

and eating disorders (Abramowitz et al. 2003; Hazlett-

Stevens et al. 2002; Muris et al. 2001; Shafran et al. 1999).

Negative interpretations of the personal meaning of

unwanted intrusive cognition have also been associated

with distress in PTSD, hypochondriasis, psychosis and

depression (Bouman and Meijer 1999; Morrison 2001;

Starr and Moulds 2006; Steil and Ehlers 2000).

In the area of nicotine addiction, little research has

investigated how individuals who are attempting to quit

smoking appraise the personal meaning of cravings. While

many people likely view cravings as a mundane or natural

consequence of smoking cessation, others may interpret

them in similarly overly personal and significant ways (e.g.,

as meaning that they are weak, going crazy, out of control or

destined to fail). Shiffman (1984) showed that individuals

who face a relapse crisis, in which they are tempted to, but

do not, smoke, experience declines in their abstinence self-

efficacy and feelings of failure similar to those who actually

do lapse. This suggests that a form of thought–action fusion

may occur in some individuals whereby cravings are

appraised as similar to actual smoking and an indication of

likely failure in the quit attempt.

Thought Suppression

According to cognitive theories of obsessions, disturbing

interpretations of unwanted thoughts motivate people to

watch apprehensively for reappearance of the original

intrusion and to try to prevent its recurrence (Clark and

Purdon 1993). Unfortunately, actively trying not to think a

thought can produce a paradoxical increase in the frequency

of the intrusion (Abramowitz et al. 2001; Wegner et al.

1987). In theory, reappearance of the original thought con-

firms initial beliefs in the importance and personal meaning

of the thought and strengthens desire for control, which in

turn begins an escalating cycle of distress, vigilance, and

unsuccessful suppression (Clark and Purdon 1993). Imply-

ing a mediational model, several correlational studies have

confirmed that the relationship between personally mean-

ingful appraisals of unwanted thoughts and OCD symptoms

declines when thought suppression is controlled (Rassin

et al. 2000; Smari and Holmsteinsson 2001). Consistent with

a broader, transdiagnostic effect, thought suppression has

also been correlated with symptoms of PTSD, agoraphobia,

depression, and insomnia (Ehlers et al. 1998; Fehm and

Margraf 2002; Harvey 2001; Wenzlaff and Luxton 2003).

The role of thought suppression in addictive behaviours

is unclear. Salkovskis and Reynolds (1994) examined the

effects of suppression in a sample of individuals attempting

to quit smoking. They found that individuals instructed to

suppress intrusive thoughts about smoking subsequently

experienced more frequent intrusions than individuals

instructed to either monitor their thoughts or monitor and

relax. However, Reynolds et al. (2005) failed to replicate

this finding in a study of drug-related thoughts among

individuals recovering from opiate or multi-substance

dependence in an inpatient treatment center. Palfai and

colleagues found that suppression of alcohol-related urges

increased the accessibility of alcohol outcome expectancies

(Palfai et al. 1997). They also observed a cross-substance

effect whereby suppressing alcohol-related urges increased

the intensity of cigarette smoking in current smokers

(Palfai et al. 1997). While this suggests that urge sup-

pression may have important behavioural consequences,

the mechanisms driving this effect are unclear.

Correlational studies designed to determine whether and

to what effect smokers actually use thought suppression

while quitting have also produced mixed results. Based on

the idea that using thought suppression techniques may make

quitting smoking more difficult, Toll et al. (2001) found that

current smokers (termed ‘‘unsuccessful quitters’’) scored

higher on a general measure of thought suppression than ex-

smokers (i.e., ‘‘successful quitters’’). This study used the

242 Cogn Ther Res (2009) 33:241–254

123

full-scale White Bear Suppression Inventory (WBSI) as an

index of thought suppression. However, researchers have

recently found that this measure actually contains two sub-

scales, only one of which assesses suppression (Hoping and

de Jong-Meyer 2003; Rassin 2003). Use of the other scale,

which reflects problems with intrusive thoughts, may artifi-

cially inflate apparent relationships with psychopathology

(Hoping and de Jong-Meyer 2003). Indeed Haaga and Alli-

son (1994) assessed suppression by coding thoughts

articulated in response to various stimulus situations and

found no association between the use of thought suppression

strategies and maintenance of non-smoking over a one-year

period. At present, it is unknown whether similar results

would be observed using self-report measures of chronic

tendencies towards thought suppression (such as the WBSI

suppression subscale).

Current Study

The present study is an exploratory investigation of the

extent to which the cognitive model of obsessions may help

explain problems with nicotine craving-related cognitions

among individuals attempting to quit smoking. We hypoth-

esized that interpretations of smoking-related thoughts as

personally meaningful or relevant to the probability of ces-

sation success would correlate with concurrent problems

with cravings (in terms of smoking-related thought fre-

quency, intensity, distress, etc.), partly as a function of

thought suppression efforts. We anticipated that this rela-

tionship would remain significant even after accounting for

other established predictors of craving severity, including

nicotine dependence, negative affect, expectations about

smoking, and cessation self-efficacy beliefs (Droungas et al.

1995; Field and Duka 2001; Gwaltney et al. 2005; Killen

et al. 1992; Willner and Jones 1996). Because of the critical

role that craving severity appears to play in cessation diffi-

culty, we further hypothesized that personally meaningful

appraisals and suppression would prospectively predict

future smoking behaviour. We anticipated that this rela-

tionship would remain after taking both concurrent (time

one) severity of craving-related thoughts and other previ-

ously established predictors of cessation success into

account. These hypotheses were investigated in an online,

questionnaire-based study of individuals quitting smoking.

Method

Participants

Participants were 180 English-speaking adults currently

engaged in a serious effort to quit smoking. Participants

were included if they reported having reduced their

smoking by at least five cigarettes per day. Participants

were excluded if they had smoked for less than one year

prior to the current attempt to quit, smoked fewer than 10

cigarettes per day (on average) before quitting, or had

initiated their current quit attempt more than six months

ago. Most participants were female (70.6%), Caucasian

(93.9%), and employed full-time (55.0%). The average age

of participants was 39.0 years (SD = 10.3). Most partici-

pants had completed a post-secondary degree (45.6%), and

resided in Canada (36.7%), the United States (32.2%) or

the United Kingdom (24.4%).

Prior to their current attempt to quit smoking, partici-

pants had smoked fairly heavily (Mdn = 20 cigarettes per

day, range = 10–80 cigarettes) for many years

(Mdn = 19.5 years, range = 1–48 years). Nearly everyone

(97.2%) had seriously attempted to quit smoking at least

once before (Mdn = four times, range = 0–100 times),

with their longest previous quit attempt lasting a median of

3 months (range = \1 day–14 years). Participants repor-

ted having initiated their current attempt to quit smoking a

median of 21 days before participation (range = 1–

190 days) and had reduced their smoking by an average of

21.1 cigarettes per day (SD = 9.3, range = 5–80 ciga-

rettes). At the time they enrolled in the study and

completed the questionnaires, most participants (80.4%)

were fully abstinent from smoking (Mdn = 0 cigarettes per

day, range = 0–17).

Procedure

Participants completed all questionnaires over the internet,

facilitated by http://www.SurveyMonkey.com, a web-

based survey development and hosting service. Participants

were recruited through links placed on smoking cessation

websites and postings in online discussion forums, and

through advertisements placed in the Vancouver area. In

the early stages of data collection, participants received an

entry into a gift certificate lottery as an incentive (n = 86;

additional draw entry received for completing one-month

follow-up). These participants were screened online for

eligibility; qualified participants were automatically direc-

ted to the informed consent page of the survey. Participants

recruited in the later stages of data collection received an

honorarium in the form of a CDN$20 cheque (n = 94;

CDN$15 for completion of main study questionnaires,

CDN$5 for follow-up).1 Researchers personally screened

these participants by email or phone using the same

questions as those screened online; eligible participants

received a link to the informed consent page via email.

1 Incentive was increased to speed data collection and ensure

adequate survey completion rates.

Cogn Ther Res (2009) 33:241–254 243

123

Aside from screening, procedure was identical for draw

and cheque incentive participants.

The study questionnaires, presented in one of three

counterbalanced orders, followed the informed consent.

Questionnaires at time one assessed metacognition (per-

sonally meaningful appraisals and thought suppression),

craving severity and previously established predictors

(depression, cessation self-efficacy, expectancies about

smoking, nicotine dependence and other characteristics of

quit attempt). The survey program neither permitted

missing responses nor allowed participants to return to

previous pages. Upon completion of the survey, all par-

ticipants were asked to re-affirm that they wanted their data

to be used in study analyses; remuneration was explicitly

not dependent on their answer. One month after completing

the bulk of the questionnaires, participants received an

email link to a brief follow-up survey assessing recent

smoking behaviour. All procedures were approved by an

institutional research review board.

Under the draw incentive, 156 individuals completed the

first page of the questionnaires, among whom 100 (64%)

completed the full survey and asked that we use their data.

Eighty-six of these cases were used in analyses (details on

case exclusion are presented below); one-month follow-up

data were available for 67% (n = 58) of this sample. Under

the $20 incentive, 115 individuals completed the first page

of the questionnaires, and 110 (96%) completed the ques-

tionnaires and asked that we use their data. Ninety-four of

these cases were used in final analyses; follow-up data

were available for 90 individuals (96%).

Thirty cases were excluded prior to analyses. Cases were

excluded for the following reasons: not meeting study

inclusion criteria (n = 18), repeat participation (based on

duplicate IP addresses; n = 5)2 and questionnaire com-

pletion under 25 min (5th percentile of all participants;

n = 7). The survey program did not record individual page

completion times. Thus, long completion times could

reflect something innocuous, such as a participant opening

the first information page of the survey and then deciding

to complete it later on, or something more problematic,

such as taking an extended break mid-way through the

survey. As long completers (i.e., 20 cases completing in

over 2 h) did not differ from the rest of the sample on

questionnaires (including craving severity) and one-month

cessation status (P’s [ .05), these cases were retained for

analyses. After case exclusions, 180 cases remained for

analyses. Average survey completion time was 46.3 min-

utes (SD = 15.3).3

Measures

Appraisals of Cravings Questionnaire (ACQ)

The ACQ assesses how individuals interpret the occurrence

of nicotine craving-related thoughts, images or impulses,

with an emphasis on the types of appraisals researchers

have identified to be problematic in studies of obsessions

(OCCWG 1997, 2001, 2003). Respondents are provided

with a definition of craving-related cognitions and are

asked to provide examples of two smoking-related

thoughts, images or impulses they have recently experi-

enced. Respondents then rate their level of belief (0–100%)

in each of 17 interpretations with reference to their per-

sonalized smoking-related thoughts. Appraisals include

beliefs that craving-related thoughts are personally signif-

icant (e.g., ‘‘These thoughts reveal something important

about me’’), directly tied to the success of one’s attempt to

quit smoking (e.g., ‘‘Having this unwanted thought means I

will act on it’’) and need to be controlled (e.g., ‘‘It is

important for me to cancel out or block the craving-related

thoughts’’).

The ACQ was developed for the current study by

modifying a commonly used measure of obsessional types

of appraisals, the Interpretations of Intrusions Inventory

(III; OCCWG 1997, 2001, 2003). Obsessional themes and

content provided in the III instructions were replaced with

nicotine craving content generated through pilot testing and

past research results (Salkovskis and Reynolds 1994).

Several minor wording modifications were also made (e.g.,

replacing ‘‘intrusive thought’’ with ‘‘intrusive craving-

related thought’’). Participants completed 21 of the original

31 items on the III.4 To ensure that items covered an

adequate range of appraisals, 11 items drawn from the

unpublished Personal Significance Scale (Rachman 2001)

and eight items with smoking specific content were also

added. From the initial pool of ACQ items, 18 items were

removed because of restricted variability or extreme skew.

Six items were removed because they did not correlate

strongly with total scale score. Further information on the

psychometric properties of the ACQ is available in the

results section.

Catastrophic Appraisals Index (CAI)

The CAI is an empirically derived scale comprised of 10

items that were initially included as part of the ACQ but

are analyzed separately due to infrequent endorsement.

2 Indicative of possible repeat participation.3 Not including 20 individuals with completion times over two hours.

4 Piloting suggested that several III items were confusing and unclear

when applied to typical nicotine craving related thoughts (e.g., ‘‘this

thought could harm people’’). These items were removed from the

scale.

244 Cogn Ther Res (2009) 33:241–254

123

Compared to the items of the ACQ, CAI items reflect more

extreme, catastrophic interpretations of cravings (e.g., ‘‘I

will go crazy if I do not stop thinking these thoughts’’).

Although participants rated these items on the same scale

as the rest of the ACQ items, CAI items were rendered

dichotomous for analysis (0 = did not believe this idea at

all, 1 = some degree of belief in this idea) because of the

highly skewed distribution of responses and the nature of

the questions. Total scale scores reflect frequency of

endorsement of extreme appraisals of craving-related

thoughts, such as, ‘‘Having this intrusive thought means

that I could lose control of my mind’’, ‘‘Having this

intrusive thought means I am a bad person’’, ‘‘If I don’t

control this thought, I’ll be punished’’ and ‘‘These thoughts

mean that I am really an impostor or a phony.’’ Both

measures are available on request from the authors.

Obsessional Beliefs Questionnaire

(OBQ; OCCWG 1997, 2003)

Included to examine the convergent validity of the ACQ

and CAI, the OBQ is a 44-item self-report measure of

characteristic obsessive beliefs regarding the importance of

controlling thoughts, perfectionism, and inflated responsi-

bility. Participants rate the agreement with beliefs on a 7-

point Likert scale. The OBQ has demonstrated excellent

internal consistency, test-retest reliability and convergent

validity (OCCWG 2003; Woods et al. 2004). Cronbach’s

alpha in the current sample was .94.

Thought–Action Fusion Scale-Revised

(TAF-R; Shafran et al. 1996)

This 19-item self-report measure was also included to

examine the convergent validity of the ACQ and CAI.

Rated on a 5-point Likert-type scale, items reflect beliefs

that thoughts are morally equivalent to action and directly

increase the likelihood of events occurring. The TAF-R has

demonstrated good reliability and validity in both obses-

sional and non-obsessional samples (Rassin et al. 2001;

Shafran et al., 1996). Cronbach’s alpha was .92 in the

current sample.

White Bear Suppression Inventory

(WBSI; Wegner and Zanakos 1994)

The WBSI is a 15-item self-report measure of general

tendency to suppress intrusive thoughts. The WBSI is

comprised of two factors—thought suppression and intru-

sive thought experience (Hoping and de Jong-Meyer 2003;

Luciano et al. 2006; Rassin 2003). As use of the intrusion

subscale can inflate correlations with measures of psy-

chological distress (Hoping and de Jong-Meyer 2003;

Rassin 2003), only the six items loading on the thought

suppression factor as identified in Hoping and de Jong-

Meyer’s (2003) study were used in the current analyses.

The suppression subscale had demonstrated acceptable

internal consistency and convergent validity with other

measures of problematic thought control (Luciano et al.,

2006). Cronbach’s alpha was .83 in the current sample.

Obsessive Compulsive Drinking Scale-Revised,

Smoking Version (OCDS-RS; Morgan et al. 2004;

Anton et al. 1995)

Originally based on the Yale-Brown Obsessive Compul-

sive Scale (YBOCS; Goodman et al. 1989), the OCDS-R is

a 10-item self-report measure assessing obsessive–com-

pulsive dimensions of alcohol and drug craving.

Participants answered questions on a 0–4 Likert-type scale

in reference to their experience with cigarette craving-

related ideas, thoughts, impulses, or images; minor word-

ing modifications were made (e.g., substituted ‘‘smoking’’

for ‘‘drinking/using’’). Like the YBOCS, the OCDS-R

includes both ‘‘obsessive’’ and ‘‘compulsive’’ subscales

(Anton et al. 1995). Because it is more applicable to cur-

rent study hypotheses, only the five-item ‘‘obsessive’’

subscale was used in analyses. Items assess the frequency,

distress, controllability, persistence, and interference

associated with smoking-related thoughts and impulses.

The obsessional subscale has demonstrated excellent

internal consistency, test-retest reliability and concurrent

validity (Anton et al. 1995). Cronbach’s alpha in the cur-

rent sample was .85.

Center for Epidemiological Studies Depression

Scale––Short Form (CES-DS; Kohout et al. 1993)

The short form of the CES-D is an 11-item measure designed

to assess depressive symptoms in non-psychiatric commu-

nity samples. Participants rate frequency of depressive

symptoms during the past week on a three-point scale. This

version of the CES-D has obtained stable and desirable

psychometric properties across multiple samples (Carpenter

et al., 1998). Cronbach’s alpha was .84 in this sample.

The Smoking Self-Efficacy Questionnaire

(SSEQ; Etter et al. 2000)

The SSEQ is a 12-item instrument used to estimate an

individual’s confidence in his or her ability to abstain from

smoking in a variety of potentially high-risk situations.

Higher scores represent greater self-efficacy. This measure

has demonstrated good content, construct and predictive

validity (Etter et al. 2000). Cronbach’s alpha in the current

sample was .95.

Cogn Ther Res (2009) 33:241–254 245

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The Smoking Effects Questionnaire

(SEQ; Rohsenow et al. 2003)

This 33-item measure assesses participants’ positive and

negative expectancies about smoking cigarettes. Respon-

dents rate their belief that smoking will have a particular

effect on a scale of 0 (false), 1 (true and not at all

important), 2 (true and moderately important), or 3 (true

and very important). Subscales are calculated by averaging

relevant item ratings. The SEQ shows good psychometric

properties among adults attempting to quit (Rohsenow

et al. 2003). Only the subscale assessing positive expec-

tancies about smoking (e.g., will relieve negative affect)

was used in analyses. Cronbach’s alpha was .88.

The Fagerstrom Test for Nicotine Dependence

(FTND; Heatherton et al. 1991)

This widely used measure assesses nicotine dependence on

a six-item scale. Participants completed the FTND with

reference to their pattern of smoking prior to quitting. The

FTND has demonstrated satisfactory internal consistency,

retest reliability, and convergent validity (Heatherton et al.

1991; Pomerleau et al. 1994). Cronbach’s alpha in the

current sample was .65.

Follow-up Questionnaire

One month after completing the questionnaires, partici-

pants were sent a follow-up email asking a couple of

questions. One of these was pertinent to the current study:

‘‘Over the past week, how many cigarettes have you

smoked (in total)?’’. Participants were classified as

‘‘smoking’’ if they reported smoking any cigarettes over

the past week and ‘‘abstinent’’ if they reported not

smoking.

Data Analysis Overview

The psychometric properties of the ACQ and CAI were

examined first, followed by tests of primary study

hypotheses. Prior to analyses, variables were screened for

outliers and fit with the assumptions of multivariate anal-

ysis. The influence of study methodology (e.g., differing

incentives, questionnaire orders and follow-up survey

completion rates) was also explored. In the next stage of

analysis, previously established predictor variables were

examined to determine relevance for tests of main

hypotheses. Partial correlations were then calculated to test

the hypothesis that metacognitive factors (personally

meaningful appraisals and thought suppression) would be

associated with concurrent severity of craving-related

cognition after accounting for previously established

predictors. Finally, the hypothesis that metacognition

would also predict future smoking behaviour (i.e., status as

‘‘abstinent’’ or ‘‘smoking’’ at follow-up) was examined

through two hierarchical logistic regression analyses. At

the first level in the model, relevant previously established

predictors were added as covariates. Thought suppression

(WBSI scores) was introduced in the second level of the

model. Because of the strong correlation between

appraisals as measured by the ACQ and CAI (r = 0.61),

we entered appraisals in the third level of the model in

separate analyses (ACQ scores in the first analysis, CAI

scores in the second).5 Overall, this model facilitates

examination of the unique influence of metacognitive

factors on future smoking behaviour over and above

established predictors.

Results

ACQ and CAI Psychometrics

An exploratory factor analysis (principal component anal-

ysis) was performed on the 17 ACQ items to examine the

structure of the ACQ. Although three factors with eigen-

values greater than one were extracted, the scree plot

suggested a unifactorial structure. Examination of rotated

factors revealed multiple complex loadings in multi-fac-

torial solutions. All items loaded highly ([.55) on the first

factor, which accounted for 45.6% of the measure variance.

As such, we elected to use the ACQ as a unidimensional

scale. Cronbach’s alphas for the ACQ and CAI were .92

and .88, respectively, suggesting excellent internal con-

sistency. CAI and ACQ scores were moderately correlated

(r = .61).

As measures of obsessional types of appraisals (applied

to smoking cessation), one would expect the ACQ and CAI

to be moderately correlated with other measures of

obsessional beliefs. Consistent with this, the ACQ corre-

lated with the OBQ and TAF at .42 and .31 respectively,

P’s \ .01. The CAI correlated with the OBQ and TAF at

.36 and .39, respectively, P’s \ .01.

Preliminary Analyses

No cases had missing data. Four outliers for the number of

times a participant had previously attempted to quit

smoking were replaced with adjacent scores. Three

smoking history variables were transformed to reduce the

number of outliers and improve their distributions. This

5 Interpretation of logistic regression results is problematic when

individual predictors are strongly correlated and expected to be

related to the criterion in similar ways (Tabachnick and Fidell 2001).

246 Cogn Ther Res (2009) 33:241–254

123

procedure affected duration of current and longest previous

quit attempt (both log transformations) and number of

previous quit attempts (square root transformation). Based

on Mahalanobis distances at P \ .01, two cases were

identified as multivariate outliers and removed from the

sample, leaving 178 cases available for analysis.

As there were no significant differences on study ques-

tionnaires between individuals participating under the draw

or $20 incentive, t’s (176) \ 1.82, P’s [ .05, the samples

were combined for analyses. Participants not completing the

one-month follow-up had quit smoking more recently than

individuals completing the follow-up (M’s = 0.45 months

ago vs. 1.26 months ago; t (47.37) = 3.87, P \ .01). These

groups did not differ on any other demographics, smoking

history variables or on study questionnaires, t’s (176) \1.59,

P’s [ .05. Analysis of questionnaire order showed no sig-

nificant effects, F (12, 342) = 1,71, P [ .05, so this factor

was not considered further. Demographics and smoking

histories did not differ for individuals completely vs. par-

tially abstinent at the time of completing questionnaires,

aside from amount currently smoking (0.0 vs. 3.4 cigarettes

per day), t (47) = 5.90, P \ .05. Table 1 provides descrip-

tive statistics for study questionnaires, calculated using both

the full sample (N = 178) and only participants completing

the follow-up, classified as abstinent (n = 78) or smoking

(n = 70). All statistical analyses were conducted at a two-

tailed alpha of .05.

Previously Established Predictors

The relevance of previously established predictor variables

for subsequent analyses was determined by examining for

significant relationships with the criterion variables (craving

severity and one-month smoking status). The frequency,

distress, and intensity of craving-related thoughts (OCDS-

RS scores) correlated significantly with two smoking history

variables: (log of) the number of days since a participant

began the current quit attempt, r = -.36, and (square root

of) frequency of previous quit attempts, r = .19, P’s \ .05.

Severity of craving-related thoughts was also significantly

associated with positive smoking expectations (SEQ-pos),

r = .33, depression (CES-DS), r = .37, and poorer cessa-

tion self-efficacy (SSEQ), r = -.50, P’s \ .05. OCDS-RS

scores did not show significant correlations with gender,

years of education, use of antidepressant medication, dura-

tion of regular smoking, current cessation status (completely

vs. partially abstinent), pre-quit nicotine dependence

(FTND), or (log of) duration of longest previous quit

attempt, r ‘s B .14, P’s [ .05.

Table 1 shows statistics comparing smoking and absti-

nent individuals at follow-up. Means and SDs are based on

raw scores, although some variables (as noted) were

transformed for analysis. Compared to abstinent individu-

als, participants who were smoking at the one-month

follow-up had been regular smokers for fewer years before

Table 1 Means and Standard Deviation for smoking history variables and questionnaires

Measure One-month follow-up status

Full sample

(N = 178)

Smoking

(n = 70)

Abstinent

(n = 78)

Smoking versus

Abstinent

M SD M SD M SD t d

Smoking History and Other Established Predictors

Years smoking before quit 20.09 10.78 18.60 10.29 22.66 11.41 -2.26* -0.37

Number of previous quit attemptsa 6.56 9.82 6.74 4.96 5.39 5.09 2.15* 0.36

Longest previous quit attempt (months)a 9.62 21.49 11.23 28.38 7.36 14.25 1.17 0.19

Duration of current quit attempt (months)a 1.12 1.29 1.04 1.47 1.46 1.23 -3.58* -0.59

Fagerstrom Test for Nicotine Dependence (pre-quit) 5.65 2.28 5.69 2.29 5.72 2.20 -0.09 -0.01

Smoking Effects Quest: Positive Expectancies 1.29 0.55 1.33 0.56 1.29 0.56 0.43 0.07

CES-Depression––Short Form 7.96 4.40 8.59 4.74 7.51 3.82 1.52 0.25

Smoking Self-Efficacy Questionnaire 39.84 12.45 33.86 11.01 44.51 12.20 -5.56* -0.92

Metacognition and craving severity

White Bear Suppression Inventory: Suppression 20.81 4.69 21.33 4.81 20.40 4.58 1.21 0.20

Catastrophic Appraisals Index 3.83 3.24 5.17 3.42 2.86 2.86 4.48* 0.74

Appraisals of Craving Questionnaire 71.81 37.27 88.29 33.97 58.69 35.04 5.20* 0.86

OCDS-RS Obsessional––Smoking Version 9.34 4.20 11.21 3.81 8.08 4.02 4.86* 0.80

Note: CES-Depression = Center for Epidemiological Studies Depression Scale, OCDS-RS Obsessional = Obsessional subscale of the Obses-

sive-Compulsive Drinking Scale––Revised, * P \ .01. a Transformed for analysis, but raw scores presented here

Cogn Ther Res (2009) 33:241–254 247

123

quitting, had quit smoking more recently, had attempted to

quit more frequently, and were less often completely

abstinent at the time of completing the questionnaires

(48.6% vs. 91.0%; v2 = 32.26, P \ .01). Smokers also

reported less confidence in their ability to quit (as measured

by the SSEQ) and more frequent, persistent and intense

cravings (OCDS-RS scores). There were no significant

differences between groups on other questionnaires or on

other demographic and smoking history variables.

Metacognition and Concurrent Severity

of Craving-related Thoughts

Thought suppression scores were moderately correlated

with appraisals of cravings as measured by both the ACQ

(r = .34, P \ .01) and the CAI (r = .27, P \ .01). Table 2

shows the relationships between previously established

predictor variables, craving severity and the metacognitive

variables. Partial correlations control for quit attempt

duration, number of previous quit attempts, positive

smoking expectations (SEQ-pos), depression (CES-DS) and

cessation self-efficacy (SSEQ). All variables correlated

\.60. SPSS collinearity diagnostics revealed that while all

condition indices fell\.30, no dimension had more than one

variance proportion [.50. Thus, multicollinearity was not

an issue (Belsey et al. 1980; Tabachnick and Fidell 2001).

Consistent with hypotheses, the frequency, distress, and

intensity of craving-related thoughts (OCDS-RS scores) cor-

related significantly with both ACQ and CAI scores (i.e.,

personally meaningful appraisals of cravings) after removing

the effects of previously established predictors. Inconsistent

with predictions, use of thought suppression was not related to

craving severity after accounting for previously established

predictors. The possibility that suppression effects were

moderated by personally meaningful appraisals was also tes-

ted. However, the interaction between suppression and

meaningful appraisals (as measured by either the ACQ or

CAI) was not significantly correlated with craving severity

either before or after partialling out the effects of other pre-

dictors (r’s B .12, P’s [ .05).

Metacognition in the Prediction

of One-month Smoking Status

At the one-month follow-up, 47.3% of participants reported

smoking over the previous week (leaving 52.7% classified

as ‘‘abstinent’’). Two hierarchical logistic regression anal-

yses examined whether metacognitive variables (personally

meaningful appraisals and thought suppression) predicted

smoking behaviour above and beyond previously estab-

lished predictors: initial smoking status (complete vs.

partial abstinence), duration of regular smoking, quit

attempt duration, number of previous quit attempts, craving

severity (OCDS-RS scores) and confidence in ability to

quit (SSEQ scores). All predictor variables correlated\.60.

SPSS collinearity diagnostics revealed that while all con-

dition indices fell \.30, no dimension had more than one

variance proportion [.50. Thus, multicollinearity was not

an issue (Belsey et al. 1980; Tebachnick and Fidell 2001).

Table 3 provides details of the model. In the first level

of the model (previously established predictor variables),

participants were more likely to be smoking at the follow-

up if they had quit smoking more recently, were not

completely abstinent at the time of completing the ques-

tionnaires and were experiencing more frequent, intense

and persistent craving-related thoughts, images and

impulses. Inconsistent with hypotheses, thought suppres-

sion (WBSI scores) did not explain a significant proportion

of variance in smoking status beyond that accounted for by

previously established predictors, nor was it associated

with a unique change in the odds of future smoking

behaviour above and beyond the covariates.

Table 2 Correlations between metacognitive variables, established predictors and craving severity

Variables White Bear Suppression

Subscale

Catastrophic Appraisals

Index

Appraisals of Craving

Quest

Quit Attempt Duration (log) .20** -.01 -.14

Frequency of Past Attempts (H) -.01 .02 .07

Smoking Effects Quest: Positive .25** .22** .30**

CES-Depression .24** .35** .32**

Smoking Self-Efficacy Quest. -.06 -.38** -.52**

OCDS-RS Obsessional

Zero-Order .16* .37** .55**

Partiala .14 .17* .33**

Notes: N = 178, * P \ .05. ** P \ .01. OCDS-RS Obsessional = Obsessional subscale of the Obsessive Compulsive Drinking Scale––Revised,

Smoking Version, CES-Depression = Center for Epidemiological Studies Depression Scale––Short Forma Controlling for time elapsed since beginning quit attempt, frequency of previous quit attempts, positive smoking expectancies, depression, and

cessation self-efficacy

248 Cogn Ther Res (2009) 33:241–254

123

As predicted, personally meaningful appraisals measured

by the ACQ, introduced in the third step of the model,

explained a significant proportion of variance in smoking

status above and beyond that accounted for by previously

established predictors and thought suppression. When all

variables were entered, ACQ scores were also associated

with a small but unique change in the odds of future

smoking. Participants were 1.02 times more likely to be

smoking at follow up for each additional increment of belief

in the personally meaningful appraisals of cravings assessed

by the ACQ (where scores ranged from 1–170). In separate

analysis, catastrophic appraisals also explained a significant

proportion of variance in smoking status incremental to that

accounted for by previously established predictors and

thought suppression, and were associated with a unique

change in the odds of future smoking behaviour. Partici-

pants were 1.2 times more likely to be smoking at the

follow-up for each catastrophic interpretation of cravings in

which they endorsed some degree of belief.

The possibility that suppression effects were moderated

by personally meaningful appraisals was tested by intro-

ducing an interaction term (suppression 9 appraisals) in

the fourth step of each model. This step did not contribute

significantly to the prediction of smoking status, regardless

of whether appraisals were assessed by the ACQ or CAI,

Step v2’s (148) B 1.95, P’s [ .05, nor did it affect the

significance of individual predictors.

Discussion

The present study investigated the applicability of cognitive

theories of obsessions to the nicotine craving-related

thoughts, images and impulses experienced by people

attempting to quit smoking. Results support the generaliz-

ability of key aspects of the model. Specifically, like

obsessions, personally meaningful appraisals of intrusive

craving-related thoughts correlated significantly with the

severity of these thoughts. Participants experienced more

problematic cravings, in terms of frequency, distress, con-

trollability, persistence, and interference, if they held a

concurrent view of their cravings as more catastrophic,

personally significant and important to control. Importantly,

these appraisals prospectively predicted whether partici-

pants would be smoking one month later after accounting

for initial smoking status, years of regular smoking, recency

of the quit attempt, craving severity and confidence about

being able to successfully abstain. Contrary to expectation,

tendency to suppress unwanted thoughts did not contribute

significantly to the prediction of either concurrent craving

severity or one month cessation outcome.

Maladaptive Appraisals of Cravings

To date, very little research has investigated how people

trying to quit smoking interpret their cravings. In the present

study, many participants endorsed beliefs that craving-

related thoughts mean that they are weak, that their attempt

to quit smoking is destined to fail, and that it is important to

cancel out or block the thoughts. On average, participants

expressed a moderate degree of belief in these ideas (average

rating of 4.2 on a scale of 0 = no belief at all to

10 = completely convinced). A substantial minority of

individuals took their appraisals even further, endorsing

beliefs that craving-related thoughts mean that they are out

of control, for example, or that the thoughts will lead to

Table 3 Logistic regression predicting smoking versus abstinent status at one-month follow-up

Variables Step 1 Step 2 Step 3 Step 3

Established predictors Thought suppression Appraisals: ACQ Appraisals: CAI

OR 95% CI OR 95% CI OR 95% CI OR 95% CI

Initial abstinence status 9.81 3.27–29.45* 10.39 3.37–32.01* 10.57 3.35–33.32* 11.06 3.48–35.16*

Years smoking before quit 1.00 0.99–1.00 1.00 .99–1.00 1.00 .99–1.00 1.00 .99–1.00

Quit Attempt Duration (log) 0.41 0.17–0.97* .36 .15–.88* .35 .14–.85* .33 .13–.81*

Frequency of Past Attempts (H) 1.48 0.96–2.27 1.47 .96–2.25 1.50 .96–2.35 1.60 1.02–2.51*

Smoking Self-Efficacy Quest. 0.98 0.94–1.02 .98 .94–1.02 .99 .95–1.04 .99 .95–1.03

Craving Severity (OCDS-RS) 1.14 1.01–1.29* 1.13 1.00–1.28 1.08 .95–1.23 1.09 .96–1.24

White Bear Suppression 1.05 .96–1.15 1.01 .92–1.12 1.03 .94–1.12

Appraisals of Craving Quest. 1.02 1.00–1.03* – –

Catastrophic Appraisals Index – – 1.19 1.02–1.39*

Step v2 65.24* 1.31 4.24* 4.90*

Model v2 65.24* 66.55* 70.79* 71.45*

Note: N = 148, * P \ .05. White Bear Suppression refers to the Suppression subscale of the White Bear Suppression Inventory. OCDS-RS

refers to the Obsessive-Compulsive Drinking Scale-Revised Smoking Version, Obsessional Subscale

Cogn Ther Res (2009) 33:241–254 249

123

insanity, punishment or condemnation. Participants

endorsed some degree of belief in an average of four of these

more catastrophic appraisals. Overall, these findings are

intriguing because they suggest that some people appraise

craving-related thoughts as powerful signals of the type of

person they are or the likely success of their quit attempt.

Cognitive theories of obsessions suggest a cyclical

relationship between personally meaningful appraisals and

unwanted intrusive thoughts, whereby negative and per-

sonally significant appraisals give rise to more frequent

intrusions, which seem to reaffirm the interpretation that the

intrusions have personal meaning for the individual or the

future (Rachman 1997, 1998; Salkovskis 1985). Results of

the current study are consistent with correlational research

conducted on obsessions in support of this theorized process

(Clark et al. 2000; Clark et al. 2003; Purdon and Clark

1994a, 1994b). That is, we found a strong positive corre-

lation between personally meaningful interpretations of

craving-related thoughts, images and impulses and the

frequency, distress and intensity of the intrusions. Although

the prospective findings of the current study provide

intriguing support for a causal effect of appraisals on

craving severity and cessation difficulty, more longitudinal

and experimental studies are needed to establish the tem-

poral relationship and causal direction. Persistent and

intense craving-related thoughts, for example, would plau-

sibly elicit more catastrophic, personally meaningful

appraisals than would fleeting, infrequent thoughts of

smoking. Researchers studying obsessions have noted

similar difficulties disentangling the causal actions under-

lying these reciprocal relationships (e.g., Teachman et al.

2006).

Nevertheless, this work complements and extends

existing work on the role of anxiety sensitivity in cessation,

which suggests that tendency to catastrophize about inter-

nal sensations (i.e., score high on anxiety sensitivity

measures) is uniquely associated with smoking to reduce

negative affect, decreased cessation self-efficacy, and

increased risk of early cessation relapse (Brown et al. 2001;

Zvolensky et al. 2006; Zvolensky et al. 2006; Zvolensky

et al. 2007). Consistent with this, the present study found

that individuals who appraised cravings as meaning

something negative about themselves or who believed their

craving-related thoughts needed to be controlled felt more

depressed and less confident in their ability to abstain from

smoking. They also expected that smoking would have

more positive effects. These findings merit further research

to discover whether personally meaningful appraisals of

smoking-related thoughts exacerbate low mood or damage

self-efficacy. It would also be very useful to know how the

appraisals assessed by the ACQ and CAI relate to anxiety

sensitivity and the extent to which these measures uniquely

contribute to understanding cessation relapse.

Just as cognitive theories of obsessions have inspired

new interventions to specifically target maladaptive

appraisals of unwanted thoughts, understanding the role of

metacognition in cravings may open the door to innovative

clinical strategies. Appraisals of the meaning of craving-

related thoughts, as investigated in the current study, are

not explicitly targeted by current cessation treatments. If

personally meaningful appraisals prove to be a robust

predictor of craving severity and cessation outcome, then

some aspects of cognitive therapy for obsessions may be

usefully applied to the cravings experienced during

smoking cessation.

Thought Suppression During Smoking Cessation

Cognitive theories of obsessions predict that individuals

who appraise their unwanted thoughts in negative, overly

significant ways will try to avoid or control their thoughts

as a means of reducing distress and preventing undesirable

outcomes (OCCWG 1997). Because the effort is doomed to

fail, trying to control unwanted thoughts is believed to be a

central mechanism involved in their persistence (OCCWG

1997; Purdon and Clark 1999). Failure to eliminate the

thoughts seems to strengthen belief in the importance of the

thought and exacerbate distress about having the thought

(Purdon and Clark 2001; Purdon et al. 2005). In the current

study, participants who endorsed a greater tendency to

suppress (general) unwanted thoughts also reported more

negative and personally significant interpretations of

cravings, a finding that is consistent with research on

obsessions (Rassin et al. 2000; Smari and Holmsteinsson

2001).

Our results, however, did not show a relationship

between thought suppression and either concurrent craving

severity or prospective smoking behaviour. Though this

result differs from research on obsessions, it is consistent

with several studies from the substance dependence liter-

ature, including the Reynolds et al. (2005) experimental

finding that suppression did not increase the frequency of

drug-related thoughts and the Haaga and Allison (1994)

prospective finding that use of thought suppression was

unrelated to maintenance of smoking abstinence. The

addictions literature, however, is not entirely consistent on

this finding, as the Salkovskis and Reynolds (1994) and

Palfai et al. (1997) experimental studies and the Toll et al.

(2001) questionnaire study reported different results. Fac-

tors that may have led to differences among these studies

include the setting of the study (with no effect found in

more naturalistic settings; Reynolds et al. 2005) and

delineation of smoking status (with no effect found in

prospective investigations). An additional issue may be

how thought suppression is measured. Previous research

has indicated that many items on the White Bear

250 Cogn Ther Res (2009) 33:241–254

123

Suppression Inventory conflate thought frequency with

thought suppression (Hoping and de Jong-Meyer 2003). As

such, we used only the thought suppression factor in an

effort to produce clearer results. This may be another

reason our results differ from Toll et al. (2001), who

employed the full scale WBSI.

This ambiguity in the literature may reflect different

effects of thought suppression for different individuals or

circumstances. Some evidence, for example, suggests that

suppression of depressive or worry-related thoughts may

actually be beneficial under certain conditions, with

expression associated with subsequent dysphoria and

rumination (Borkovec et al. 1983; Roemer and Borkovec

1994). A similar phenomenon may occur for craving-

related thoughts: postponing or redirecting thoughts of

smoking may be adaptive at times when attempting to quit.

Consistent with this idea, current smoking cessation treat-

ments encourage people to use distraction when

experiencing urges to smoke (Abrams et al. 2003). Alter-

natively, thought suppression may become problematic

only when it fails or when individuals appraise failures in

thought control as overly significant. Indeed, individuals

who believe that they should be able to perfectly control

obsessional types of thoughts are more upset by suppres-

sion failure (Purdon et al. 2005). Finally, the degree to

which thought suppression is adaptive or counterproductive

may also vary with situational variables, such as the rela-

tive salience of smoking cues or the accessibility of

cigarettes. Given the array of possible complicating factors,

it is important to keep in mind that the measure of thought

suppression used in the current study was not specific to

cravings or to particular settings. If the effect of thought

suppression depends on context or thought content, then it

may be important to assess suppression of specific forms of

unwanted intrusive thoughts.

Limitations

Several limitations of the current study are important to

bear in mind when interpreting the results. To begin, all

variables were assessed via self-report. Individuals

undoubtedly vary in the degree to which they are able to

recognize and recall their appraisals of intrusive thoughts.

Momentary, in vivo assessment or the use of implicit

measures of cognition would improve confidence in the

findings. Though research suggests that assessment of

smoking via self-report is generally accurate (Patrick et al.

1994), confirmation with biochemical assessment would

similarly increase certainty in the results.

The measures used in this study also leave some ques-

tions unanswered. Neither the ACQ nor the CAI have been

subjected to rigorous psychometric evaluation, although we

did aim to provide some support for reliability and validity

in this study. Demonstrating convergent validity, the ACQ

and CAI were moderately correlated with measures of both

obsessive beliefs and other forms of problematic cognition

during smoking cessation (e.g., poor cessation self-effi-

cacy, positive beliefs about the effects of smoking).

Discriminant validity was also demonstrated indirectly

though the tests of the main study hypotheses. That is,

these measures correlated in expected ways with craving

severity even after accounting for several other relevant

predictors (like depressed mood and cessation self-effi-

cacy). The ACQ and CAI also predicted smoking

behaviour after controlling for these established predictors.

The ACQ and CAI were derived from measures of

appraisals relevant to obsessions, which is both a strength,

in that some of those measures were carefully developed,

and a weakness: these measures may not cover all content

areas relevant to smoking cessation. Future research

investigating the clinical utility of the ACQ and CAI may

wish to broaden their scope to include other types of

smoking-specific appraisals.

We also assessed craving severity with the OCDS-RS.

We chose this measure because it is analogous to a com-

monly used index of obsessive–compulsive symptoms (the

Y-BOCS), because it assesses several facets of craving

severity (unlike traditional single item 0–100 urge scales)

and because it has demonstrated strong psychometric

properties. Nevertheless, it is not widely used and it is not

clear how it relates to traditional single item measures of

craving or to other symptoms of nicotine withdrawal.

Similarly, we assessed ‘‘future smoking behaviour’’ via

self-reported recent (i.e., past week) smoking at a one-

month follow-up. Other conceptualizations of cessation

success (e.g., continued abstinence over the entire month,

abstinence at six months or a year) may present different

and meaningful information. Replication with alternative

measurement of both craving severity and cessation out-

come is warranted.

The sample also has strengths and weaknesses.

Although all participants reported actively trying to quit

smoking, they represent a particular slice of the population.

Specifically, the results may not generalize well to indi-

viduals without regular computer or internet access (e.g.,

people with low socioeconomic status or older individuals).

Cultural diversity of the current sample was also limited;

participants in the current study were mainly of a Cauca-

sian or Western European ethnic background. Finally,

participation was restricted to individuals with a fairly

specific smoking history.

In summary, the current study provides some of the first

indications of how people who are trying to quit smoking

appraise the occurrence of cravings. The types of appraisals

that have been found to be important in obsessions (per-

sonal significance of the thoughts, responsibility arising

Cogn Ther Res (2009) 33:241–254 251

123

from the thoughts, and the importance of controlling the

thoughts) were related to craving severity. More cata-

strophic appraisals of the meaning of craving-related

thoughts, although endorsed less frequently, were also

predictive of craving severity. Both types of appraisals

predicted cessation status one month later. In contrast to

theories about obsessions, thought suppression did not

appear to play a role in craving severity in this sample.

Clearly these results need to be replicated and further

investigated, but they provide evidence that cognitive

theories of obsessions generalize to other types of

unwanted thoughts and suggest fruitful directions for

research and clinical strategies in smoking cessation.

Acknowledgements This research was funded through the strategic

initiative Advancing the Science to Reduce Tobacco Abuse and

Nicotine Addiction, which is a partnership of government and non-

profit organizations under the coordination of the Canadian Tobacco

Control Research Initiative (CTCRI), http://www.ctcri.ca. This study

was also supported by a Social Science and Humanities Research

Council Scholarship awarded to the first author. We thank Scott

Carlson and Charlotte Johnston for their helpful contributions to this

project.

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