CONTROLLED SIMOKING: SINGLE CASE STUDY LIIITH MULTICOMPONENT INTERVENTION

STEVE BALDWIN and NICK HEATHER

Addtctive Behaviours Research Group. Department of Psbchiatrv, University of Dundee

Summary - The case study of controlled smoking treatment reported here Includes multicomponent behavioral interventions. Follow-up data of 30 months’ duration are examined with particular reference to shifts in topogaphical aspects of smoking and a focus on other health-related behaviors. Cigarette smoking was reduced bv S.i”b without compensatory shifts in topography and with successful long-term maintenance. The need to specify detailed ingredients of multicomponent smoking packazrs for individual clients IS discussed. paying particular attention to the potential for development of -positive addictions”.

Controlled smoking has been advocated for client-subjects who have previously found themselves unable to quit (Frederiksen. Petersen and Murphy, 1976; Frederiksen and Petersen, 1976). Such controlled smoking re- fers to the consumption of tobacco products that minimizes associated health risks. More recently. programmes involving the use of nicotine fading, self-monitoring and cigarette fading have produced promising results for subjects achieving either abstinence or con- trolled smoking goals at long-term follow-up (Foxx and Axelroth, 1983; Foxx. Brown and Katz, 1954). Among subjects who select con- trolled smoking options, significant reductions of both tar and nicotine levels have been achieved by shifts to milder brand cigarettes (e.g. Fosx, Brown and Katz, 19S-t). However, two limitations of this work require closer examination.

Firstly, whilst these studies have demon- strated that both tar and nicotine levels can be influenced by the application of behavioral methods (e.g. stimulus fading, self- monitoring), they do not account adequately for the topographical shifts that sometimes

occur when subjects attempt reduction of smoking behavior (Frederiksen, Epstein and Kosevsky, 1975; Fredcriksen, hliller and Petersen, 1977). More specifically, whilst shifts in subjects’ behavior are evidenced by selec- tion of milder brand cigarettes, topographical components of smoking sometimes also change qualitatively; amount of time spent smoking each cigarette, number of puffs taken and length/depth of puffs may increase as a “com- pensatory” mechanism. These findings, how- ever, are neither universal. nor conclusive.

Secondly. these studies have limited applic- ability (e.g. Elliot and Denney, 1978) and generalizability due to a somewhat narrow focus upon smoking in isolation from other appetitiveladdictive behaviors. For example. it has been argued that weight gains associated with attempts to stop or control smoking represent a major problem for many subjects and that there is an urgent need to incorporate such health-related issues into clinical interven- tions (e.g. Pomerleau, Adkins and Pertschuk, 197s). In particular. it is critical to include medical or exercise interventions for positive changes relating to ECG abnormalities.

Requests for reprints should be addressed to: Steve Baldwin, Addtctive Behaviours Research Group, Department of Psychiatry, University of Dundee, Ninewells Hospital and Medical School. Dundce DDI 9SY. Scotland, U.K.

795

?Yh STEL’E B.-\LDWIY ~nil 41CK HEATHER

hypertension and ciyspnoe~~ with the Ions-term the long-term history indicated ;1 need for effects of smoking: abstinence or controlled initiation of health-related activity to cornpI+ smoking. ~~hilst highly appropriate tre:itment ment the primary controlled smoking goal. soak. ma>’ be of themsrlkes insufficient to reverse the negative effects of long-term Procedure smoking (Epstein and hlcCo>,. 1975). klorr- o\‘er. there is some initial e\.idence to suggest

A multicomponsnt packasc Leas in-

that Lsith careful zeal planning. subjects can plementsd according to S.‘s indlvldual needs.

shift from negative addictive behaviors (e.g. (i) A behavioral contract \V;IS made Lvith S.

smoking. hey, drinkins) to --positive so that smoking behavior would be limited to a

addiction” (2.~. physical exercise. running) single \~~~elilv Z-L-hour period commencing Fri-

(Glasser. 1971; klarlatt and George, 19S-4). day midnight and running to Saturday mid-

The treatment method described in the night: during this period unlimited access to his

present case study attempts to build on the favorite brand was permitted. whilst smoking

strengths of previous controlled smoking work outside of this time ~vas prohibited.

by incorporating n consideration of topograph- (ii) Environmental manipulatic>ns were initi-

ical components of smokin, (7 and also the issue ated during non-smoking periods to achieve a

of the development of ;I health-related bc- degree of stimulus control (e.g. removal of

havioral repertoire. ashtravs, keeping cigarettes out of sight etc.). S. aIs0 ayeed to make use of nonsmoking public areas and to avoid/restrict situations in

P+lETlHOD tvhich smoking had been previously ;I high

The subject (S.) was ;I Zh-)-ear-old male \vho probability behavior. c.g. visiting pubs (Ep-

\vishsd to reduce his cigarette smoking from ;I stein and P+lcCoy, 1975).

level of t\venty (hlarlboro) per day. Behav- (iii) Health-related hch:t\,iors \vere initiated

ioral assessment of smoking revealed ;I IO- on a daily basis: S. agreed to complete not tess

year history, during which time S.‘s levels had than 15 min physical exercise per clay. selecting

ranged fiom &45 per day during different various options (e.g. floor exercises. running)

stages of development. He had changed brands that ivcre competing responses to the problem behavior.

on at least twelve occasions, varying between low to high tar and nicotine levels at different

(iv) Contingcncv m;ln;igemcnt IV;I; also iw

times. He had made more than 50 attempts to troduccd by S. to self-rev.xr-d nonsmoking

stop smoking completelv and had achieved a during the \veek (e.g. money saved by not

period of 6 months’ -complete abstinence buying ciqircttcs ~cas used to bus small “lusur>

5 years previously. He was requested to initiate items”).

daily self-monitoring of cigarette consumption (v) Self-monitorins for (a) cigarette co~i-

to obtain baseline data relating to (a) number sumption and (b) hourly rate was continued:

of cigarettes smoked. (b) hourI>, rate of random samples to monitor (c) number of

smoking, and (c) number of puffs per cigarette. puffs per cigarette and time spent smoking 8

Behavior analysis of S.‘s smoking patterns cigarette M’c’re introduced.

suygzsted that a controlled smoking goal would be appropriate in the first instance: S. es- RESULTS

pressed a desire to modify to an acceptable The data Indicate an S~‘:/~I decrease of

level rather than eliminate smoking behavior cigarette consumption from more than 650 per

altogether. One previous success with 21 n month to an average ie\,el of 50 per month. ;I

abstinence goal indicated an ability to control finding maintained for ;I duration of 30 months‘

some aspects of smokin, (7 behavior. In addition. follow-up (see Fig. 1). Regular checks on

COS<ROLLED S,LlOKING

BaselIne Gmfu 12mfu 18mf u. 24mfu 30mfu

MAMJ J ASONOJ FMAMJJASONOJ FMAMJJ ASONDJ FMAMJ J

1983 1984 1985

Fig. 1.

progress at six-monthly intervals suggested that self-monitoring of consumption continued throughout this period; observations of S.‘s smoking patterns suggested that hourly rate was almost unchanged during this period of time. Random samples to monitor number of puffs per cigarette indicated a slight decrease in mean frequency at first follow-up, which was maintained for the subsequent 3_J-month follow-up period.

An overall increase in time spent on daily esercise was reported during the follow-up period, with a ranse of 15-65 min per day and an average. of 15 min per day at 30 months’ follow-up. Although physiological data were not collected, self-reports indicated a higher Icv~el of fitness from improved respiratory and cardiovascular functioning.

Cot2rit~geticy niotiagettiet2r

Savings of up to f-IO ($60 US) per month were accumulated as a result of reductions achieved in cigarette consumption. with which S. was able to purchase several small luxury items, e.g. tape player, short holiday etc.

DISCUSSION

The results suggest that a multi-component

behavioral package may be highly effective in establishing and maintaining substantial reduc- tion of cigarette consumption. using -‘con- trolled smoking” as a primary intervention goal. An S_i”% decrease in overall consumption was obtained using a combination of behavioral contracting, contingency manage- ment. self-monitoring and differential reinforcement of other behaviors (DRO) methods. The data obtained support the proposition that controlled smoking may bc an acceptable goal for some long-term smokers who do not wish to give up completely (Epstein and McCoy. 1975; Levinson, Shapiro and Tursky, 1971; McFay and Hanmen. 1971) and that a carefully devised intervention package can produce substantial and lasting reductions in smoking behavior (cf. Foxs, Brown and Katz, 19SJ).

The results also suggest that reductions in smoking were obtained uithout a compensa- tory shift in topographical components, such as number of puffs per cigarette or time spent smoking each cigarette. Close examination of smoking behavior during follow-up indicated more frequent use of lower nicotine brand cigarettes and use of hand-rolled cigarettes, although S. maintained a clear preference for medium tar/nicotine cigarettes (e.g. hlarlboro. Winston) despite having achieved a reduction in overall consumption. These data suggest that controlled smokers also smoke to achieve

29s STE\.E B.ALDWIS dnd NICK HE.ATHER

a specific physiological nicotine level, after which satiation occurs (e.g. Russell. 1974).

It is likely that the development of a health- related behavioral repertoire such as physical exercise helped to establish and maintain the pattern of controlled smoking and may also have reduced the deterioration in physical fitness due to prolonged smoking. Inclusion of physical fitness goals have been identified as essential components of smoking control pro- grams (e.2. Delarne and kloss, 1972: Epstein and McCoy. lY75; Pomerleau, Adkins and Pertschuk. 1978). This broad focus upon the measurement of multiple behaviors follo\ving interventions directed at smoking patterns is in keeping \vith previous work (e.y. Kazdin. 1973) which has attempted to evaluate sys- tematic changes in behavior not specified as intervention targets (e.g. Epstein and hlcCoy. 1975). It is also consistent with a relapse pre\.ention approach (bfurlatt and Gordon. 1985) which enables clients to achieve more balanced lifestyles, often by development of the so-called positive addictions (e.~. Glasser, 197-i; Marlntt and George. 1954). The lzvcl of exercise increased from 15 to 43 min per day at follokv-up. Whether this amount of exercise IV;IS sufficient to bring about a “positive” addiction remains unanswered.

Clearly there are ethical issues to be con- sidered in the selection of controlled smoking goals for clients. Despite a focus upon “reduc- tion to a medically safe level” (Epstein and bfcCoy, 1975). it is likely that any smoking behavior increases specific risks to health. It ma>’ be, ho\vever. that for the client who is either unwilling or unable to achieve an abstin- ence goal, an option of controlled smoking may be a pragmatic alternative. The present study suggests that some smokers kvith pre- viously high levels of nicotine intake can maintain substantially reduced cigarette con- sumption in the long term following a multicomponent behavioral intervention. As in the debate about controlled drinking as a treatment goal for alcohol abusers (see Heather and Robertson. 1983), it is now

necessary to establish what characteristics of smokers make it more likelv that the! Lvill benefit from a controlled sm;king rather than an abstinence approach.

REFERESCES

Dzlarne N C. .md .Clos, G. (1972) The Toronto Smoklne

CONTROLLED S%IOKING ‘99

Pomerlsau 0.. Adkins D. and Pertschuk 11. (1978) Russsll Xl. A. H. (1971) Realistic goals for smoking dnd Predictors of outcome and recidivism in smoking cess;f- health: a case for safer smokinul_. Ldnssr 1. ZS4-2%. tion treatment. Addicr. Bchav. 3. 65-70

AcX~~owlecigemenrs - Thanks are due to Isabel Ormsrod for the typin g xnd Iawut of this m.muscript