Sustaining the Decline in Smoking Prevalence: an Examination of the Attitudinal Difference Between Lighter and Heavier Smokers

ABSTRACT - Over the years there has been a steady decline in smoking among Americans, but the rate of smoking has been inversely related to the rate of quitting. The purpose of this study was to examine the difference between heavier and lighter smokers' attitudes and beliefs about quitting smoking. The results show that compared with lighter smokers, heavier smokers have a less positive attitude toward quitting because they believe more strongly in the negative consequences of quitting and less strongly in the positive consequences of quitting. Practical implications for antismoking campaigners are discussed.

Citation:

Subir Sengupta (1995) ,"Sustaining the Decline in Smoking Prevalence: an Examination of the Attitudinal Difference Between Lighter and Heavier Smokers", in E - European Advances in Consumer Research Volume 2, eds. Flemming Hansen, Provo, UT : Association for Consumer Research, Pages: 337-342.

European Advances in Consumer Research Volume 2, 1995      Pages 337-342

SUSTAINING THE DECLINE IN SMOKING PREVALENCE: AN EXAMINATION OF THE ATTITUDINAL DIFFERENCE BETWEEN LIGHTER AND HEAVIER SMOKERS

Subir Sengupta, Pennsylvania State University

[The author would like to thank Marvin E. Goldberg, Robert Trumpbour and the anonymous ACR reviewer for the comments on an earlier draft of this article.]

ABSTRACT -

Over the years there has been a steady decline in smoking among Americans, but the rate of smoking has been inversely related to the rate of quitting. The purpose of this study was to examine the difference between heavier and lighter smokers' attitudes and beliefs about quitting smoking. The results show that compared with lighter smokers, heavier smokers have a less positive attitude toward quitting because they believe more strongly in the negative consequences of quitting and less strongly in the positive consequences of quitting. Practical implications for antismoking campaigners are discussed.

INTRODUCTION

Since the Surgeon General's report in 1964 there have been considerable changes in the prevalence of cigarette smoking. In 1955, almost 57 percent of Americans smoked; in 1966, 51 percent were estimated to be smokers. Between 1966 and 1985 the smoking rate dropped drastically to 33.5 percent, and in 1990, 25.5 percent of the Americans were smoking (Fiore et al. 1989; Morbidity and Mortality Weekly Report 1992; Nuehring and Markle 1974).

In spite of a steady decline in the smoking population it is believed that this trend will begin to slow down as prevalence falls to very low levels. This may happen because a greater proportion of the smoking population is likely to be comprised of "hard core" smokers (Pierce et al. 1989), and there is increasing evidence that the number of cigarettes smoked per day is inversely related to quit rates (Eisinger 1972; Gordon et al. 1975; Graham and Gibson 1979; Novotny et al. 1988; Smoking and Health 1979; Srole and Fischer 1973; West et al. 1977).

It is interesting to note the results of a few longitudinal studies that examined the relationship between the rate of smoking and quit rates. Having followed smokers over an eighteen year period, Gordon et al. (1975) found that 58 percent of those who smoked up to ten cigarettes a day had quit, compared with 38 percent of those who smoked more than 10 cigarettes a day. Garvey et al. (1983) tracked male smokers between 1962 and 1976 and found that the average annual rate of smoking cessation was six percent for those who smoked up to ten cigarettes a day, and four percent for those who smoked more than 30 cigarettes a day. West et al. (1977) found that, over a five year period, 23.4 percent of the smokers who smoked 20 cigarettes or less a day had quit, compared to 13.6 percent of those who smoked 30 or more a day. Although there are no clear cut definitions of "heavy" and "light" smoking, there is ample evidence to show that the rate of smoking is an important determinant of smoking cessation.

There may be a number of reasons why some smokers quit, while others do not. Like many behaviors, smoking cessation may be contingent upon the availability of adequate resources, skills, self-efficacy and cooperation of others (Bandura 1977; Kuhl 1985; Liska 1984; Sarver 1983). However, attitudinal factors have been found to have a significant impact on smoking decisions (Grube, McGree and Morgan 1986), and it makes perfect sense to state that in order to quit it is necessary for smokers to have a positive attitude toward quitting. Thus, in addition to other possible differences that may affect the quit rates of lighter and heavier smokers, the two groups may be different in respect to their attitudes toward quitting.

The purpose of this exploratory study is to examine if there is a difference in attitude toward quitting between lighter and heavier smokers. It must be noted that the present study does not attempt to explain all the factors that may cause the two groups to quit at different rates, rather, it will examine only one factor C attitude, that is believed to have a significant influence on behaviors. If the attitudes are found to vary, differences in the factors that determine attitude toward quitting of lighter and heavier smokers will be examined.

ATTITUDE

Attitude is a preeminent concept in contemporary social psychology because of its relationship with human behavior (Petty and Cacioppo 1981). Attitude is a learned predisposition that guides or influences behavior. Thus, a person holding a favorable attitude toward an object will behave favorably with respect to that object, whereas the reverse is true for a person holding an unfavorable attitude (Fishbein and Ajzen 1975).

The expectancy-value model of attitude postulates that AB=Seibi. In other words, attitude toward the behavior (AB) is determined by multiplying each of the beliefs that a person has about the outcome (positive and negative) of performing the behavior (bi), by the evaluation of those outcomes (ei) and then summing the products for the total set of beliefs (Fishbein and Ajzen 1975).

Since attitudes are based on the total set of a person's salient beliefs, understanding attitude requires elicitation of the salient beliefs. By measuring the strength and evaluations of the modal salient beliefs it is possible to measure an individual's attitude and also have specific information about the determinants of attitude (Ajzen and Fishbein 1980). A direct measure of attitude, although employed by many researchers, is not advisable in certain situations, especially those in which subjects are likely to give socially desirable responses (Petty and Cacioppo 1981).

As stated earlier, there are a number of factors in addition to attitude that determine behavior. According to the theory of reasoned action, for most volitional behaviors, attitude toward the behavior and subjective norms make unique contributions to the determination of intention to perform behavior (Ajzen and Fishbein 1980; Fishbein and Ajzen 1975). For other nonvolitional behaviors, the theory of planned behavior postulates that attitude toward the behavior, subjective norms as well as perceived control (which includes the concept of self efficacy) determine intention (Ajzen and Madden 1986). In both theories, intention is believed to be the immediate antecedent of behavior.

The theories of reasoned action and planned behavior are compensatory models (Ajzen 1988). It is possible for two persons or groups to behave differently in spite of having similar attitude toward performing the behavior because of differences in the other component(s) that determine intention. Therefore, although lighter and heavier smokers quit at different rates, it is not possible to predict with a great deal of certainty that the two groups will differ in their attitude toward quitting. The research question is do lighter and heavier smokers differ in their attitude toward quitting? If the attitude toward quitting is significantly different for heavier and lighter smokers, the second research question is what specific attitudinal beliefs are significantly different for the two groups?

METHODOLOGY

Questionnaire Development

Following Ajzen and Fishbein (1980), 40 smokers from a broad cross section of people were asked to list beliefs about the positive and negative consequences of quitting. This procedure resulted in the listing of modal attitudinal beliefs that are salient to quitting. These, along with corresponding outcome evaluation items, were used to construct the questionnaire.

To test the questionnaire, 42 smokers (not a part of the earlier sample) were identified. Of the 42 smokers, 35 agreed to complete the pretest questionnaire. Three of the completed questionnaires were found unusable, resulting in a final pool of 32 usable pretest questionnaires. At first, to ensure that only items most sensitive to the attitude measure were included in the final questionnaire, Likert's item reduction technique (Fletcher 1981) was used.

The responses of the five subjects having the most positive attitude toward quitting and the five having the most negative attitude toward quitting were separated. Separate t-tests were then done on each item to determine the item's ability to discriminate between subjects with the most positive and most negative attitudes toward quitting. A few items failed to discriminate, but before these items were rejected, inter-correlations between these items and the remaining items were computed. In order to be retained, inter-correlations had to be greater than .40 (accounting for at least 15 percent of the variance). Based on these tests, four attitudinal belief items and the corresponding outcome evaluation items were rejected.

Next, the reliability of the questionnaire was tested. According to Churchill (1979), if the construct has more than one identifiable dimension or component, internal consistency must be tested separately for each dimension. Cronbach's alphas obtained for the two separate item groups were .90 for negative beliefs about quitting and .85 for the positive beliefs about quitting C all above the level suggested by Nunnally (1978).

The final questionnaire included 14 attitudinal belief items. Seven negative belief items (e.g., "Quitting smoking will make me start another habit") were measured on seven-point scales anchored by extremely likely (1) and extremely unlikely (7). While, seven positive belief items (e.g., "Quitting smoking will enable me to prevent cancer"), were measured on seven-point scales anchored by extremely unlikely (1) and extremely likely (7).

The seven negative outcome evaluations (e.g., "To me, not starting another habit is ...") were measured on seven-point scales anchored by extremely important (1) to extremely unimportant (7). The seven positive outcome evaluations (e.g., "To me, preventing cancer is ...") were measured on seven-point scales anchored by extremely unimportant (1) to extremely important (7). The use of importance scale is consistent with the measurement procedure employed elsewhere (e.g., Boyd and Wandersman 1991; Manstead, Proffitt and Smart 1983) and is considered appropriate by Ajzen (1988). By reversing the scoring of positive and negative beliefs and the positive and negative outcome evaluations, higher scores would mean a more positive attitude toward quitting smoking. In the final section of the questionnaire, demographic information as well as information about the average daily consumption of cigarettes were collected.

Field Data Collection

The study was conducted in a city where 30 percent of the population is comprised of students from a major university located in the area. As a result, a random sample of the city population would have yielded a disproportionate number of young subjects, and there is some evidence that age is related to the likelihood of quitting, although the evidence is not unequivocal (Garvey 1984; Gordon et al. 1975; Srole and Fischer 1973).

In this exploratory study it was deemed important to recruit smokers with varying demographic characteristics and not just college students. To that end, smokers were recruited from a variety of settings in a city located in the southeastern region of the United States. Following Edwards (1957), to minimize possible effects of social desirability, subjects were assured of confidentiality and anonymity.

Initially 376 smokers were identified but 238 completed the questionnaire. An overall response rate of 63 percent was obtained, which is within acceptable range (Alreck and Settle 1985). Six questionnaires were found to be incomplete and were discarded, resulting in a sample size (N) of 232 smokers. Mean age of these subjects was 29.06; 54.3 percent were males and 45.7 percent were females; 73.3 percent were white and 26.7 percent non-white.

By using a median split, subjects were separated into two groups: those smoking 15 or less cigarettes a day (N1=123), and those smoking more than 15 cigarettes a day (N2=109). Although they are not meant to be global definitions of light and heavy smoking, for the purpose of this study, individuals smoking 15 or less cigarettes a day were labeled lighter smokers, while people smoking more than 15 cigarettes a day were labeled heavier smokers. The two groups were then compared on the basis of certain demographic characteristics. Although the mean age of lighter smokers (M=28.85) was less than that of heavier smokers (M=31.52), the difference was not significant (t-value=1.67, P>.05). No significant differences between the groups on the bases of sex (chi-square=2.35, p>.05) and race (chi-square=0.07, p>.05) were evident.

RESULTS

In order to determine the attitude toward quitting of smokers who smoked 15 or less cigarettes a day and those that smoked more than 15 a day, based on the expectancy-value model of attitude, each belief about the outcome of quitting was multiplied by the corresponding outcome evaluation and the product was summed for all items. Mean attitude scores of 343.03 and 308.87 were obtained for lighter and heavier smokers respectively and the difference was found to be statistically significant (t-value=3.81, p<.01).

To examine differences in factors that determine attitude, t-tests were run on each belief and outcome evaluation items. For the negative outcomes of quitting, the two groups differed on the beliefs that quitting would make them: start another habit (t-value=4.73, p<.01); nervous all the time (t-value=3.85, p<.01); sleepless (t-value=5.45, p<.01); gain weight (t-value=3.26, p<.01); stressful (t-value=3.17, p<.01). For all of the above negative outcomes of quitting, beliefs of the lighter smokers were not as strong as those of the heavier smokers (see Table 1).

Lighter and heavier smokers were found to differ on four positive beliefs about quitting (see Table 1). Lighter smokers believed more strongly than heavier smokers that quitting smoking would prevent them from having: cancer (t-value=2.65, p<.01); heart attack (t-value=2.27, p<.05); emphysema (t-value=2.92, p<.01), and persistent coughing (t-value=1.97, p<.05).

Among the evaluations of negative outcomes, the two groups differed on the importance of not starting another habit (t-value=2.14, p<.05). Lighter smokers evaluated this factor more positively than heavier smokers (see Table 2). Among the positive outcomes of quitting (see Table 2), lighter smokers evaluated the following outcomes more positively than heavier smokers: not having cancer (t-value=2.38, p<.01); not having a heart attack (t-value=2.32, p<.05); not having emphysema (t-value=2.26, p<.05), and not having persistent coughing (t-value=2.44, p<.01).

TABLE 1

ATTITUDINAL BELIEFS ABOUT QUITTING SMOKING

In sum, it is evident that heavier smokers have a less positive attitude toward quitting than lighter smokers. It appears to be a result of differences between the groups in beliefs about the outcome of quitting and the evaluation of those outcomes. Generally, heavier smokers appeared to believe more strongly in the negative outcomes of quitting, while lighter smokers believed more strongly in the positive outcomes of quitting. The two groups did not appear to be significantly different in the evaluations of negative outcomes of quitting, but lighter smokers appeared to evaluate the positive outcomes more strongly than the heavier smokers.

DISCUSSION

Dependence is one important factor in giving up smoking, while the degree of motivation is another. Therefore, strategies to increase quit rates fall into two broad categories C motivational approaches, for example, conducting communication campaigns to change existing attitudes, and treatment approaches to overcome dependence (Russell 1989, 1990). However, motivational approaches are fundamental, because a less dependent smoker with a strong motivation will be able to quit without specific help or treatment (Russell 1990). Furthermore, treatment approaches have been found to be ineffective for smokers who do not have a strong motivation to quit (Pomerleau and Pomerleau 1988).

Antismoking communication campaigns in the past have focussed on making people aware of the negative health consequences of smoking (McAlister 1981; Sorensen and Pechacek 1987). But, negative health consequences of smoking are not the only reason people decide to quit. More than twenty years ago Mausner (1973) noted that smokers decide to quit not only because they have a heightened fear of the consequences of continuing to smoke but also because they have increased expectations of the benefits of quitting. Hence, it is also important to strengthen their attitude toward quitting. To that end, the present study examined differences between heavier and lighter smokers in their attitude toward quitting and beliefs about the positive and negative consequences of quitting.

It is apparent from the results that heavier smokers have a less positive attitude toward quitting in comparison with lighter smokers. In order to change existing attitudes of heavy smokers, a closer look at their beliefs about quitting may have practical implications for message development. For example, it appears from the results that heavier smokers believe less strongly in the positive health consequences of quitting C reducing the likelihood of having cancer, heart attack, emphysema, and persistent coughing, although there is ample evidence that quitting improves the likelihood of avoiding certain health problems commonly associated with smoking (Chyou et al. 1992; Tosteson et al. 1990). It is possible that heavier smokers may not be aware of them or they may even tend to discount them. Therefore, results of latest scientific studies should be convincingly conveyed (using testimonials, if possible) to heavy smokers to change their attitude about the positive health consequences of quitting.

TABLE 2

EVALUATION OF OUTCOMES OF QUITTING SMOKING

It is also apparent from the results that heavier smokers focus more strongly than lighter smokers on the negative consequences of quitting. They are more likely than lighter smokers to believe that quitting will make them feel nervous, stressful, sleepless, and may cause them to gain weight. Most of those fears are real, hence it is germane to convince heavier smokers that the negative effects of quitting can be effectively neutralized by treatment approaches (see Henningfield and Jasinski 1988; Pomerleau and Pomerleau 1988; Tiffany and Baker 1988).

Enhancing perceived benefits and reducing perceived costs of an action is a holistic approach to developing communication campaigns. With proper execution such an approach may strengthen the attitude toward quitting, and since attitude is a motivational construct (Ajzen 1988), it may ultimately enhance the motivation to quit of heavier smokers. However, it must be noted that if effective treatment approaches are not made easily accessible to this high risk group, we may not be able sustain the hitherto steady decline in smoking prevalence in the years ahead.

CONCLUSIONS

Smoking prevalence in the United States has been declining steadily over the years, but heavier smokers have consistently quit at lower rates than lighter smokers. This may be due to a number of reasons. By focussing on one likely cause for the difference in quit rates C attitude toward quitting, the present study shows that heavier smokers have a less positive attitude about quitting than lighter smokers. Having examined differences in beliefs, the fundamental building blocks of attitude, some suggestions for antismoking message development were made.

Due to the sampling procedure used in this study, the results may be somewhat less generalizable, although such sampling procedures are commonly used by motivation researchers (Selltiz, Wrightsman and Cook 1976). A follow-up study on a nationwide sample is planned for the future.

Finally, not long ago Andreasen (1993) urged consumer researchers to actively involve themselves in solving social problems. Since it is well known that cigarette smoking is major contributor to the burden of illness in most societies (McAlister 1981), the present study has, albeit in a small way, addressed an important social problem.

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