The predictive utility of micro indicators of concern about smoking: Findings from the International Tobacco Control Four Country study
Introduction
Tobacco use is a chronic, relapsing behavior (Fiore, Jaen, Baker, et al., 2008), as most smokers want to quit and make a number of attempts to quit over a period of years (Borland et al., 2012, Centers for Disease Control, Prevention (CDC), 2011). This suggests sustained negative attitudes to smoking. Expressed motivation and attitudes to smoking predict making quit attempts (Borland et al., 2010, Hyland et al., 2006, Zhou et al., 2009). This research is grounded in cognitive theories of behavior change, whereby intentions predict the “actions” that may ultimately lead to the maintenance of healthy behavior, and the desire to quit translates into intentions, which lead to quit attempts or other activities related to the desired behavior change (Vangeli, Stapleton, Smit, Borland, & West, 2011). However, negative attitudes only appear to translate into attempts to quit from time to time, with smokers on average making only around two attempts to quit each year, only one of which lasts a day or more (Borland et al., 2012).
The challenge of smoking cessation is to persist in a task in the face of ongoing contingencies which create strong impulses to smoke. Understanding this challenge requires a reconceptualization of decisional balance away from a simple balancing of the pros and cons of acting (Janis & Mann, 1977), to one between rational, executive preferences and the operational contingencies of the moment (Borland, 2014). The likelihood of making a quit attempt in any given period is theorized to be related to the frequency with which reasons for quitting are made salient, and the capacity for sustained executive control when the thought of quitting is activated; that is, not too many competing demands (Borland, 2014). Measures of attitude accessibility have been shown to predict behavior over and above the valence of the attitude (Fazio and Olson, 2003, Fazio et al., 1986). Thus someone convinced that they should quit, but who never thought about it may be less likely to try to quit than someone initially less certain, but who thinks about it a lot. Frequently worrying about the health consequences of smoking can increase a smoker's motivation to quit (Costello et al., 2012, Magnan et al., 2009, McCaul et al., 2007, McCaul et al., 2006) or make the idea of quitting more salient, and be associated with increased quit attempts (Borland et al., 2010).
Smokers also take actions from time to time that fall short of initiating a full attempt to quit such as forgoing cigarettes and premature stubbing out of cigarettes in response to thoughts about the harms (Borland, 1997). Originally, these micro-behaviors were conceptualized as partial initiations of action, in a context where the smoker was unready to transform this into a full-blooded attempt, but which may contribute to them learning strategies that ultimately help them successfully quit (Borland, 1997). We refer to the occurrence of thoughts and behavioral responses collectively as micro indicators of concern about smoking, as they are situation-based consequences of underlying beliefs, but are not inevitable consequences of holding the beliefs. Micro indicators can be elicited by either contextual factors or active executive consideration of the issue. A tendency for them to occur concurrent with the act of smoking, or when tempted to smoke, may indicate a greater readiness to resist smoking, and thus to make a quit attempt.
Micro indicators have been shown to increase in frequency following population level anti-smoking interventions such as warning labels on cigarette packets (Borland, 1997, Borland et al., 2009a) and advertising campaigns (Borland and Balmford, 2003, Trotter, 1998). The behavioral micro indicators forgoing a cigarette and prematurely stubbing one out, have both been shown to predict subsequent quit attempts (Borland, 1997, Borland et al., 2009a, Borland et al., 2009b, Borland et al., 2010). Greater frequency of prematurely stubbing out cigarettes has also been found to be strongly associated with failure among those trying to quit (Borland et al., 2010). A similar paradoxical relationship has also been observed among smokers with a history of more frequent and/or more recent quit attempts being more likely to make further attempts, but being less likely to maintain abstinence when they tried (Partos, Borland, Yong, Hyland, & Cummings, 2013). These findings have been theorized to possibly mean that the occurrence of micro indicators, at least after an initial quit attempt, might indicate a high desire to quit, but a lack of ability to sustain the effort; that is, anybody who really wanted to quit and who tries multiple times, is manifestly demonstrating a lack of ability to sustain his intention (Borland et al., 2010). Rather than these activities representing preliminary steps, those micro indicators that are not part of a necessary path to making attempts (i.e., other than thinking about the harms), may be more displacement activities taken as a means of doing something in the face of the task of quitting being seen as beyond them. Thus such measures may be able to be used to identify smokers who will find it more difficult to quit and may be in need of extra cessation assistance. The aim of this study is to better understand how micro indicators relate to cessation outcomes and whether the cognitive and behavioral indicators have different relationships. We are also interested in whether the relationships between micro indicators and quitting are independent of an expressed desire to quit, in particular whether they can predict cessation outcomes among smokers with no immediate plans to quit. This latter group is of considerable interest as they are routinely excluded from many studies of cessation outcomes.
Section snippets
Participants
Participants were adult smokers from the International Tobacco Control (ITC) Four Country (Australia, Canada, the UK and USA) study, who were recruited using stratified random sampling and computer-assisted telephone interviewing. The ITC aims to then follow up participants annually, regardless of whether they have quit or are still smoking, and the numbers lost to attrition are replenished at each follow-up with new smokers from the same sampling frame. Further information on ITC survey
Results
The prevalence of the micro indicators remained fairly stable from wave to wave, as may be seen in Table 1. There was, however, a small but significant trend for thoughts about the harms to oneself of smoking to increase, and for thoughts about the money spent on cigarettes to decrease over time. Intention to quit also fluctuated with time however this trend was not linear. Around 30% of smokers reported stubbing out cigarettes before finishing. Many smokers also often thought about the harms
Discussion
The experience of micro indicators of concern about smoking was quite prevalent among our sample of smokers, especially thoughts about the harm their smoking is doing to them and others, and the money they spend on cigarettes. There were some small time-based trends in the levels of micro-indicators, but these did not appear to have interacted with their predictive relationships with quitting.
As expected there was a positive association between more frequent reporting of micro indicators and
Conclusions
Micro indicators of concern about smoking are prevalent, even among smokers with no expressed desire to quit, and indicate future interest in quitting, partly mediated by intentions, where these are present. Micro indicators, particularly prematurely stubbing out cigarettes, also seem to be measuring a lack of capacity to quit successfully in the context of high concern about smoking. We need to better understand smokers in this situation and find ways to help them in their apparently desperate
Role of funding sources
The ITC Four-Country Survey is supported by multiple grants including R01 CA 100362 and P50 CA111236 (Roswell Park Transdisciplinary Tobacco Use Research Center) and also in part from grant P01 CA138389 (Roswell Park Cancer Institute, Buffalo, New York), all funded by the National Cancer Institute of the United States, Robert Wood Johnson Foundation (045734), Canadian Institutes of Health Research (57897, 79551), National Health and Medical Research Council of Australia (265903, 450110,
Contributors
T.R.P. conducted literature reviews, statistical analyses, and wrote the first draft of the manuscript. R.B. designed the study, provided interpretations of the data, and contributed substantially to drafting the manuscript. J.F.T. was involved in statistical analysis and contributed to interpreting the data. L.L. was involved in study design, and contributed to drafting the manuscript and interpreting findings. H-H.Y contributed to study design, statistical analysis, interpretation of findings
Conflict of interest
All authors declare they have no conflicts of interest.
Acknowledgments
We would like to thank members of the Data Management Core at the University of Waterloo for their assistance in preparing the data for this analysis.
Ethics clearance
All waves of the study have received ethical approval from the relevant institutional review board or research ethics committee at the Cancer Council Victoria (Australia), Roswell Park Cancer Institute (USA), University of Waterloo (Canada), and University of Strathclyde (UK).
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