Many smokers believe that a rational, unambivalent desire to quit is needed before it is worthwhile trying, and that short-term impulses to act are not sufficient.1 Helping smokers to overcome their ambivalence about quitting is crucial to increasing quit attempts.
7.5.1 Personalisation of risk
Studies of smokers’ risk perceptions have generally found that many are unrealistically optimistic about their personal health risks.2,3 Smokers show a clear tendency to believe that they are at lesser risk than other smokers of becoming addicted or suffering health effects.2, 4, 5 One study found that those who perceived their own risk of developing lung cancer to be less than the actual risk were more likely to accept myths associated with smoking, overestimate the number of lung cancers that are cured, and be less likely to quit.6 While the risk of lung cancer and other smoking-related diseases are acknowledged by smokers, they often judge the size of these risks to be smaller and less well established than do non-smokers or than scientific evidence would justify.2, 4
Correcting unrealistic judgements about risk may facilitate increased quitting.7 For example, providing adults with an estimation of their risk of global coronary heart disease can improve the accuracy of their risk perception and may increase the intention of those at medium to high risk to initiate preventative actions such as quitting smoking.8 There is some evidence that encouraging smokers to think and worry more about their smoking behaviour, rather than focusing on their beliefs about the risks involved, encourages them to try to quit.9 A study that presented participants with a simulated and personalised experience of a heart attack combined with motivational interviewing found that more than half of participants were abstinent at six months.10
Another strategy that has been suggested for increasing smoking cessation rates is to provide smokers who have contact with healthcare systems feedback on the biomedical or potential future effects of smoking. However, a 2012 Cochrane review found that of 15 studies that provided smokers with feedback on the physical effects of smoking using physiological measurements (for example, exhaled carbon monoxide measurement or lung function tests), only two significantly increased long-term quitting.11 A 2015 randomized controlled pilot study similarly found that lung age feedback did not improve quit rates or compliance at 28-day follow-up in smokers seeking intensive treatment.12
7.5.2 Addressing self-exempting beliefs
According to cognitive dissonance theory, people seek consistency among their beliefs, attitudes, and behaviours. When there is inconsistency (dissonance), people experience discomfort, and attempt to resolve it through changing or rationalising their thoughts and/or actions.13 Smokers widely accept that smoking is bad for them, yet continue to do it. A high proportion of smokers hold various beliefs that serve to minimise the reality of the harms caused by smoking or rationalise their behaviour, and allow them to avoid engaging in the task of quitting.7, 14-17 For example, there is evidence that use of dietary supplements may create illusory invulnerability in smokers and discourage changes in their smoking behaviour.18
Four categories of these beliefs have been identified:14
- Skeptic beliefs indicate smokers do not believe the evidence about the health effects of smoking: ‘Lots of doctors and nurses smoke, so it cannot be all that harmful’, ‘More lung cancer is caused by such things as air pollution, petrol and diesel fumes than smoking’.
- Bulletproof beliefs allow smokers to think that they are personally immune to smoking-related illness: ‘You can overcome the harms of smoking by doing things like eating healthy food and exercising regularly’, ‘I think I would have to smoke a lot more than I do to put my health at risk’.
- 'Worth it' beliefs suggest the benefits of smoking outweigh the risks: ‘You have got to die of something, so why not enjoy yourself and smoke’, ‘I would rather live a shorter life and enjoy it than a longer one where I would be deprived of the pleasure of smoking’.
- Jungle beliefs normalise the risks of smoking: ‘Everything causes cancer these days’, ‘It is dangerous to walk across the street’.
Australian research found that each of the four sets of risk-minimising and self-exempting beliefs was inversely related to intention to quit, however some were more important than others. ‘Worth it’ beliefs in particular were more prevalent among smokers not planning to quit. Higher knowledge of the hazards of smoking and being able to recall at least one anti-smoking commercial was linked to holding fewer such beliefs.14
Subsequent research in the USA, Canada, UK, and Australia found that after controlling for demographic factors, the risk-minimising beliefs (bulletproof, worth it, and jungle beliefs) predicted lower quit intentions and attempts among smokers, but the self-exempting belief (skeptic belief) did not. The authors conclude that countering risk-minimising beliefs may facilitate increased quitting, but this may not be so important for self-exempting beliefs.7
7.5.3 Putting quitting on a smoker's agenda's agenda
The level of media attention that a particular issue receives can affect how important the issue is perceived to be, and the extent to which it is prioritised on a person’s agenda. For example, a greater volume of news coverage has been linked to increased contraceptive use19 and breast screening.20 Research in NSW found that high levels of self-reported exposure to tobacco news were associated with important smoking-related cognitions, including beliefs about harm from smoking and frequent thoughts about quitting. The authors highlight that the media are an important source of information for smokers, and can put or keep quitting on the smokers’ agenda.21 Further, media coverage of the implementation of new health warnings on cigarette packs can stimulate discussions in social settings, and talking with family and friends about health warnings is an independent predictor of subsequent quit attempts.22
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References for Section 7.5
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3. Helweg-Larsen M and Nielsen G. Smoking cross-culturally: risk perceptions among young adults in Denmark and the United States. Psychology & Health 2009;24(1):81–93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20186641
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10. May R, Tofler GH, Bartrop R, Heinrich P, Baird J, et al. Smoking cessation through a novel behavior modification technique. The American Journal of Cardiology, 2010; 106(1):44–6. Available from: http://www.sciencedirect.com/science/journal/00029149
11. Bize R, Burnand B, Mueller Y, Rège-Walther M, Camain J-Y, et al. Biomedical risk assessment as an aid for smoking cessation. The Cochrane Library, 2012. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004705.pub4/full
12. Foulds J, Veldheer S, Hrabovsky S, Yingst J, Sciamanna C, et al. The effect of motivational lung age feedback on short-term quit rates in smokers seeking intensive group treatment: A randomized controlled pilot study. Drug and Alcohol Dependence, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26051163
13. Festinger L, A theory of cognitive dissonance. London: Tavistock; 1962.
14. Oakes W, Chapman S, Borland R, Balmford J, and Trotter L. "Bulletproof skeptics in life's jungle": Which self-exempting beliefs about smoking most predict lack of progression towards quitting? Preventive Medicine, 2004; 39(4):776–82. Available from: www.ncbi.nlm.nih.gov/pubmed/15351545
15. Brennan E. Smokers’ self-exempting beliefs: Findings from the 2006 Victorian population survey. Melbourne: Centre for Behavioural Research in Cancer, 2007.
16. Radtke T, Scholz U, Keller R, and Hornung R. Smoking is ok as long as I eat healthily: Compensatory health beliefs and their role for intentions and smoking within the health action process approach. Psychology & Health, 2011; 27 Suppl 2:91–107. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21812704
17. Fotuhi O, Fong GT, Zanna MP, Borland R, Yong H-H, et al. Patterns of cognitive dissonance-reducing beliefs among smokers: A longitudinal analysis from the international tobacco control (ITC) four country survey. Tobacco Control, 2013; 22(1):52–8. Available from: http://tobaccocontrol.bmj.com/content/22/1/52.abstract
18. Chiou W, Wan C, Wu W, and Lee K. A randomized experiment to examine unintended consequences of dietary supplement use among daily smokers: Taking supplements reduces self-regulation of smoking. Addiction, 2011; 106(12):2221–8. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03545.x/full
19. Jones EF, Beniger JR, and Westoff CF. Pill and iud discontinuation in the United States, 1970-1975: The influence of the media. Family planning perspectives, 1979; 12(6):293–300. Available from: http://europepmc.org/abstract/med/7202692
20. Chapman S, McLeod K, Wakefield M, and Holding S. Impact of news of celebrity illness on breast cancer screening: Kylie minogue's breast cancer diagnosis. Medical Journal of Australia, 2005; 183(5):247–50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16138798
21. Dunlop SM, Cotter T, Perez D, and Chapman S. Tobacco in the news: Associations between news coverage, news recall and smoking-related outcomes in a sample of Australian smokers and recent quitters. Health Education Research, 2011; 27(1):160–71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22156232
22. Thrasher JF, Abad-Vivero EN, Huang L, O'Connor RJ, Hammond D, et al. Interpersonal communication about pictorial health warnings on cigarette packages: Policy-related influences and relationships with smoking cessation attempts. Social Science & Medicine, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26092600