1. Behav. Thu. & Exp. Psychial. Vol. 14, No. 4, pp. 325-330, 1983 Printed in Great Britain.

ooO5-7916183 $3.00+ .@I 0 1983 Pergamon Press Ltd.

MEDIATING FACTORS IN THE MODIFICATION OF SMOKING BEHAVIOR

JOEL GOLDBERG and AVRAHAM ZWIBEL

Department of Psychology, Bar-Ran University, Ramat-Gan, Israel

MARILYN P. SAFIR

Department of Psychology, University of Haifa, Haifa, Israel

and

MICHAEL MERBAUM

Department of Psychology, Washington University, St. Louis, Missouri

Summary-This study was designed to investigate two personality variables that may influence the effectiveness of covert sensitization in reducing smoking behavior. These are GSR reactivity to stressors and GSR adaptation to repeated stressors. It was predicted that both high reactivity and nonadaptivity to stressors would facilitate covert sensitization therapy. Fifty- nine subjects underwent treatment and were followed up at 3,6 and 12 week intervals. Subjects were distributed among four groups: A. High reactors, nonadaptive (15); B. High reactors, adaptive (14); C. Low reactors, nonadaptive (9); D. Low reactors, adaptive (21). The results demonstrate that the measure of reactivity to stressors is significantly related to the success of the treatment, but the relevance of the measure of adaptivity factor was not demonstrated.

One method for modification of smoking is the covert sensitization technique developed by Cautela (1966). The covert sensitizer (aversive stimulus) is paired with the behavior to be extinguished. Similarly, a pleasurable stimulus is paired with avoidance of the undesirable behavior. Studies by Wish, Cautela and Steffen (1970) and Steffy, Meichenbaum and Best (1970) indicate that covert, imaginary stimuli are more effective and also generalize better than concrete stimuli. A number of studies have demonstrated the technique’s effectiveness. Comparing covert sensitization with a didactive, supportive approach, Viernstein (1968) ran seven sessions plus a 5-week follow-up and reported significant gains for this method.

Gerson (1971) used four treatment methods and found that the group which received

covert sensitization and the group that received covert sensitization together with desensitiz- ation showed comparably significant smoking reduction at post-treatment and l- and 5-week follow-ups. Wagner and Bragg (1970) also found that a variation of covert sensitization, together with desensitization, is most effective.

On the other hand, Little and Curran (1978), in their critique of covert sensitization studies, claim that this technique has not been satis- factorily demonstrated as an effective treat- ment for smoking and that covert sensitization groups have fared no better than control groups. They conclude that: “A good deal more research needs to be conducted before an unequivocal assessment of the effectiveness of covert sensitization in the treatment of smoking can be made.” Lichtenstein and Danaher (1976) also claim that the evidence supporting

Requests for reprints should be addressed to Marilyn P. Safir, Department of Psychology, University of Haifa, Haifa, 3 1999, Israel.

325

326 JOEL GOLDBERG, AVRAHAM ZWIBEL, MARILYN P. SAFIR and MICHAEL MERBAUM

the effectiveness of covert sensitization “appears to be relatively weak; however, the economy and portability of the procedure suggest that it deserves additional empirical study” (pp. 104-105). We believe that signifi- cant results may be obtained by manipulating personality variables which might be suscep- tible to this procedure.

Many recent studies on the modification of smoking behavior (Keutzer, 1968; Bernstein, 1969; Lichtenstein and Danaher, 1976) have concentrated on the interaction of certain mediating personality variables which might affect the success of therapy. However, extroversion, locus of control, anxiety level, cognitive dissonance and suggestibility were found to be unrelated to successful treatment. Nor was any relationship discovered between success of therapy and such factors as strength of motivation for smoking, longevity, or the period of pretreatment smoking behavior (Sachs, Beam and Marrow, 1970; Wagner and Bragg, 1970).

A personality variable which does appear to us to be more relevant has been investigated by Lazarus et al. (1962). They assumed that the degree of autonomic responsiveness represents a general quality of the personality. They postulated that persons exhibiting minimal autonomic responsiveness to an aversive film are less empathetic towards the events in the film than those showing high reactivity. Block (1957) and Opton and Lazarus (1967) found that persons who react strongly to such films are more anxious and suggestible. We hypothesize that these people should be better candidates for covert sensitization. Another personality variable studied is adaptability of autonomic responsiveness to repetitive aversive stimulation stressor films. According to Clemens and Selesnick (1967), persons demonstrating such adaptability are less influenced by the film. Therefore, they should be poor candidates for covert sensitization.

An analysis of these studies reveals that the following factors may contribute to the efficacy of covert sensitization: (1) the ability of the

subjects to “identify” with the situation which is described verbally to them; (2) their suggesti- bility in aversive situations based on deter- minants of repulsion and fear; (3) their adapt- ability to the aversive stimulus which is repeatedly presented during treatment. Adap- tability should reduce the punishing effect of the stimulus and weaken the effectiveness of the technique.

According to studies by Lazarus, the above factors may be predicted from autonomic responsiveness (GSR) to a visually presented stressful stimulus. Thus, we would expect that subjects with high autonomic responsiveness will tend to be more influenced by aversive situations, since they are more anxious and suggestible. In addition, the subjects who do not adapt to repeated aversive stimuli will show a greater decrease in smoking behavior than those who adjust to the stimuli. These personality variables appear to be extremely significant when examining the effectiveness of covert sensitization. Therefore, a strategic decision was taken to focus on a within- treatment rather than a between-treatment design. The two variables which may enable us to predict the effectiveness of covert sensitiz- ation on smoking habits are the degree of GSR reaction and the adaptivity to aversive stimuli.

The following two hypotheses may be deduced:

1. Covert sensitization will be more effective with those subjects who react strongly to an aversive film (and whose smoking behavior will therefore show a greater decrease) than with those subjects who react weakly.

2. The subjects who do not adapt to repeated aversive stimuli will show a greater decrease in smoking behavior than those who adapt to the stimuli.

METHOD Sample

The sample of volunteers who responded to advertisements in local newspapers consists of 59 subjects who completed the treatment and follow-up: 30 men and 29 women. Fourteen additional subjects dropped out at various stages of the

MEDIATING FACTORS IN THE MODIFICATION OF SMOKING BEHAVIOR 321

experiment. No difference was found between the drop-outs and those that remained in treatment on levels of adaptability or reactivity.

Average age of subject was 36.6 yr (S.D. = 10.13). Fifty- three per cent were professionals: e.g. teachers, engineers, nurses; 25.8% farmers (kibbutz members); 8.6% students; 8.6% housewives; 3.6% factory workers. Mean years of education was 12.69 (S.D. = 2.1).

History of the target behavicr for all subjects showed a mean longevity of 10.74 yr (S.D. = 8.72) and a mean initiation age of 19.2 yr (S.D. = 4.13). Over two-thirds of the subjects had previously made unsuccessful attempts to give up smoking. Baseline level of smoking for the subjects was 27.4 cigarettes per day.

Instruments 1. Three scenes from the film “The Epileptic Seizure”

(White, 1963). This is a 16 mm color film. The three scenes, chosen from a total of nine, run for 12 min. The film opens with a demonstration of the technique of EEG recording, showing how electrodes are connected to the head. An explanation of epilepsy follows, plus three scenes of actual seizures in a child, woman and man.

The purpose of the film was to create an aversive, stressful situation in order to facilitate separation of the subjects into the GSR-based categories of “over- responders” and “under-responders”. The difference between the reactions to the first scene (stressor-stimulus No. 1) and the last (stressor-stimulus No. 3) was taken as a measure of adaptability to a stressor-stimulus.

In the pilot study, the reliability of the tool in differen- tiating between subjects was confirmed by analysis of variance, as well as by the split-half technique (r= 0.79).

2. Apparatus for measuring and recording GSR. The GSR unit was connected to a d.c. recorder (Truth Verifier, Stoelting Co. Chicago, Ill.) whose needle moved at a constant rate, recording the responses on graph paper divided into fixed time intervals. The apparatus was calibrated so that a 1K resistance resulted in the needle moving 4 mm.

The scoring was performed in the following manner: Each scene was divided into equal time intervals of 2 sec. On each such interval, the GSR amplitude was measured and the mean computed for each scene. Means for the first and third scenes were compared. If the third mean was equal or greater the subject was classified as non- adaptive otherwise the subject was classified as adaptive.

3. Behavior-monitoring sheets. On these sheets the subjects recorded date, number of cigarettes smoked and circumstances when they smoked.

4. Treatment tape. This included complete and abbreviated versions of instructions for relaxation of muscles, five “aversive” presentations and five “pleasur- able” presentations, all equal in length and presented alternately.

The following is an example of an aversive presentation: “You take out a cigarette and put it between your lips.

You light up. You take a long draw and inhale deeply. You feel a certain inward swelling in your throat, closing and clogging up your throat. It becomes painful, terribly

painful. You continue smoking and you finish half a cigarette. You try calling, but your voice is hoarse and weak. You feel strangled, all clogged up. You try calling again, but nothing comes out. It’s as if you’re dumb. You continue smoking the last quarter of the cigarette. The pains are very bad in the whole area of your throat. You can’t breathe, you are strangling. You are very nervous, tense. You feel strangled, all clogged up.”

The following is an example of a “pleasant” presen- tation:

“You take out a cigarette. You strike a match and begin to light up. Suddenly you decide not to smoke. You put out the match and throw away the cigarette. You breathe in, taking in fresh air. You feel great. You feel better and better. You feel great. You have no discomfort, no pain. Your muscles are relaxed. You don’t smoke, and you feel like someone who wakes up from a long, relaxed sleep. Your throat is open and clean. Your voice is strong and clear. You don’t smoke. You feel good. You breathe freely, not very deeply, just freely and the air goes in and out cleanly and freely”.

The “aversive” material was based on two sources: firstly, the bodily symptoms of the subjects as indicated by their answers to the questionnaire; and secondly the symptoms of throat cancer as reported by a medical researcher on this disease.

Procedure Each applicant received a background questionnaire

including detailed smoking history, returnable by mail, followed by a written or telephone invitation to a preliminary examination in the laboratory. Ever:, subject viewed the stressor film individually, sitting 5 m from the screen. Two electrodes were attached to the index and middle fingers of the right hand which rested on the arm of the chair. Prior to the film some light conversation was made about the subject’s family or business until the apparatus indicated that the subject had adapted to the new situation.

Each subject then received a letter indicating date and venue and duration of treatment, an explanation of the importgnce of regular attendance, plus a request for a deposit of $10 returnable only on completion of treatment.

Ten treatment sessions, each lasting one-and-a-half hours, were spread over 3 weeks. Subjects sat in separate cubicles within the laboratory, wore earphones, and each heard the presentations at the same volume. At intervals of 3 weeks, 6 weeks and 3 months following treatment, each subject was asked by telephone how many cigarettes were smoked daily. We attempted to limit the conversation to a single question and answer. Subjects without telephones received stamped, addressed envelopes for reply by mail. All covert sensitization treatments were performed very mechanically and no remarks or suggestions that might have affected smoking behavior were made.

Design An index of GSR reactivity was computed in terms of the

area between the response curve and the horizontal axis. The 59 subjects were categorized into over-responders (29 persons) and under-responders (30 persons), according to their position above or below the median response to the

328 JOEL GOLDBERG, AVRAHAM ZWIBEL, MARILYN P. SAFIR and MICHAEL MERBAUM

film. Thirty-five subjects showed a lowered mean reactivity to stressor stimulus No. 3 in relation to stressor stimulus No. 1, thus demonstrating what was defined as “adap- tation”. Twenty-four subjects showed an increased mean reactivity to stressor stimulus No. 3, defined as “non- adaptive” response.

I 00

t

o-High reactors-non-odaptlve b-High reactors-adaptwe c-Low reactors-non-adoptive d-Lowreactors-odaptlve

Subjects were distributed among four groups: A. High reactors, nonadaptive 15 subjects B. High reactors, adaptive 14 subjects C. Low reactors, nonadaptive 9 subjects D. Low reactors, adaptive 21 subjects According to our first hypothesis, high responders

should show greater change in smoking habits than low responders; .therefore, groups A and B should show greater change than C and D. Following our second hypothesis, nonadapters should show greater change in smoking habits than adapters. Therefore, A should show more change than B, and C more change than D. Although we cannot predict the relationships between A and C or B and D from these hypotheses, it would appear logical to assume that, due to their greater suggestibility and ability to feel the “verbal” situation, group A would show more improvement in smoking habits than group C. No subject increased rate of smoking following treatment, therefore we have no negative index.

0 I 1 I Termnatlon 3weew 6weeks I2 weeks Of therapy

Time

Fig. 1. Smoking behavior over twelve weeks time following covert sensistization

RESULTS

Applying a three-way analysis of variance, the research hypotheses were tested with respect to behavior change at all post-treatment check dates: i.e. on the last day of treatment, 3 weeks, 6 weeks and 12 weeks later.

The index for behavior change was the As shown by Table 1, hypothesis 1 was number of cigarettes smoked before treatment supported by the significant difference between minus the number of cigarettes at post- groups A and B, and groups C and D-the treatment date, divided by the number of former being well above the general mean and cigarettes before treatment. Thus, the index the latter below it. Hypothesis 2, that non- varies between 0 and 1, with 1 indicating adaptivity would be a significant factor in treat- complete termination of smoking behavior and ment effectiveness, was not supported. We 0 indicating no change at all. Figure 1 presents attempted to retest hypothesis 2, after the difference in behavior change between the excluding all subjects whose difference in GSR four groups. (Data were examined by sex. No reactivity between scenes 1 and 3 of the film significant differences were found, and the data equalled or exceeded 5. The hypothesis was for men and women were combined.) again rejected.

Table 1. A three-way classification ANOVA with repeated measures over time with smoking as the dependent variable

Source ss df MS

A B C AB AC BC ABC 1. 2.

Time 2.156 3 Reactivity 3.984 1 Adaptivity 0.006 1

0.046 3 0.107 3 0.142 1 0.039 3

Error term 28.869 55 Error term 8.023 165

0.719 3.984 0.006 0.015 0.036 0.142 0.039 0.525 0.049

Error F term

P

2 14.78 < 0.01 1 7.59 < 0.01 1 0.011 N.S. 2 0.312 N.S. 2 0.736 N.S. 1 0.269 N.S. 2 0.801 N.S.

MEDIATING FACTORS IN THE MODIFICATION OF SMOKING BEHAVIOR 329

With regard to intragroup trends over the four check-dates, we see a similar pattern in all four groups. The immediate post-treatment behavior-change index shows a sizeable reduc- tion in smoking behavior. The termination of treatment is followed by a fairly sharp drop in the index, which tends to stabilize between 6 weeks and the end of the 1Zweek follow-up phases.

DISCUSSION

The consistent support for our first hypothesis is a confirmation of our prediction regarding GSR reactivity-that persons who “over-respond” to a visually presented stressor stimulus will be more amenable to an aversive- control technique for modifying smoking behavior than persons who “under-respond” to such stimuli.

Safir (1968) found significantly greater GSR adaptability to stressors (threat) when person- ally irrelevant than when personally relevant. Possibly by using a nonrelevant stressor film on epilepsy in this study rather than a film on the effects of cancer, we did not adequately differentiate between the adaptors and non- adaptors (B vs A, and D vs C). It appears more likely that high reactivity vs low reactivity is a more critical variable.

An attempt was made to control as many variables as possible; the number of subjects was relatively large, and an identical procedure was applied to all, under equivalent laboratory conditions. The same therapist was employed for all groups. All our subjects demonstrated a high motivation to give up smoking. All had requested our help and some had exerted pressure to be included in our program. Although our goal was not to investigate the effectiveness of the treatment as such, the results in Fig. 1 show an overall mean reduction of 61% in smoking behavior. We also see that the behavior change stabilized with time and was maintained for at least 3 months. The findings indicate a decrease in the mean number of cigarettes: pretreatment-27.4 a day; post

treatment-lo.34 per day. Twenty-seven per cent of the subjects stopped smoking com- pletely following treatment. At follow-up (3 months later) mean number of cigarettes smoked increased to 15.8 per day. However, 24% of the subjects still refrained from smoking. The large number of subjects, follow- ups and the careful data collection, increases the reliability of these results.

The index for behavior change was a pro- portional criterion which related the number of cigarettes on the check-date to the number of cigarettes before treatment. In a further retest of the hypotheses, we employed an improved index including extent of reduction of smoking behavior, total elimination of smoking behavior, and rate of behavior change. Here, too, the basic results of the study remained the same. In future studies, particularly those investigating the effectiveness of this technique, a more sophisticated index of behavior change should be developed.

On follow-up, we defined behavior change in terms of the subjects’ verbal reports. We are aware of the weakness of this measure. We had hypothesized that reactors are more anxious or suggestible. We might infer that they may give

~more favorable verbal reports relative to the low reactors. At follow-up, i.e. they might tell the experimenter what they think the experi- menter wants to hear, that they have reduced their smoking. However, we were able to obtain some independent evidence of actual behavior change. Kibbutz nurses observed and reported on the smoking behavior of kibbutz members who were among our subjects (26%). Con- firmation of data from such independent observers may be regarded as more reliable than self-reports. Although the kibbutz subjects made up a quarter of the total group their results paralleled the general findings. We know of no completely reliable measure as it would be impossible to observe subjects 24 hr a day outside of a laboratory setting.

The major contribution of this study is that it focuses on a personality variable which appears to be a significant factor in the success

330 JOEL GOLDBERG, AVRAHAM ZWIBEL, MARILYN P. SAFIR and MICHAEL MERBAUM

of covert sensitization-GSR reactivity. It was Lichtenstein E. and Danaher B. (1976) Modification of

found that high reactors have significantly smoking behavior: A critical analysis of theory, research

greater success in reducing smoking behavior at and practice, Prog. Behav. Modific. 3,79-124.

Little L. M. and Curran J. P. (1978) Covert Sensitization: the conclusion of covert sensitization and that they were able to maintain their gains at a higher level during 3 follow-up periods.

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