Pilot study of inducing smoking cessation attempts by activating a sense of looming vulnerability

Abstract

Despite widespread knowledge of the negative health consequences of cigarette smoking, in 2007 a majority (60%) of daily smokers in the USA did not make a quit attempt lasting at least 24 h. Drawing on Riskind's looming cognitive vulnerability model of anxiety, we developed a guided imagery induction intended to increase smokers' perceived susceptibility to the consequences of continued smoking and thereby to increase quit attempts. In a pilot study of this induction, 72 adult daily smokers were randomly assigned to the looming imagery condition or to a control condition exposed to guided imagery that did not concern smoking or its dangers. Those in the looming condition reported significantly higher state anxiety and highly accessible negative outcome expectancies for smoking immediately after the induction, and a significantly lower smoking rate in the month after the experiment. Nonsignificant trends favored the looming condition also for increasing contemplation of quitting, self-efficacy for abstaining from cigarettes, intrinsic motivation to quit as a function of health concerns, and most importantly the likelihood of making a quit attempt in the month following the experiment. Further development and testing of the looming induction as a way to motivate quit attempts is warranted.

Introduction

Despite widespread dissemination of facts about the negative consequences of cigarette smoking, approximately one-fifth of American adults are current smokers (Centers for Disease Control and Prevention, 2008). A majority of daily smokers in the U.S. have no intention of quitting within 6 months (Wewers, Stillman, Hartman, & Shopland, 2003); that is, in the terms of the transtheoretical model (TTM; Prochaska & Velicer, 1997), they are “precontemplators.” In terms of actual behavior, as opposed to intention, recent trends are unfavorable. In 2007, 40% of daily smokers in the US made a quit attempt lasting at least 24 h, down from 47% in 1993 and 44% as recently as 2006 (Centers for Disease Control and Prevention, 2008).

Health behavior change models such as the Protection Motivation Model (Floyd, Prentice-Dunn, & Rogers, 2000) and the Health Belief Model (Strecher, Champion, & Rosenstock, 1997) specify variables that may promote or inhibit smokers' progress toward making a quit attempt in response to concerns about the negative consequences of smoking. Applied to smoking, these models suggest that in response to a perceived threat smokers will be most likely to attempt to protect themselves by quitting (Norman, Conner, & Bell, 1999) if they believe their smoking is hazardous (threat appraisal), believe that their intended cessation strategy is effective, and are confident in their ability to follow through with this strategy.

Smokers' threat appraisals have typically been conceptualized as the perceived severity of the negative health consequences of smoking as well as perceived susceptibility to these consequences, consistent with data indicating that health concerns are cited as the most important reason for quitting (McCaul et al., 2006). Many large scale campaigns aimed at motivating smokers to quit have emphasized perceived severity, informing smokers of the potential fallout of smoking behavior, such as cancers or respiratory diseases.

One type of mass media campaign uses images of smoking-related diseases in order to reduce smoking. These images have been found to increase salience for these consequences, contemplation of quitting, and quit attempts (Borland et al., 2009, Hammond et al., 2007, Hammond et al., 2003). However, use of such images has been criticized for lowering one's sense of personal risk as activated defense processes may result in the smoker dismissing this type of threat (Brown & Smith, 2007). These images represent a potential outcome that the smoker could experience if smoking continues, but there is a documented inclination among smokers to believe that they are less likely than the average smoker to experience negative health consequences (Weinstein, 2001).

For information about the severe negative consequences of smoking to have maximal impact, smokers must personalize it, gaining a sense of their own perceived vulnerability. Perceived susceptibility, i.e., “one's subjective perception of the risk of contracting an illness” (Strecher et al., 1997, p. 74), has been linked empirically with progress through the stages of change identified in the TTM (Prokhorov et al., 2003).

Traditionally, interventions have sought to enhance smokers' perceived susceptibility by increasing the smokers' perceived probability of contracting smoking-related illnesses. Several studies have included a biological screening for the risk of lung cancer to increase abstinence motivation (Ostroff et al., 2001, Sanderson et al., 2008). These interventions can certainly play a role in the effort to increase quit attempts, but they have apparent limitations as well. First, widespread implementation could be expensive, in view of the large population of smokers and numerous smoking-related diseases for which to screen. Second, smokers found to be at lower risk in such screenings could, if anything, show a decrease in the extent to which they contemplate quitting.

Given these possible drawbacks of biological screening, psychosocial interventions to increase perceived susceptibility should also be developed and evaluated. Copeland and Brandon (2000) had daily smokers watch videotaped interviews of others who had contracted smoking-related illnesses and then undergo their own interviews to try to personalize this information. By increasing smokers' perceived likelihood that they would suffer from smoking-related illness, it was found that smokers became more motivated to quit smoking, but this effect was not sustained over time (Copeland & Brandon, 2000).

Anxiety research suggests that a larger and more lasting effect on motivation to quit might be achieved by trying to enhance smokers' perceptions that the dangers to which they are susceptible are increasing, in contrast to relying on a more static appraisal of these dangers as highly probable and severe. The looming cognitive vulnerability model (LCVM; for review see Riskind, Williams, & Joiner, 2006) holds that anxiety is created by the perception that stimuli are dangerous and “are rapidly rising in risk as they approach through time or through space” (Riskind et al., 2006, p. 781). In other words, threat appraisal is not only composed of static appraisals of threat, such as perceived likelihood, but also entails how the individual perceives the threat as changing or escalating. According to this model, anxiety is associated specifically with perceiving a threatening stimulus as moving closer in space or time. As the person imagines the process by which a threat is approaching, anxiety increases. For example, a general, static perception that the world economy is fragile might arouse little anxiety, but a vivid image of an accelerating sequence of events threatening oneself (high rate of mortgage defaults–lower credit availability–lower business activity–recession–decreased consumer demand–declining revenues–layoffs–loss of my job–inability to pay rent–loss of home) would provoke high anxiety. The perception of looming vulnerability has been linked with several types of anxiety, including fear of spiders, fear of contamination, social anxiety, OCD, generalized anxiety, and PTSD (see review by Riskind & Williams, 2005).

The purpose of the study reported in this article was to develop and pilot-test an imagery intervention based on the looming vulnerability model as a way of increasing smokers' perceived susceptibility to negative health consequences and their state anxiety, with the effect of increasing contemplation of quit attempts and (preferably) actual quit attempts. Guided imagery interventions based on the looming vulnerability model have been used to decrease maladaptive anxiety. For instance, anxiety was reduced among participants with subclinical obsessive compulsive disorder by teaching them to “freeze” their looming images of increasing risk of spreading contamination (Riskind, Abreu, Strauss, & Holt, 1997). Conversely, our objective was to increase smokers' anxiety regarding an objectively dangerous situation, the health consequences of cigarette smoking, in the hope that this will motivate them to try to take protective action by attempting to quit smoking.

Using the looming cognitive vulnerability model as a basis for intervening to increase quit attempts offers two potential advantages. First, looming vulnerability has been associated with more sustained anxious responding to a stimulus (Riskind, 1999). Threats viewed as changing and escalating do not easily dissipate and are less apt to be diminished and ultimately ignored (Riskind, 1999). Second, looming cognitive vulnerability could serve to promote anxiety in smokers without decreasing self-efficacy (Riskind et al., 2004, Riskind et al., 2006), which is important given that self-efficacy is a consistent predictor of successful smoking cessation. Typically, increased anxiety is associated with decreased self-efficacy among smokers (Dijkstra and Brosschot, 2003, Zvolensky et al., 2006), but a clinician implementing a looming vulnerability intervention can control the movement and velocity of the threatening stimuli and can make the threatening consequences contingent on the individual's own behavior (Riskind et al., 2006). As such, the participant should retain the belief that averting the feared outcome by taking preventive action is something she or he can accomplish. Looming management techniques have been used before to increase self-efficacy and reduce perceived vulnerability to threatening stimuli (Riskind et al., 2004); therefore, we hypothesize that a looming vulnerability induction could increase anxiety about smoking-related illness while still preserving the belief that one can avoid these negative consequences.

In summary, we conducted a pilot study of a guided imagery intervention to induce a sense of looming vulnerability to the negative health consequences of smoking. To our knowledge, no previous studies have applied the looming cognitive vulnerability model to smoking or smoking cessation. Smokers were randomly assigned to receive either the looming intervention or a control (neutral) guided imagery exercise. The looming and control conditions were compared on several variables measured immediately after the induction: (a) state anxiety immediately after the induction, (b) contemplation of quitting smoking, (c) motivation to quit with specific reference to health concerns, (d) negative outcome expectancies concerning the health risks of smoking, and (e) self-efficacy. We also completed a one-month follow-up assessment as a preliminary examination of (a) the durability of any immediate effects on contemplation, motivation, and outcome expectancies, as well as (b) the impact of the induction on smoking rate and actual quit attempts in the intervening month.