CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
A ONE-TIME HEALTH EDUCATION APPROACH
FOR SMOKING CESSATION
A thesis submitted in partial satisfaction of the
requirements for the degree of Master in
Public Health
by
Richard Jay Katz
January, 1981
The Thesis of Richard Jay Katz is approved:
P. E. Lestre1, Ph.D.
W. A. Alkhateeb, Dr.P.H.
M. V. Kline, Dr. P.H.
Committee Chairperson
California State University, Northridge
ii
"Ah these cigarettes!... They are
pernicious, positively pernicious
and yet I can't give them up! I
cough, I begin to have tickling
in my throat and a difficulty in
breathing. You know I am a coward, ...
Porfiry Petrovitch in,
Crime and Punishment
by Fedor Dostoevsky
i i;
11
DEDICATION
I dedicate this thesis to my parents, Julius
and Florence, and my two brothers, Louis and Charles,
who have encouraged and stimulated my intellectual
growth through my years of formal education.
And I
dedicate i t to my wife, Janet, who stood by me and
motivated me throughout the study.
i
v
ACKNOWLEDGEMENTS
This thesis is the culmination of the curriculum
in the Department of Health Sciences in partial fulfil1ment of the Master of Public Health (M.P.H.) at the California State University, Northridge.
I would like to express my gratitude to those
who played important roles in nurturing my ideas about
smoking cessation, and in helping to bring them to fruition in the form of this study.
Dr. Michael, V. Kline, as my advisor and committee chairman, has served as a mentor with his abundance
of cogent thoughts and his ability to steer me away from
superfluity and towards the substantive.
Dr. Pete Lestrel,
a committee member and friend, guided me in every step
from the proposal through the data analysis with unrelenting patience and insightful suggestions.
Dr. Waleed
Alkhateeb, as professor and committee member, helped make
important decisions and suggestions regarding the research
design as well as on the final draft of the paper.
In addition, I would like to make note of the
kind assistance provided by my Uncle Bernard S. Katz in
the editing of this thesis.
This is often a tedious pro-
cedure, and in this instance it was made more difficult
due to the distance (Washington, D.C. to Los Angeles) that
v
the copy had to travel.
An expression of gratitude also
goes to Warren Auyong for his assistance with the computer
programming, Martin Lee, Ph.D. for his advice on nonparametric statistics, and Elliot Gordon and William West for
their assistance with the library work.
Finally, I would like to thank all of those
friends and acquaintances who shared my interest in this
project, and who patiently tolerated my behavior during
the months which it took place.
vi
TABLE OF CONTENTS
Page
ABsTRAcT ... " ..........................
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i
X
CHAPTER
1.
General Introduction
I nt roduc t ion. . . . . . . . . . . . . . . . . . . . . . .
Purpose of. the Project .............
Hypotheses of the Study ............
Definition of the Terms ............
Limitations of the Study ...........
Delimitations of the Study .........
2.
7
8
8
Review of the Literature
Renewal of Interest in Smoking
Cessation. . . . . . . . . . . . . . . . . . . . . . . . . .
Searching the Literature ...........
Health Education Programs for
Smoking Cessation ..................
Behavioral Approaches ..............
Programs for Cardiovascular
Patients. . . . . . . . . . . . . . . . . . . . . . . . . . .
Multiple-Method Studies ............
Media Programs .....................
Advice-Giving by Physicians ........
The Kaiser-Permanente Program ......
Evaluation of Smoking Cessation
Programs ...........................
3.
1
3
5
10
11
12
12
14
17
19
23
25
25
Methodology
Phase I: Development of the AudioVisual Instructional Tool. ....... 30
Phase II: Desian of and Selection
of Knowledge-and Attitude Scales
and Measurement of Behavior
Change.. . . . . . . . . . . . . . . . . . . . . . . . . . 31
vii
CHAPTER
Page
Phase III: Subject Selection and
Discussion of the Sample .........
Phase IV: Research Design ..........
Phase V: Administration of the
Treatment Instrument and
Questionnaires ...................
Phase VI: Evaluation of the Health
Education Intervention
1. Data Collection and
Recording .....................
2. Selection of Appropriate
Statistical Tests .............
4.
34
35
37
39
41
Results and Discussion
1. Mann-Whitney U-Test ............. 46
2. Spearman-rho Results ............ 47
5.
Conclusions and Summary .............. 51
6.
Suggestions for Further Research ..... 56
REFERENCES CITED .............................. 58
TABLES
Mann-Whitney U-Test .................. 66
Spearman-rho Correlation ............. 67
Data ................................. 70
APPENDIX A.
Consent Form . .................... 71
APPENDIX B.
Questionnaire .................... 74
APPENDIX
c.
Instructional Design ............. 77
APPENDIX
D.
Script ........................... 88
APPENDIX E.
Computer Pro grams ................ 94
viii
ABSTRACT
A ONE-TIME HEALTH EDUCATION APPROACH
FOR SMOKING CESSATION
by
Richard Jay Katz
Master of Public Health
An extensive literature review indicated that a
large number of programs have been developed to assist
smokers to stop smoking.
However, few dealt with the
hospitalized patient, or provided specific information on
smoking and its relationship to circulatory diseases
thought to be aggravated by cigarette use.
Furthermore,
many of these programs failed to use statistical procedures to evalutate their effects.
pretest interaction.
Few controlled for
This study was conducted within a
Veterans Hospital setting and evaluated a specialized
smoking cessation program for hospitalized cirulatorydiseased patients who smoke cigarettes.
A health education program dealing with the
ix
effects of cigarette use on circulatory disorders, and
the possible reduction in damage upon cessation of smoking
was presented in a 15 minute audiovisual program.
It was
given individually, at bedside to each patient using a
self-contained projector-audio cassette player.
A research
design employing one control group and· two treatment
groups, one which did not receive a pretest, was employed.
Attitudes, knowledge and smoking behavior were examined,
by means of a questionnaire, immediately before and after
the presentation, and a follow-up was done at one month.
These variables were tested for statistically significant
differences between groups using the Mann-Whitney U-test.
The association between variables within each group was
also tested using the Spearman-rho correlation coefficient.
No statistical significance was found for cigarette use, even though a decrease did take place in the
two treatment groups.
However, statistical significance
was present when comparing the attitude scores between
groups I and III and the knowledge scores between groups
I and III.
Also, significant correlations were found
between knowledge and attitude scores within groups I and
II, and between knowledge scores and number of cigarettes
in group I.
Detailed examination revealed a disparity
between what subjects knew to be true (according to their
X
answers on the knowledge test) and what their attitude,
regarding smoking and health, made them feel was true
(according to their response on the attitude scale).
The
element of cognitive dissonance was examined with regard
to how it might relate to smoking behavior and the design
of smoking cessation programs.
research were also proposed.
xi
Recommendations for future
Chapter 1
INTRODUCTION
In recent years there has been a sharp increase
in the extent of health promotion activities directed at
the American public.
From Nutrition magazine to the
Harvard Medical Letter, all segments of the population
are being bombarded by information about health.
Tele-
vision is also represented in providing health related
topics to its audience.
As a result, health professionals are questioning
the extent and value of these efforts to effect behavior
change, and whether or not the dissemination of information can be equated with education.
The question also arises as to whether there is
a significant value difference between formal programs
dealing with education, or whether a more-or-less shotgun dissemination of information can bring about results.
According to Vickery (1979:87), 33 million Americans quit smoking during the past 15 years.
number~
Of that
95 percent stopped without the benefit of any
formal program--other than the information received from
various
info~mal
sources.
At first glance, this would
seem to indicate there is no need for formal education.
1
2
Of course) what would be the effect of a formal education
program on all the many others who continue to smoke?
It
would seem that the many smokers could use a formal education progt·am, or that perhaps additional information
about smoking and its health hazards needs to be disseminated to the smoking or potential smoking populations.
In a study carried out on U.S. veterans it was
shown that life expectancy varied inversely with the
number of cigarettes used per day {Rogot, 1978).
This
study confirmed an earlier investigation on American men
and their life expectancy in relation to their smoking
habits {Hammond, 1969).
It also is a well-known fact
that coronary heart disease is the leading cause of
death in American men, and those who smoke cigarettes
have twice as great a chance of mortality from all cardiovascular diseases (DHEW, 1976; 1979).
Observation of the patients at V.A. Medical Centers demonstrates that many patients who are afflicted
with severe diseases of the respiratory and circulatory
systems continue to smoke unrelentingly, even though they
know that cigarette smoking is a major risk factor in the
exacerbation of these disease entities (Jail lard et al
1977).
·~
In addition to such factors as smoking and inad-
equate nutr·i ti on, the V.A. Medical Centers • population
suffering from chronic diseases tends to be 50 years or
3
older and are in these centers owing to the effects of
the chronic diseases, besides the war-related injuries
which many sustained.
Abramson (1977), in surveying four
major studies now underway, indicates that continued
smoking in the 50 years and older group presents a significant health hazard to the smoker .. The consensus of
the. studies further indicates that for those 65 years or
older there was a higher mortality rate (24 percent
greater) for those who continued to smoke than for those
who had quit.
the general
Other sources have also indicated that in
population~
even though the outlook for
active smokers may be bleak, former smokers experience
declining mortality ratios as the years of not-smoking
increase (DHEW, 1979; Gaylean, 1978).
Statement of the Problem
Patient data at the Sepulveda California Veterans
Administration Medical Center disclose that a significant
number of hospitalized veterans smoke cigarettes.
Fur-
thermore, a large number of veterans suffer from maladies
of the circulatory system, most notably atherosclerosis,
peripheral vascular disease, chronic venous insufficiency
and coronary heart disease
(Kahn~
1966).
Virtually all patients are told that they should
discontinue or reduce the number of cigarettes when they
4
enter the hospital because of circulatory disorders.
However, little formal or specific education takes place
011
this top-ic.
Among behavioral scientists, it is generally
understood that positive reinforcement is an affirmative
shape1·· of man's behavior (Kanfer, 1975; Korman, 1971;
Sa r d son , 19 7 2 ) .
Info rm i n g a smoker o f better he a 1 t h
through the cessation of smoking might be a major factor
in any program.
Particularly, when this is presented at
a time of higher receptivity, because patients are usually interested in procuring whatever type of care is
available to make them well.
Even though there is little
guarantee for carry-over, hospitalization does tend to
have a sobering effect on many.
One commentator has sug-
gested that in providing health education, reinforcement
of the information is a necessity (Vickery, 1979).
Therefore, it would be helpful to the patient, during the
illness, to explain that the disease process is not
always irreversible if one is willing to change certain
habits.
Thus, patient education has begun to be used for
preventive medicine in the treatment of many diseases,
including efforts to change behavior in the field of
cigarette smoking.
This interest is further reinforced
by the greater concern over the alarming rate of increase
5
in health care delivery cost.
And consequently, i t is
not only prudent but necessary to design and implement
programs which are beneficial and at the same time financially feasible.
It is believed that communication can
play an important role in motivating changes (Freimuth,
1978), and that there is a need to design and implement
a health education program that will accomplish the fall ow i n g :
1.
provide information to the subject during
hospitalization;
2.
provide factual information on the relation-
ship of cigarette smoking to circulatory diseases;
3.
inform the subject of the possible positive
changes and benefits if he were to stop smoking;
4.
provide a health education program which is
brief enough to be given in one short sitting; and,
5.
employ an experimental design to evaluate the
effects of the program.
Purpos~
.Qi. the. Project
The purpose of this study was to design an educational intervention which would meet the needs of a
select group of hospitalized patients.
In order· to .ful fi 11 the aims of this project the
following was done:
6
1.
An educational intervention consistent with
the needs of the population was developed.
This was a
brief audiovisucll presentation, suitable for individual
viewing (see Appendices C and D).
2.
A schedule was prepared for the audiovisual
program for selected subjects at the Sepulveda VA Medical
Center.
3.
Criteria were developed by which the effects
of the health education intervention
~'/ere
evaluated.
A
behavior, knowledge and attitude component were used as
a means of assessing the differences between the treatment and the control groups.
4.
Statistical methods were employed to look at
the differences between groups, and provide additional
information from the data.
Hypotheses of
1.
th~
Study
The null hypothesis to be tested is that
there is no significant difference: between controls and
treatment groups in regard to the following parameters:
1) the number of cigarettes smoked per day, 2) the
changes in knowledge score, and 3) the changes in attitude score, when compared at the same trials.
2.
The nu11 hypothesis to be tested is that
there is no significant correlation between the knowledge
7
scores and number of cigarettes, attitude scores and
number of cigarettes and attitude scores and knowledge
scores at the respective trials within each group.
Definition .Q_f_ Terms
£!rcul!tory-Impaired Veteran:
one or more of the following diseases:
any patient having
peripheral vascu-
lar disease, atherosclerosis, cerebrovascular disease and
coronary heart disease.
Tr~atment
Group:
those individuals who receive
the brief audiovisual presentation in addition to the
questionnaires.
In one treatment group the subjects
received the questionnaire at two different times while
in the other group they received questionnaires at three
d·ifferent times.
Control Group:
Subjects who only complete the
questionnaire at three different times, but receive no
other educational intervention from this Investigator.
Short-Term Educational Intervention:
a one-time,
brief (15 minute) audiovisual presentation (slidecassette), dealing with the effects of cigarette
smoking
on circulatory disease and the positive outcomes if one
quits smoking; administered to each subject individually.
Reactivism:
extraneous factors, other than the
treatment, which influence the behavior of the subject,
8
e.g., simply being observed .
.C~gn·itive DisSOf1ance:
psychological conflict
resulting from incongruous beliefs and attitudes held
simultaneously.
Limitations. of the Study
This study is aimed at a specific population, the
hospitalized veteran with the diagnosis of a circulatory
impairment who also smokes cigarettes.
As this investi-
gation took place at the Sepulveda V.A. Medical Center,
findings of this study cannot be generalized to other
settings without further adaptation and testing.
Delimitations of the Study
Measures to reduce the effects of demand characteristics--the subject feeling compelled to answer questions in a manner which would please the investigator
--are employed. These include:
the use of a standard
mode of presentation by utilizing an audiovisual formats
and minimal subject-investigator interaction by using
mail and telephone questionnaires.
In addition, a con-
trol group design with two treatment and one
non-treat~
ment groups was used to regulate for the consequences
of reactivism.
Factors which could not be controlled were:
9
1) the interaction of the subjects with others in the
environment, 2) the subjects' prior receptivity to the
material and the veracity of the subjects in reporting
the data on the number of cigarettes being used.
To assess honesty and accuracy of reporting of
these data. it has been proposed by others (Burt, 1974;
Wald, 1978} that the level of carboxyhemoglobin in the
subjects• blood be monitored at various follow-up intervals.
This type of quantitative objective observation
while highly desirable was not feasible owing to the
short-term nature of this study.
However, another inves-
tigator (Whitman, 1969) demonstrated the efficacy of
using just a control group and multiple follow-up design
in assessing the benefits of educational programs involving smoking and
health
were employed in this study.
-similar to those which
Chapter 2
REVIEW OF THE LITERATURE
This chapter deals with the literature review
which is organized into three parts.
The first section
describes the reasons for the recent upsurge in smoking
cessation
programs~
followed by a description of the
sources consulted and concluding with seven subsections
detailing numerous smoking cessation programs which have
been reported on in the past 10 years.
Each subsection
deals with different methods used to achieve smoking
cessation, and their subsequent attempts at evaluating
them,
Ren e \'I a l o f I n t e r e s t i!!_ Smo k i n g_ Ce s s a t i o n
The appointment of Joseph Califano, Jr. as
Secretary of HEW renewed interest among researchers and
educators in the area of smoking cessation in the United
States.
Califano (1979:2), a proponent for the anti-
smoking lobby, launched his campaign by increasing the
1978 budget by 50 percent for smoking education activities.
This appropriation was earmarked for programs
which involved
" •.. research, education and public infor-
mation in the field of cigarette smoking and health
10
11
( Ca 1 i fan o , 19 79 : 1 ) ."
Dr. Julius B. Richmond, Assistant Secretary of
Health and Surgeon General, stated that "admonitions
[against the use of cigarettes on the part of physicians]
coupled with the pertinent facts relative to the patients
history can be a factor in an individual's determination
to stop smoking (Richmond, 1979:4)."
Further, the Sur-
geon General's Report on Smoking and Health indicated
" ... that overall, nine out of ten current smokers have
either tried to quit or probably would have quit, if
they could find an effective way to do it (Califano,
1979:7)."
With HEW support a wide range of investigations
and programs, dealing with smoking cessation, were inaugurated.
Some of these programs and techniques will be
discussed below.
Searchin~
the Literature
In the process of searching for published works
in the area of smoking cessation programs for patients
with circulatory disorders, the Index Medicus, American
Public Health Association Index and the Office of
Smoking and
H~alth
were the major sources consulted.
12
Health Education Programs
fo~ Smoking Cessation
A variety of methods have been developed to
assist smckers in quitting their habit.
These include:
desensitization, behavior modification, mass media campaigns, and small-scale health education programs in
specialized settings such as clinics, advice-giving and
multi-media methods.
1.
Behavioral
~_eproac_hes
A behavioral approach was used by Hamilton and
Bornstein (1979) when they randomly placed 60 smokers
into three experimental groups or one of two control
groups.
Instead of choosing subjects with specific ail-
ments they purposely excluded individuals with respiratory disorders, cardiovascular disorders and any other
chronic disease.
The Smoking Abstinence Program (SAP)
consisted of self-control methods, problem solving ana
rational restructuring, and not the delivery of information on the dangers of smoking as related to various
diseases (Hamilton and Bornstein, 1979:598).
Each of the
three treatment groups consisted of 14 sessions over a
period of three weeks.
Group one members were subjected
only to the SAP format, while group two members also
signed contracts stating that they agreed to wear an
13
'I Quit Button' for at least one month, were listed in
a congratulatory notice, received a letter of commendation and were assigned to a buddy system.
Group three
members were subjected to all the actions provided to
group two members, with the additional fact that group
three members were made paraprofessional trainers at the
end of the program.
Results indicated that the last two treatment
groups reached smoking cessation rates which were significant.
However, a six-month follow-up showed a high per-
centage (50%) of relapse in these groups (Hamilton and
Bornstein, 1979:559).
to
11
They mention that there is a need
parcel out the active therapeutic ingredients in the
Social Support Package (Hamilton and Bornstein, 1979:
600).
11
A stop-smoking program sponsored in an industrial
setting used a five consecutive day format (approximately
1~
hours per session) for employing both behavior modifi-
cation and information dissemination techniques.
Of the
118 people who attended the five sessions, 25 percent
were still not smoking at the twelve month follow-up
(Mossman, 1978:213).
One Of the behavior techniques employed by psychologists to help change people's smoking habits is
emotional role playing.
Mann and Janis (1968:339)
14
followed 35 subjects over a period of 18 months to study
the long-term effects of emotional role playing on
smoking behavior.
One month following the treatment
the experimental group showed a greater decrease in number of cigarettes smoked than the control group which
proved to be a significant at the ol=0.05 level (Mann and
Janis, 1968:341).
The investigators felt that emotional
role playing may have a pervasive effect on the patients•
attitudes regarding smoking and ill health, and thus
would account for the long-term influence since a significant difference was found between the control and
experimental group at the 18 month follow-up (Mann and
Janis, 1968:342).
2.
Programs f~ Cardiovascular
Patients
Studies which cater to the patient with cardia-
vascular disorders who smoke are discussed in this sect
ion.
Croog and Richards (1979) and
Burt~~-
(1974),
in separate investigations studied cigarette use in post
myocardial infarction patients.
Reduction in the use of
cigarettes was shown to occur over time.
The former
study employed no educational intervention relying solely
on the patient•s health beliefs, while the Burt et al.
study included medical advice by physicians and nurses,
15
and reinforcement by junior medical staff as
pamphlets~
well as severe warnings against the continuance of
smoking.
Croog and Richards (1977) followed the smoking
patterns of selected patients, who had myocardial infarctions, from discharge to 7-8 years after.
They found
that patients had either quit or had reduced cigarette
use and maintained themselves at a constant intake level
from one month following discharge through the seven
year follow-up.
According to these authors this pheno-
menon occurred regardless of the subject's attitudes
towards their control of their diseases, suggesting a
contradiction of the
Burt 5:.1
2.1~
Burt~~-
study.
(1974) had a success rate (nonsmokers)
of 62 percent for a 1-3 year follow-up.
They suggested
that this unusually high rate was due to the fact that,
11
Pa t i e n t s
\'J
h o ha v e a my o c a r d i a 1 i n fa r c t i o n a r e , o f c o u r s e,
more strongly motivated to accept advice than apparently
health individuals who feel well
(Burt~
E..!.·, 1974:306)."
These studies in addition to earlier ones
(Weinblatt, 1971; Werko, 1971) have suggested that the
reduction in the use of cigarettes, even though not
necessarily complete cessation, might be linked to the
occurrence of a life-threatening event.
Consequently,
it has been presumed that the level of receptivity to
16
health messages may be altered during periods of serious illnesses.
Halhuber (1978) employed a twice-weekly program
over a period of 4·6 weeks to get post-myocardial infarction patients to cut down or completely stop smoking.
Group techniques were used stressing an interdisciplinary
approach (physician/social worker).
This long-term
treatment program was without any controls, and it did
not begin the sessions until the subject was an outpatient.
Rather than providing information it relied
'
largely on group interaction which included discussions
on why one smokes.
Another study involving outpatients diagnosed as
having cardiorespiratory problems, found that using
general health education along with counseling yielded
a higher number of subjects who quit smoking, than either
technique alone (Rose and Hamilton, 1978:278).
Anti-
smoking advice was given to civil servants by physicians.
The study incorporated a randomized-control group design
resulting in more than 50 percent of the subjects still
not smoking after one year.
This study used high risk
cardiorespiratory patients and imparted information at
a personal level.
However, they felt that their success
rate was obtained through using "a health-conscious and
receptive group of civil servants (Rose and Hamilton,
17
1978:280) .
11
Even though all of the above
studie~
had the
common thread of using subjects with cardiovascular disease none started the stop-smoking program when the patient was hospitalized.
3.
!1_ult_i.J?.l..§':__:-f·~etho_9_
Studies
The next studies involve the use of more than one
technique in an attempt to find out which approach is
most effective in achieving smoking cessation.
In Winebago County, Illinois three different
approaches to smoking cessation were employed as educational tools in a high school setting.
One hundred 9th,
lOth and 11th grade subjects were placed in one of four
different experimental groups (25 in each group),
1) using the scare tactics approach, 2) delivering factual information on smoking and health, 3) focused on
changing attitudes, and 4) was the control groupreceiving no educational material on smoking or any
other techniques; but instead spending a comparable period of time in the study hall (Greenberg and Deputat,
1978:499).
Follow-up was done at five months through
the use of questionnaires which the subjects completed
themselves.
Results of this study showed that the attitude
18
~hange
approach had the greatest success rate at the five
month follow-up while the scare tactics approach was most
successful after the session had immediately ended.
This
suggests, that while scare tactics may succeed in getting
people to initially stop smoking, the duration of this
effect is not necessarily long-term.
On the other hand,
an approach which provides factual material in conjunction with attitude change methods is one which may have
a sreater effect over the long run.
S c h e ~" c hu k , Dub r en tl
ods to help smokers quit.
~.
( l 9 7 7 ) us e d t ln~ e e me t h -
They found that group therapy,
individual counseling and hypnosis all yielded approximately the same 20 percent of ex-smokers after a one year
fQllow-up.
Rose and Hamilton (1978:280) also mentions
that the success rate at all smoking clinics--where subjects volunteer--is about 20 percent after one year.
Milligan and Suttake (1975) recorded a figure of 19.5
percent (ex-smokers after one year) in their report on
corr~unity
smoking cessation clinics in New Jersey.
It
is interesting to note that all three authors mentioned
a 20 percent rate of cessation after one year as an
average finding for clinics.
Thompson (1978:251) in her study on smoking
cessation programs mentioned one such program which
evaluated the effects of four different techniques of
19
conveying information on the subjects' attitudes, knowledge and behavior.
This study included the didactic
approach, group discussion, psychological persuasion and
a comb·ination, and found that
11
Where a method scored best
in one area it was least successful in others ...
4.
Media p_ro gr~uns
The following programs involve the use of media
methods for smoking cessation.
This includes television,
audio-visual aids and the telephone.
A 1978 Finnish study used a televised stopsmoking clinic to
11
assist adults to succeed in stopping
smoking in the country (Puska et iLl_., 1979:2)."
The
program consisted of three sessions on alternate days
the first week, and sessions on Mondays for the subsequent four weeks, during the evenings lasting a total of
45 minutes each.
Besides giving the reasons for not
smoking and providing methods for achieving this goal,
a studio group of smokers was observed throughout the
program.
In order to evaluate the value of this mass media
presentation (N = 5,987), a national survey was conducted.
The survey used a pre- and posttest format with all
questionnaires to be received and returned by mail.
results of the survey immediately after the program
The
20
showed that 11.6 percent of those who had indicated that
they were smokers stopped smoking.
A one year follow-up
on these individuals showed that 4.1 percent were still
non-smokers.
Though the percentage of non-smokers seems
small, it must be remembered that this program dealt
with a very large sample size out of an even larger population.
lt was noted that it had the added effect of
stimulating many articles and programs on smoking cessation in the various newspapers and news broadcasts, as
well as bringing about interest in starting up smoking
cessat·ion clinics in the community (Puska.
~_! ~l··
1979:
1 0) •
A Swiss study (Biener, 1977) involving the
effects of a health education interventation on men and
women, 17-20 years old, showed that between 10-15 percent
of the subjects quit smoking, while 50 percent reduced
their smoking.
The project incorporated audiovisual aids
into an intensive course lasting one week.
Although the
author considered the results to be good, he suggested
that health education of this type be started at an
e a r 1 ·j e r a g e .
In his doctoral dissertation, McAlister compared
a videotaped
~making
cessation program, which was run
u n d e r t h e g 1.1 i d a n c e o f a p a r a p r o f e s s i o n a 1 , wi t h t h e c o n -
ventional smoking control clinic (Danaher, 1980:151).
21
In his study he suggested that the videotaped paraprofessional-run program
short run) as
t~e
11
\~as
an effective (at least in the
more costly quit smoking clinic con-
ducted by a trained consultant (Danaher, 1980:151}.
11
Danaher in his revievJ of "Smoking Cessation Programs in
Occupational Settings 11 directs his attention to studies
by Dubren, Green, Schwartz and others who illustrate the
utility of employing various types of media as adjuncts
to smoking cessation programs or as occasional reinforcers.
In addition, he states that this technique
helps reduce the amount of professional contact time,
can be used over and over, and is cost effective (Danaher,
1980:151).
When combined with a physicians advice
(particularly when given to a patient after suffering
a myocardial infarction) such aids have proven as effect i v e t ha n whe n g i ve n to p a t i e n t s i n c l i n i c s ( Pu s ka ,
~!.,
_gj:.
1979:21).
Butcher (1977) reviews the Tel-Med system which
provides health and medical information over the telephone.
Among the 271 tapes are six which deal with the
subject of how to quit cigarette smoking.
These six
tapes have accouQted for 10,000 of 325,000 requests
over a two-year period.
Butcher mentions that one popu-
lar five-day stop smoking program uses similar audiotapes as a means of reinforcement.
Although no controlled
22
study has been completed on the efficacy of the Tel-Med
system in bringing about smoking cessation, it is one
which is both brief and inexpensive as well as highly
accessible.
Public Service Announcement have made the public
aware of the dangers of cigarette smoking ever since the
Surgeon General ;s first warnings in 1964.
Subsequently,
all cigarette advertising was removed from television.
Now, instead of telling the public whith brands of cigarettes they should be smoking, television news people
are informing people of how to stop smoking.
One such
program which was studied and reported took place in New
York City and was televised on the WNEW-TV news between
10-ll p.m. (Dubren, 19l7).
A total of 20 messages
covering such topics as the danger of smoking, a smoker's
self-testing kit and a day-by-day quiting plan.
The
entire course was televised over a period of one month.
This was the first mass communication stop-smoking which
was televised and at the same time evaluated for its
effectiveness.
Smokers were requested to register for
the program by sending in postcards with certain information.
After four weeks a telephone follow-up showed
that nearly 10 percent of the 292 respondents had quit
smoking; 15 percent men and 7 percent women (Oubren,
1977:82}.
It should be noted that women responded at
23
greater than twice the rate of men.
The author concludes
that through the results of this study one sees "a significant role for the mass media in helping people stop
smoking (Dubren, 1977:84).
5.
Advice-Giving~-
11
Physicians
In the following studies, advice-giving was
advocated as a technique to influence smokers to quit.
Raw (1976) studied the correlation between patients' motivation to give up cigarette smoking and their
actual smoking behavior over a three-month period.
Also,
he evaluated the value of advice given by health professional types upon the patient's smoking behavior.
There
was found to be a positive correlation between motivation
scores and a reduction in the quantity of cigarettes
smoked.
It was shown that subjects who received advice
reduced their cigarette use "by 39% on average compared
wi t h 17% i n tho s e who r e c e i v e d none ( Raw , 19 7 6 : 9 9 ) .
il
Another stop-smoking program (1979) took place
in Great Britain where 2,138 subjects were divided into
four groups:
Group One -A nonintervention control,
Group Two -Questionnaire only control,
Group Three - Orally advised not to smoke,
Group Four - Also orally advised not to smoke,
24
but also provided with literature relating to smoking and
health.
In a follow-up review after one year -with 73
percent repeating - group four showed the most ex-smokers.
The author suggested this technique of oral advice by
the physician and the use of literature on the subject
could result in about five percent of the
pati~nts
to
stop s mo k i n g.
~loads
(1979:349) recommends that all family
physicians give advice on ways to stop smoking along with
pointing out the dangers if one continues, and the
benefits when one quits.
He suggests that since studies
show that "only half of the population believes that
srr.oking •can help cause' heart disease •.. (Woods, 1979:
349)" and since family physicians see a large number of
these high-risk individuals, they are the ideal focus for
beginning a stop-smoking program.
These two articles
both suggest that advice against the use of cigarettes
be given in the specialized setting of the physician's
office.
However, they make no mention of investigating
the attitudes and knowledge of the subjects, on cigarette
smoking and health, nor do they select patients with
disorders that are aggravated by the use of cigarettes.
25
6.
The Kaiser-Permanente
Proora~
One of the more successful smoking cessation
clinics reported on in the recent literature is the
Kaiser-Permanente of Northern California program.
This
program covers eight weeks, meeting for two 90 minute
sessions tv-lice weekly (Harrup et _gJ., 1979).
Prior· to
program initiation, an interview session takes place to
decide whether or not the client needs to join the group.
If not, the subject is provided with self-help materials
and a telephone or return visit follow-up.
For those
who join the group the next 13 meetings involve the
teaching of motivation strategies and the creation of
support systems.
The concept of maintaining cessation
of cigarette smoking is stressed rather than immediate
quitting.
After one year, 47 percent remained non-
smokers (Harrup
~
Ql., 1979:1230).
This program took place in a Health Maintenance
Organization employing the help of eight trained counsel ors.
Therefore it is probably not practical for mass
consumption in all types of settings, and it requires a
good deal of time.
7.
Evaluation of Sm()Jsj_~
Programs
~~saJ:iQ_n_
A Canadian study dealing with an evaluation of
smoking clinics suggested that concentrated educational
26
programs are most successful when efforts are directed
at persons who desire help the most.
This study indi-
cated that the average rate of cessation was 28.6 percent
after one year, and that this group was dominated by
individuals who were older, had smoked for a long time,
and had never tried to quit smoking before (Delarue,
1973).
Thus, providing information which suggests posi-
tive health outcomes appears to be a greater influence
to these individuals.
Thompson (1978), in her review of smoking education programs over a period of 16 years, suggested the
need for a standard measure of success.
She also gives
a list of areas which should be covered in reporting on
the study.
These areas include:
1.
Comprehensive description of the treatment
2.
Description of the data collection procedures
program.
and (where applicable) an experimental design.
3.
Complete presentation of response rates and
reasons for nonresponse at each point in time.
4.
Presenation of results, including:
a.
description data regarding the characteristics of the participants
b.
analytic
data~
explofing factors related
to success/failure or other aspects
27
measured (Thompson, 1978:254).
Pomerleau t l li.s (1978), in a recent study,
tried to find predictors to identify whether or not a
subject is likely to return to cigarette smoking.
The
characteristics of one hundred subjects were ana1yzed in
regard to their behavioral change following their participation in a smoking cessation program.
This program
incorporated a multicomponent psychological approach
beginning with eight 90-minute sessions spaced over
eight weeks, with five additional sessions during the
subsequent ten months.
Thus this program provided rein-
f o r c e me n t u n t i l t h e o n e y e a r f o 1 l o \<I - u p .
The i n d i v i d u a l ' s
smoking status was also reported at two years.
Even
though the number of cigarettes being smoked was selfreported) nicotine urine samples were taken from nine
subjects to help control for honesty of reports.
The first follow-ups (8 weeks) showed that 61
percent of the 100 participants had stopped smoking; the
next two follow-ups showed a 32 percent (1 year) and 29
percent (2 year) cessation rate (Pomerleau et al., 1978:
66) .
The variables which were used as predictors were:
percent
overw~ight,
prior smoking rate, years smoking
and degree of cooperation or compliance.
It was found
that those subjects which were classified as negative-
28
affect smokers (a smoker who smokes under conditions such
as tension, anger and impatience) had the highest rate
of relapse.
The findings would suggest that this type
of smoker might require relaxation techniques before
he/she would become receptive to the usual
combination
of behavioral and educational strategies.
In conclusion, these studies tend to show an
interest in programs which use either a psychological
or mass information dissemination approach in dealing
with the problem of smoking cessation.
There were
several programs which dealt with cardiovascular patients,
and other programs which gave advice on a personal level.
However, none of them focused their attention on the
hospitalized patient who suffers from a specific disease
which is known to be acutely affected by cigarette
smoking.
None used a formal brief education program at
this crucial time in the patient•s illness.
In addition,
many programs neglected to employ designs which incorporated control groups.
The problems inherent in research dealing with
smoking cessation and the need for even more investigations is aptly expressed by McFall who indicated:
29
Generally, the standards for good design in
smoking research are not different from the
standards in other clinical areas. The very
nature of smoking behavior however, poses certain
difficulties in attempts to achieve those design
standards. Specifically, measurement problems
have been a chronic weakness . . . . An efficient,
safe, effective treatment for smoking behavior
remains an elusive goal, although progress
toward this end seems to have been made in
recent years (McFall, 1978:712).
This thesis, while sharing some common elements
in design and format (pretest-posttest, audiovisual aids,
and cardiovascular patients) differs from the above by
concentrating on hospitalized veterans with specified
illnesses, and relying solely on a one-time audiovisual
presentation.
Finally, it goes beyond examining the
rate of change in cigarette use by also evaluating the
subjects• attitudes and knowledge concerning smoking
an~
health.
Chapter 3
METHODOLOGY
In this Chapter the procedures and methods of
implementing and evaluating this program will be described.
in detail.
To provide a more systematic approach in the
planning stage, this section was divided into six phases
each corresponding to the approximate order in which they
were carried out.
The 1) first phase entailed the development of
the audiovisual tool, 2) the second involved the design
and selection of the
knowledg~,
attitude and behavioral
measures, 3) the third phase covered the subject selection, 4) the fourth phase describes the research design,
5) the fifth phase began with the administration of the
questionnaires and the treatment tool, and 6) the sixth
phase dealt with the evaluation of the health education
intervention.
Phase I:
Development Qf try_§. Audio-Visual
Instructional Tool
A slide-audiocassette presentation was used to
convey information on smoking to hospitalized patients
in the veterans hospital.
The Investigator met with the
Chief of Medical Media at the Sepulveda VA Medical
30
31
Center.
A treatment, instructional design and a script
with storyboard were done (see Appendices C & D).
With the planning stage completed, the production
work was begun.
This involved photography work and medi-
cal illustration for the slides.
After the visual portion of the program was completed the audiocassette was made.
The audiocassette,
using one of the soundproof rooms in the Audiology Department, was recorded.
Synchronization of the slides with
the tape was done by introducing a signal on the tape
where a slide change was desired.
Variations in pacing
were experimented with until a speed was achieved which
would allow the viewer to view the slide and listen to
the audio comfortably.
Phase II: Design of an~ Selection Qf Knowled~
-----and Attitude Scales and Measurement
of Behavior Ch~A search of the literature yielded a number of
references on the use of scales to measure the opinions
of smokers.
One such study examined smoking behavior in
a large population (Maillet and Chappell, 1977).
The
ten-statement attitude scale in the New Brunswick study
was used (see Appendix B).
Each statement has five possible responses:
1-strongly agree, 2-agree, 3-no opinion, 4-disagree or
32
5-strongly disagree.
The respondent is asked to mark the
number which best describes how he/she feels about this
statement.
After giving this test to 10 non-smokers it
was concluded that five of the ten statements are agreeable toward the non-smoker while the remaining five are
favorable to the smoker.
Thus, a low score on questions
1, 3, 4, 8 and 9 would indicate a bias toward the nonsmoker, and a low score on statements 2, 5, 6, 7, and 10
would indicate a bias toward the smoker.
statement 9 which says:
For example,
''A person smoking around other
people takes away their right to breathe clean air.
11
was a statement which all non-smokers who were tested
give either a 1 or 2.
The first group of statements (1,
3, 4, 8, 9) was designated as type A and the
group was designated as type B.
s~cond
If the individual has
a bias towards the non-smoker a small sum of type A and
a large sum of type B statement would be expected.
The
ratio of B/A will fall within the limits since there are
5 questions with a maximum positive/negative count of
25:
B/A
= 5/25 = 0.2------1.0------5.0 = 25/5 = B/A
A score of greater than one would classify the subject as
biased toward the non-smoker whereas a score of less than
one would bias the subject toward the smoker end of the
scale.
p '
33
The ratios were then evaluated for the presence
of a change in attitude from one trial to the next, and
between the experimental groups and the control group.
Next, ten questions which could either be
answered as true or false were then generated from the
information which was given on smoking and health for
the knowledge part.
Six of the questions were scored as
true and four as false (see Appendix B).
Each correct
I
answer was scored as 10 points; thus ten times the number
of correct answers gives the subject•s score in percent.
The questions were evaluated for understanding through
discussion with patients who would not participate in the
study, but who fit the criteria.
Adjustments to the
questions were made as necessary.
Two additional questions were included in the
questionnaire at two different times to measure behavior
change through an estimate of the number of cigarettes
being used.
The first question asks the subject how many
cigarettes were being used before hospitalization and
the second asks how many cigarettes are being used at
the time the questionnaire is being filled out.
The
first question is designed to establish if the hospitalization itself caused a decrease in cigarette use.
This
could occur for a number of reasons, including an accessibility to cigarettes, fewer hours awake per day or
34
concern for the effects of cigarettes on the illness.
Phase III:
Subject Selection and Discussion
Q.f. the Sa~
A demographic profile of the participants showed
that the mean age was 59.95 years with a range of 39-75
years.
All subjects were male United States veterans
with the following breakdown of diagnoses:
1) peripheral vascular disease - 12 percent
2) myocardial infarction - 38 percent
3) diabetes mellitus- 24 percent
4) cerebral vascular accident - 6 percent
5) hypertension - 20 percent
Since this research took place in a V.A. hospital
it required that certain prescribed governmental regulations on the use of human subjects be met.
The research
proposal was sent to the Sepulveda V.A. Medical Center
Human Studies Subcommittee for approval.
In addition.
the proposal required the use of Human Studies Consent
Form (Addendum to V.A. Form 10-1086) which informed the
subject of the possible risks that this type of research
involved (see Appendix A).
The following method was employed in selecting
the patients for this study and assigning them to one of
the three groups:
in order for a patient to be eligible
35
for this study, he must be a male veteran inpatient, who
currently smokes cigarettes, and who suffers from a circulatory disease, as described earlier.
Certain wards
were selected from which participants would be chosen
(Cardiology, Vascular, Medicine and Pulmonary).
Each day the admissions sheet was scanned to
check for new patients or transfers to these wards.
In
addition, the help of physicians and nurses on the wards,
who were notified of the study, was actively sought as
well as a notice in the daily bulletin on three consecutive days.
These approaches were used until at least
twenty patients were selected for each of the three
groups.
Once a patient volunteered to participate in the
study he was placed in one of three groups.
This was
done by using a random number table (Dixon, 1957:366370).
Thus the subject nor the investigator had no in-
fluence in deciding which group the subject was placed.
Phase IV:
Research Design
The research design for this study was selected
after consulting with the thesis committee in addition
to several texts on this subject (Kerlinger, 1973;
Issac,
1977~
Selltiz et
~.,
1959).
Rather than em-
ploying a one treatment group and one control group
36
design, a third group was added which received the treatment, but no pretest.
The addition of this third group
served as a control on the presence of a pretest effect
(Kerlinger, 1973:339).
Pretest
Gro~
Treatment
Pos ttest-1
Posttest-2
1-Pretested ( R)
2-Pretested ( R)
X
3-Unpretested (R)
X
( R):
Tl:
Random assignment
Immediately preceding the treatment, or first presentation
of the questionnaire in the case of the control group.
Immediately follm'-ling the treatment, or in the control
group 15 minutes after the administration of the first
questionnaire.
If the patient is not in the hospital at one month this
questionnaire will be mailed (exactly one month following
the administration of Tz) with a self-addressed stamped
envelope enclosed. If there is no response after two
weeks, fo 11 ow-up phone calls wi 1l be made.
X:
Audio-Visual health education presentation.
The analysis depends on the assumption that the pretest
scores for group 3 are similar to the pretest scores of
group 2, but since group 3 was not pretested, no interaction between the intervention at Tl should be present
in the posttest scores (Isaac, 1977:41).
37
StatisticaL Hypothesis:
The null hypothesis for the purposes of testing
is shown as:
H0 : Group I = Group IITl; therefore it should follow that
Tl
Group IT2 : Group IIT2
:
Group ITJ : Group IIT3
:
Thus, there should
Group IIIT
2
and
Group IIIT .
3
be no difference in the means
of the number of cigarettes, attitude scores and knowledge
scores of the three groups at the respective trials
(times).
Phase V: Administration of the Treatment
------Instrument and Questionnaires
Once a patient was selected for the study and was
found to have met the criteria, he was randomly assigned
to one of the three groups as described previously.
If
the subject was selected for either group I or II he was
given the pretest questionnaire and instructed to complete
all three parts to the best of his ability.
It was empha-
sized that honesty in answering all questions was extremely important otherwise the information gathered
would lead to faulty conclusions which would be of little
value.
If the subject was placed in group III he was
38
given the 15 minute slide-cassette presentation immediately
following the completion of the consent form, without any
pretest.
Following the completion of the pretest, Group I
members waited 15 minutes and were then given another copy
of the questionnaire to fill out (containing both knowledge and attitude sections but not the behavior questions).
However, members of group II received the audio-
visual presentation and the second questionnaire following
the viewing of the presentation.
Once subjects in group
III finished watching the presentation they completed
their questionnaire, which included all three parts (as
in T1 for groups I and II). Each subject was requested
to put his name and address on the questionnaire for purposes of follow-up at one month, though Questionnaires
were coded for data collection.
One month {T 3 ) following the administration of
the treatment/questionnaire each subject was contacted
either by mail, or if still hospitalized, by a personal
visit.
At this time the subject (all three groups) was
requested to complete the same questionnaire as he had
earlier filled out at T1 in groups I and II or r 2 in group
III. Thus} h~ was questioned, again, about his knowledge
and attitudes about cigarette smoking, and also asked how
many cigarettes he was presently using.
If no response
was received via the mail, after a period of two weeks,
39
the subject was contacted by telephone and asked the
questions while the Investigator completed the form with
the subject•s responses.
If the telephone number was
unobtainable and the questionnaire was returned, due to
incorrect address, no further attempt was made at locating
the subject.
If, however, the questionnaire was not
returned, and the phone number was unlisted one additional
questionnnaire and self-addressed, stamped envelope, was
sent to the original address.
It should be mentioned that
all questionnaires and slide-audio presentations were
given by the Investigator to prevent the possibility of
•between presentor' error, since this way they would all
receive the same contact.
Finally, the intervention was provided on an
individual basis, in the patient•s room, using a Singer
Caramat
®
Projector with a set of headphones.
The pa-
tient was simply requested to view and listen to the presentation.
Headphones were
~sed
to guarantee optimal
privacy, and reduce extraneous noise.
Phase VI: Evaluation of the Health
-rducation Intervent10n
1.
Data
Col.}_~ctio_D_
and Recording_
As each r 3 questionnaire was received it was
collated with the earlier questionnaire(s), with the same
I
4-0
coded number.
Once the questionnaires were put in order
tt1ey were then analyzed for the number of correct answers,
the attitude scores, and the number of cigarettes across
time.
This information was recorded on the top of each
sheet.
A deadline for all data collection was set for
June 30, 1980.
Thus, any questionnaires received after
this date would not be used in the
initi~l
data analysis,
but may be used if necessary for further analysis.
At
this time 65 subjects were collected for the study
(Group I, N=14; Group II, N=l6; and Group III, N=15) with
45 completed sets of questionnaires.
That is, 45 parti-
cipants completed and returned the T3 follow-up, while
the 20 remaining subjects did not for various reasons
which were not determined.
After the deadline, the questionnaires were
separated into groups, as designated earlier and the data
were extracted and made into charts. for easier interpretation.
When the accuracy was verified, means (i) and
standard deviations (SD) were calculated for each of the
variables, at each trial in each of the three groups.
It
was necessary to convert the attitude scores into a single
ratio, as discussed earlier, before this could be done.
'
41
2.
Se~_c t.l..2_!l
Q_f fu:uu"o p d
Statistical Tests
at~­
Once all the data were compiled they were evaluated as to the sample size, and the scale of measurement.
The usable sample was limited to 45.
Since the data con-
sisted of ordinal or rank type it required the use of nonparametric methods.
To test the null-hypotheses (discussed earlier)
the
~1ann-Whitney
U Test was chosen.
It determines
11
Whe-
ther two independent groups have been drawn from the same
population (Siegel:1956:T16).
11
This test is similar to
the parametric t-test, but unlike the t-test, it can be
applied to data which is at least ordinal.
Since in this case directionality is not an issue,
the region of rejection is tv.ro-tailed for c<:=0.05 level of
significance.
When the statistical sample shows a large number
of ties in each group a correction factor must be intraduced.
Otherwise the ntest is more 'conservative•, i.e.,
decreases the probability of a type I error (rejecting the
null hypothesis when it should not be rejected (Runyon and
Haber, 19 7 7 : 2 61 ) . ''
It s ho u 1 d be em ph a s i zed that t i e s
within a group do not affect the Mann-Whitney U-test; but
ties between two or more trials which are being compared
do.
Siegel (1956:123·125} provides a formula to correct
42
for the ties.
To perform the Mann-Whitney U-test a Wang 2200
Minicomputer was used incorporating the program supplied
by Wang (see Appendix E) with a correction factor for
between-group ties.
Group I was tested against Group II
for all three variables (knowledge, attitudes, and number
of cigarettes) at T1 , r 2 and r 3 . Group I was tested
against Group III, for all three variables at T2 and T
3
(T 2 in group III for number of cigarettes is the same as
T1 in groups I and II), and Group II was tested against
Gro u p I I I f o r a 1 1 t h r e e v a r i a b 1 e s .
In addition to using a test of significance tb
make comparisons between trials of the three groups for
each variable, it was of interest to test for correlations
between variables within each group.
In other words, was
there· any relationship between an individual's attitudes
and knowledge of smoking and his smoking behavior.
In order to measure the association between
selected variables, two at a time, the nonparametric
Spearman Rank Correlation coefficient (rs) was chosen.
I-t-r-e-q-u-i-re-s-t-!1-a-t--b-o-t-h~v-a-r-i-a-b-l-e-s---b-e---o-f-a-t-l-east---a-n-ord-;-n-a-l
scale and that when tied scores occur that they be given
the average of the ranks.
If a small number of ties
occurs they will have little effect on the rs; however,
if a large number of ties occur then a correction factor
43
should be incorporated into the formula.
Once the rs is
determined, significance is found by using the student-t
table when N (the number of subjects) is 10 or greater
(Siegel, 1956:212).
For testing the null hypothesis in
terms of the correlation the r
5
is entered into the fol-
lowing formula:
N - 2
------2
1 - rs
The df=N-2, and the level of significance was set a
e<.=0.05.
This tells us if the two variables are associ-
ated in the population.
If the null hypothesis is rejec-
ted it can be presumed that in the population of subjects
from which the sample was randomly drawn, the variables
were associated.
As no routine program was available for the
Spearman Rank Correlation Analysis (on the Wang Minicomputer), a program was written incorporating the correction
term for ties (Siegel, 1956:203-207).
The program was
written in Wang Basic and tested with sample data from
Siegel (see Appendix E).
It was necessary to convert all
the data to rank type numbers, i.e., the smallest number
is designated as one and the next as two ... N.
were given the average rank.
All ties
44
In addition to finding the correlation coefficient between the variables it was necessary to check for
the effect of outliers.
In reviewing the questionnaires in this study
specific attention was focused on dissonance between the
answers given to questions on the knowledge part of the
questionnaire and their subsequent responses on the attitude part with a similar leaning.
For example on the
kn ow 1e d ge t e s t t he f o 11 o\'I i n g q u e s t i on s a y s :
demonstrated that if one stops smoking
on~
11
I t ha s b e e n
can increase
one•s chance of living a healthy life when compared with
the individual who continues to smoke (true/false), and
on the attitude section the subject is asked to express
either his agreement or disagreement with the following
statement:
11
lf a person has already smoked for many years
it is too late for stopping to do any good.
11
Therefore,
if a subject answers true on the knowledge question and
either strongly agree or agree on the attitude statement
he is saying cognitively that what he knows to be true is
not so according to his set of beliefs.
If this occurs
an individual would not be expected to change his/her
smoking behavior.
All the data consequently, were checked to find
if this
11
dissonance 11 might have influenced the subjects•
45
behavior and therefore be one source of failure for many
smoking cessation programs.
Lastly, data were tabulated and presented in
this report to illustrate changes that took place, even
though they might not have been statistically, significant.
The next Chapter discusses the analysis of data,
followed by a summary and conclusions from the findings.
Chapter 4
RESULTS AND DISCUSSION
In this Chapter the findings are presented with
a discussion which attempts to interpret the results as
they apply to the hypotheses.
Additional data are exam-
ined when certain tendencies were observed.
1.
Mann-Whitney Q Results
In evaluating the knowledge scores for groups I
and III at T2 the difference between means was statistically significant according to the Mann-Whitney U-test
(Table 2).
Also, the difference between the means of the
attitude scores for groups I and III at T was statisti2
cally significant (Table 2). This same effect carried
over to T3 one month later (Table 2).
None of the U's obtained (Tables 1, 2 & 3)
showed statistical significance for the number of cigarettes smoked, even though an overall decrease did occur
in groups II (34%) and III (35%).
An increase was seen
in group I {16%) where no educational intervention took
place.
The mean number of cigarettes reported at the
onset of the study for all three groups was 21 per day.
At T1 each questionnaire (T 2 in group III) contained the additional question asking the subject how
46
I
47
many cigarettes he was using prior to hospitalization.
This question was compared with the question dealing with
the number of cigarettes being used at the time when the
first questionnaire was given.
It was found that there
was a net decrease of 337 cigarettes per day between prehospitalization and T1 for all subjects (N=45) or a 7.5
cigarette per day reduction.
It can be assumed that the treatment (audiovisual presenation) had an effect on the knowledge scores
of the subjects in group III.
However, another important
factor which might have influenced the scores between
groups I and III is the lack of a pretest in group III.
This idea is further supported when one looks at the
comparison between groups I and II where no statistical
significance was found.
It must be remembered that both
groups II and III received the identical educational intervention while group I did not receive any.
As expected
there was no significant difference between groups II and
III at any of the three variables at the respective trials.
2.
Spearman-rho
R~sults
In addition to the test of significance (MannWhitney U-test) which was performed on the groups, each
group was examined individually for with-in group correlations between the three variables at the respective
'
48
trials.
For example, knowledge scores were matched
against number of cigarettes for each trial.
Once rs
values were obtained for each trial for the variables
being tested (knowledge
~core,
attitude score, and number
of cigarettes), a student-twas done to test for statistical significance.
This procedure requires that N be
greater than 10 for each group being compared {Siegel,
1956:212).
In reviewing the associations between the variables (Tables 4 & 5) statistically significant correlations
w~re
only seen in groups I and II.
A strong posi-
tive correlation (rs=.85 ) was shown to exist between
knowledge and attitude scores at T1 (Table 4). In
testing the same variables in group I at T2 a significant
correlation of lesser strength was obtained (Table 4).
These findings would suggest that those individuals who
received high scores on the knowledge test also had high
attitude ratios, indicating that they held attitudes which
were more positive towards the non-smoker.
Knowledge
scores and number of cigarettes in group I were correlated at rs=.49
(p<0.05) at T1 which proved to be significant (Table 4). This weak, but paradoxical associ-
ation suggested that those individuals with higher knowledge scores smoked more cigarettes.
Perhaps, this lends
support to the idea that knowledge itself is not always
49
a deterrent for unhealthful behavior, or that not all
cigarette smokers are ignorant of the deleterious effects
of cigarette use.
Group II showed a positive correlation of
rs=.56
between knowledge and attitude scores at T1
(Table 5). Again, as in group I at T1 those subjects with
higher knowledge scores held more positive attitudes
towards the non-smoker.
In group III (nonpretest group with the educational intervention) there were no instances of significant correlations between any of the variables.
It is
interesting to note that three of the four cases of statistically significant correlations showed up at T , and
1
since there was no T1 (due to the absence of a pretest) in
group III it followed that there were no statistically
significant correlations found in this group.
One expla-
nation for this finding is that the educational intervention effected or influenced the correlations in groups II
and III at T2 and T3 in a negative way, upsetting the
expected relationships between the variables. At T1 in
groups I and II the educational intervention had not
taken place.
Also the patient 1 s condition might have
changed over time effecting his perceptions.
There were five correlation coefficients which
were negative (Tables 4, 5 & 6).
This indicated that
50
there was an inverse relationship.
However, none of these
correlations proved to be significant.
All of the nega-
tive correlation coefficients were found when one of the
two variables matched was number of cigarettes.
Finally, some additional data were looked at in
view of the equivocal nature of some of the findings in
the correlation analysis.
The questionnaires (N=45) were
examined to find out what percentage of individuals answered true on question 9 of the knowledge section, and
either strongly agree or agree on statement 2 of the
attitude section.
This would demonstrate a disparity
between what is known and how one feels about smoking.
Twenty-two percent of all those who completed the set of
questionnaires were found to answer the questions in this
ambiguous manner.
This finding will be discussed in the
next Chapter in relation to cognitive dissonance, and
methods to deal with it.
Chapter 5
CONCLUSIONS AND SUMMARY
In this research two types of inconsistencies
w~re
in evidence.
As pointed out earlier in the results
section 22 percent of those who answered the questionnaires at
T 1 showed a disparity between knowledge and at-
titudes.
A further inconsistency was demonstrated between
knowledge and behavior when it was shown that those with
higher knowledge scores also had higher cigarette use in
group I at r 1 (Table 4).
Even though it is generally held that consis-
tency is an individual ideal, there are those exceptions
where attitudes a·re not consistent with behavior.
Quite
often how one feels is not consistent with what the individu~l
knows to be true, that is, "A person may know that
smoking is bad for him yet continue to smoke ...
11
(festinger, 1957:2).
Festinger further suggested that
•.• the person who continues to smoke knowing
that i t i s bad for hi s heal t h, may a 1so feel ( a) he
enjoys smoking so much it is wol~th it; (b) the
ch~nces of his health suffering are not as serious
as some would make out; (c) he can't always avoid
every possible d~ngerous contigency and still live;
and (d) perhaps even if he stopped smoking, he would
put on weight which is equally bad for his health.
So continuing to smoke is, after all, consistent with
his ideas about smoking. (Festinger, 1957:2).
51
52
Festinger terms this type of behavior "cognitive
dissonance".
He defines it as follows:
1. The existence of dissonance, being psychologically uricomfortable, will motivate the person to
try to reduce the dissonance and achieve consonance.
2 .. When dissonance is present, in addition to
trying to reduce it, the person will actively avoid
situations and information which would likely increase
the dissonance (Festinger, 1957:3).
As this hypothesis suggests, an individual who finds dissonance between how he acts, and what he knows, or how he
feels, will try to reduce it.
must be made.
Some type of adjustment
A good example of how the smoker might
tend to reduce the dissonance between his/her knowledge
(smoking is bad for you) and is cognition (that he/she
feels it is alright to continue to smoke) is suggested by
Festinger in the following scheme:
1. He might simply change his cognition about
his behavior by changing his actions; that is, he
might stop smoking. If he no longer smokes then his
c o gn i t i o n o f ·w h a t he d o e s wi 1 i be c o ns o n an t wi t h the
knowledge that smoking is bad for his health.
2. He might change his knowledge about the
effects of smoking. This sounds like a peculiar way
to put it, but it expresses well what must happen.
He might simply end up believing that smoking does
not have any deleterious effects, or he might acquire
s o mu c h 11 kn ow 1 e d ge 11 po i n t ·j n g to t he goo d e f f e c t s i t
has that harmful aspects become negligible. If he
can manage to change his knowledge in either of these
ways, he will have reduced, or even eliminated, the
dissonance between what he does and what he knows.
(Festinger, 1957:6).
The second scheme is one which might have been
used by those subjects who received high knowledge scores,
53
and who also smoked a large number of cigarettes.
In
order to rationalize their behavior they might have expressed the attitude that if one were to stop smoking it
would not improve their health.
Thus their behavior was
consistent with their attitude, but not with their knowledge,
An additional problem in relation to dissonance
theory and education programs is that
Forced or accidental exposure to new information
which tends to increase dissonance will frequently
result in misinterpretation and misperception of new
information by the person thus exposed in an effort
to avoid a dissonance increase (Festinger, 1957:
265).
Although this health education program did not
significantly reduce the number of cigarettes smoked, it
did bring up some salient examples of inconsistency
between the subjects' knowledge, attitudes and behavior
in regard to cigarette smoking and health.
This was dis-
cussed in some detail in terms of the theory of Cognitive
Dissonance.
The utility of these findings are that in
considering this interplay between knowledge, attitudes
and behavior, one should realize the need for planning
and developing health education programs which focus
their attention at these needs of the subject.
An additional finding, worth noting, is that only
group III (no pretest) when compared to group I (control)
showed any significance for any of the variables.
This
54
suggests that there is a need for pretest interaction
control in all studies where a pretest-type questionnaire
is used - particularly in those studies where a posttest
is given within a short interval after the pretest (as
in this study 15 minutes).
Perhaps the subject is influ-
enced by the answers which he/she gave on the pretest,
since the interval is quite brief.
This influence even
carries over to trial 3 which is one month later.
At trial 3 in comparing the attitude scores of
group I against group III (no pretest) significance was
found at p<O.Ol.
These observations have to be taken
into account when looking at studies where no pretest
control was employed.
In summary this study brought out the following
findings:
1.
There were numerous inconsistencies between
the subject's attitudes, knowledge and behavior in relation to smoking and health.
2.
These inconsistencies can be partly explained
through dissonance theory, and this theory can aid in
designing more effective health education programs.
For
example, methods to reduce the effects of cognitive dissonance) and restore consistency should be employed
(Olshansky and Summers, 1974).
55
3.
Even though there was no statistically sig-
nificant reduction in the use of cigarettes, both group
II and III showed slight decreases of 106 and 115 cigarettes per day respectively, while the control group (I)
showed an increase of 42 per day on the average.
This is
an average reduction of 6.6 cigarettes per subject in
group II and 7.7 per subject in group III.
Only 3 sub-
jects achieved complete cessation at 1 month; 2 in group
II and l in group III.
In view of these findings, an
inexpensive self-contained educational intervention of
this type would be a good first step in helping the hospitalized patient to stop smoking.
4.
Statistical evidence was given which indi-
cates that any research using pretest and posttest within
a short interval of each other should incorporate some
type of design which controls for pretest interaction.
Research presented in this thesis may assist
others who endeavor to help the smoker conquer this
devastating habit.
For, it is easier to prevent disease
than to treat its consequences.
Chapter 6
SUGGESTIONS FOR FURTHER RESEARCH
The program developed for this study should be
considered as a first approach.
Additional components
such as individual patient counseling, and looking for
dissonance between the patients knowledge and attitudes
and finding ways of combating it would be worthwhile
adjuncts.
Subjects who appear to be sincerely interested
'
in giving up cigarette smoking, as seen in the results of
the questionnaire which they filled out, should be
f il t e r e d i n to a mo re ex ten s i v e 1 on g - t e r m p r o g r a m, e . g . ,
the Seventh Day Adventist 5-day Plan.
This would provide
a pre-conditioned candidate for these programs.
AnQther technique which could augment this program is including some type of reinforcer or supplement
after the one month follow-up.
This would serve to remind
the subject of the seriousness of his/her illness even
after he/she has left the hospital.
To fmprove upon the design several changes should
be considered.
First, a fourth group could be added
which would receive the posttest, but not pretest or
treatment.
This would further control for pretest and
treatment interaction, balancing the design and forming
56
57
a Randomized Solomon Four-Group Design.
In addition, the
data collection period could be extended to a one-year
follow-up with a larger sample.
As suggested earlier a
one-month supplement could be given to one treatment
group and its influence tested.
Finally, the application of nonparametric multivariate methods to the data might provide some additional
information on the variables of use to the social science
researcher in the area of smoking cessation.
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-
TABLES
65
66
Table 1
Group I vs. Group II
~li'Tl
· T31T:z
T3/'l3
97
lOS
7i.S
ao.s
76.5
67
82
Table .2
Group I vs. G~cup III
T3/'l'~
*53
56.5
'f;,/'!3
*55.5
90.5
**28. 5
83.5
Table 3
Group I I vs. Group III
T2/T2
Tl/T3
"' for
u
p< o.os
for p <.
o. o1
85
113
114
119
91
116
67
Syea:rma.•-rho Correlation. Analysis
Table 4
Group
Kno-,r~lectge
r_
.......
~
T /T
1
!
vs. Attitude
1
**0.851
7.63
*0.468
2.22
1
T /T
2
2
T/T
3
0.240
3
Knowledge vs No. of Cig.
T/T
1 1
*0.493
2.40
T /'!
3 3
0.321
1.35
Attitude vs. No. of Cig.
TIT
1
0 .1)77
-0.265
'1' /T
3
'*
**
0.278
1
3
forp<O.OS
!or i? < 0.01
1.07
68
Spearman-rho Correlation Analysis
'!'able 5
QE_o~E I !
Knowledge vs. Attitude
'l'rials
/T
'1'
1
t
**0.565
3.21
0.046
0.18
0.284
1.26
1
/T
'f
r
=-a
2
2
'r
3
/T
3
lCnowledge vs. No. of Cig.
'l'
/T
1
0.192
0.80
0.031
.118
1
TiT
3
3
Attitude vs. No. of Cig.
T/T
1
~0.04
.153
-0.306
1.37
1
T/T
3
*
**
3
for p < 0.05
for p
< 0.01
69
Spearman-rho Corrtlation Analysis
Tablo 6
Group !.!!.
Knowledge vs. il.ttitude
Trials
--'1' /T
2 2
/T
'1'
~
t
0.301
1.30
0.214
.870
3
3
Knowledge vs. No. of Cig.
T /T
2
'1'
3
n
0.338
l.SO
-0.144
1.56
2
3
Attitude vs. No. of Cig.
T/T
2 2
0.087
T ·f't
•0.421
3
3
*
for
**
p~
for: p
o.os
< 0.01
.328
2.0
Table 1
Group II (N•16)
Group I(N=l4)
Knowledge
T
T
1 "2
7
6
8
8
9
5
9
4
7
5
9
8
8
so
3
6 . 9
6
7
8
8
8 8
9
7
5 5
9 6
4 8
8 8
5 9
9 9
8 8
7 6
7
6
7.1 1 7.5
l.o 1.1 1.2
6
X
T
Attitude
No. of Cig.
Knowledge
T T T
1 2 3
T
1
T
1 1
.88 • 78
1.4 1.4
1.2 1
1.1 30
T
1
T
2
T
3
T
1
T
3
T
2
T
T
2
3
6
9
10
20
20
9
8
8
9
9
.82 .82 1.1 10 . 10
1.9 1.8 2.1 20
0
• 75 • 7 .81 40 40
9
9
9
9
.86 20
9
7
7
9
8
!)
8
9
8
9
8
9
8
7
3.0
1.2
1.8
.73
9
9
8
9
9
8
8
1.2 15
1.1 20
.78 15
.94 20
1.1
0
1.3 .83 20
1.3
1.7 1.3
7
30
3
40
60
10
50
10
2
1.7 1.7 20
.32 1.0 11
1.0 1.0 19
.:'5 .75 14
20
15
1.2 1.0 . 93
.75
T T
2 3
N;,, of Cfg.
20
.72 .94
.81
1.1
1
Knowledge .Attitude
40
.72
1.9
3
No. of Cig.
P.ttHude
.9 20
1.3 1.14
.72 .83
1.5 .77
.82 ,88
1..3
T
·Group III (N2 15)
8
a
6
7
9
6
8
1
a
9
9
7
7
9
9
1
20
6
2
8
5
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........
0
APPENDIX A
CONSENT FORM
71
72
R!SfONStBLE Ii'1'!ESTICATOR:
Richa<d Jay Katz
CO-INVESTIGATOR:
11TLE OF PROTOCOL:
VM!C-Smokin~
TlTL! OF CONSENT FORM:
Education Project for the Circulatory-Impaired
VA~C-Smokin~
Education Project
I have been asked to participate in a research study that is
i~1esti~atin~
the effects o(
a one-time smoking educacion session in the circulatory-impaired ver.eran.
In participatin~ in this study I agre~ to the following procedures: I will be rando~ly
a•a1gned to one of 1 groups: <.roup I will receive an audio-visual smokinr. education
tape telling of the risk factors in patients with circulacory disease as well as the
e«tlook for the ex-smok~r; and in addition will complete a que3tionnai~e at 3 different
times (immediately before, after and one month after), Group 2- this group-will not
reee!ve the audio-visual presentation, but will complete the questionnaires (before,
~teVez-al minutes late;.· and one month after, Group 3- this group will receive the
lludio-visual presentation and be requested to c01:1plete a questionnaire itr.mediately
&fter ~nd one month later,
I UAd~rstand that I might be assigned to either group and have no·choice in the selection.
Tbu ~ssible benefits of this program are that I wight change my behavior in regard co
ay ~resent use of dgat:ettes, consequently reducing one o~ the risk factors associated
'ltith !:!y present cnadition,
uy questions I have concerning my participation iu the study vill be answered by
Richard J. Kat?., B.S., R.P.T.
I l.Cll1 withdraw fror-1 the study at any time without prejudice to , . health care. The
r-s&ulta of this study may be published, but my na- and identity "'ill r:ot be revealed
~md my records vill re..uin confidential unless dis<:losure of my identity is required
by law.
N7
~o~sent
OlJ
fi:1 decision.
is g:lven voluntarily. without being coerced or forced by any undue influence
In the event physical injury is
sustain~d as a result of participation in this program.
may receive -!men~ency medical care and, in approoriate c11ses, may be
entitled to compensation under the provisions of the Federal Tort Claims Act
DOD-V~terans
(28
u.s.c.
1346(b), 2671-2680).
Dae._,_____________________________
PATIENT OR RESPONSIBU: PARTY
PAtiDIT'S SOCIAL SEc:3ITY N!P.il!ER
A\Jllito!iJWIT~ESS
iNvEsttCATOR/PHYSICIAN RF.PRESF.NTATIVF.
73
'IU!SPONSI'BLE HiVF.STtCATOR:
CO-IN'IESTlCATOR:
Tttt,! OF PROTOCOL:
tiTLE Of' CONSENT FORM:
Conttnutn~ Medical care vill be provided eli~ible veterans in the event physical ht_1urv
1• eustained as a result of participation in this pro~ram. Addicionallv, compensation
aay be ~ayable to eli~ible veterans under 38 U.S.C. 351 or, in appropriate cases,
unde~ the provisions of the Federal Tort Claims Act {28 u.s.c. 1346(b), 2671-2680).
fo~
clarification of these laws, contact the VA District Counsel (213)(824-7379).
It t have complaints about the study t may express them to Richard J. Katz or the
Aa$0eiate Chief of Staff for Research, Bldg. 1, Room A-159, 891-2481.
1 h&ve received a copy of this consent form for
-r
file.
1 have read the above and understand it and hereby consent to
t~
procedure(s) set
fo.:th above.
PATIENT OR RESPONSIBLE PARTY
PATUJI'I 1 S SOCIAL SEQ;RITY NillffiER
YNVifuCATOR/FHYSICU.'l REPRESEN'rA'ri\'E
Page..,!_ of ..1_
APPENDIX B
QUESTIONNAIRE
74
75
NAME:._ _ _ _ _ _ _ __
Quest1onnar1e - VA Smoking Study
B-1
Approx11T'.ately how many cigarettes d1 d you smoke per day before
entering the hospital? _ _ _ _ _ _ __
1)
how many cigarettes
do you smoke per day at this
2) Approximately
time?_________________
_
K·l
Answer each question by circling either {T) True or (F) False
1)
2)
3)
4)
5)
6)
Smoking cigarettes can aggravate the symptoms of various circulatory
ailments. T F
Cigarette smoking is one of the three leading risk factors associated
with heart disease.
T
F
Cigarette smoking can alter the effects of medications and the results
F
of laboratory tests. T
Nicotine--a component of cigarette smoke--has been implicated as a
causative agent in lung cancer. T F
Nicotine can cause the release of certain substances thereby creattog
an increase in heart rate and blood pressure. T
F
Cigarette smokers have about the same incidence of acute disorders and
lost days of work as nonsmokers. T
F
·7) Using cigarettes before one engages in physical activity improves ones
endurance. T F
8) There is only one proven method to stop smoking - that is just to go cold
turkey. T
9)
10)
F
It has been demonstrated that if one stops smoking one can increase ones
chance of living a healthy life when compared with the individual who
contlnues to srooke. T F
Some studies indicate that smoking compounds the ri$k of contracting
various diseases for the individual living in an a1·ea with a high amount
F
of a1r pollution. T
76
APPENDIX C
INSTRUCTIONAL DESIGN
77
78
~E~ctional
!opic:
Design
A Smoking Educational Program (one-time intervention) for the
cir.culatory~impaired,
hospitalized veteran.
_QEjecthre~:
1) Cognitive (knowledge) ~!1
-
to increase the knowledge of the effects of cigarette
smoking as related to the genesis of circulatory and related diseases.
§.:~ifil"-. --
a) the subject will be able to rec.all at least six disorders which
are potentiated by cigarette smoking; in P,articular those which
affect the circulatory sy&tem.
b). the subject will be able to list th1:ee immediate effects which
smoking has on the periphe!al vasculature and cardiac
fun~tion.
·c) the student will be 'able to identify several statistics suggesting
increased morbidity and mortality rates in those Yho smoke cigarettas.
2) Affective (attitudinal) -
increase the individuals' positive attitudes to~ards the abstention
from smoking;
3s
evider.c~d by the subject being able to explain the
value of the cessation of smoking and its relation to the amelioration
of a given disease process and as a positive move towards showing
on2s personal responsibility in his/her individual health.
3) Behavior.:1l
a) encour3ge the subject to enroll in.one of the many suitable
classes which instructs the individual in a technique to stop smoking.
b) reduce the number oi cigarettes that the individual used previous
to the educacional intervention.
c)
th~
individual will completely abstain
fro~ ~~oking
cigarettes
by the time of the final follow-~p as a long range objective.
79
Method relevant to objectives
The entire presentation will be self-contained as an audio-visual display.
A synchronous slide and audio cassette unit will serve as the mode of
presentation.
1. a) In order to enhance.the students' knowledge--as stated in the
general cognitive objective--first, it will be necessary to show a
group of slides, with an accompanying narrative, listing a number of
disease entities which are known to be potentiated by the smoking
of cigarettes.
b) A series of graphs will be used to demonstrate the immediate
effects of smoking as related to several physiologic parameters this will of course be done in a very simplified and meaningful manner.
c) Slides will be shown illustrating the increased mortality and
morbidity rates found in cigarette smokiers; both graphically and
in printed form.
2. To influence the individuaYs'·attitudes whereby he/she exhibits
pos:ftive feelings re:
the' abstention of smoking and added responsibility
1u the preservation of ones health.
Thus, the
followi~g
slides anc.
bits of narration will be presented:
a) demonstrating the immediate and long term changes that the body
~ergoes
following the cessation and/or the reduction of smoking
cigarettes.
b) illustrating the social and financial benefits which can be
accrued once one stops smoking.
c) slides and narration demonstrating the impact and self-fulfillment
experimenced by one who shows responsibility for ones individual
health; for example. it
could promote greater self worth, less stress
and ultimately enhance ones productivity and prestige.
3. Through the use of slides and narration this portion of the presentation
will serve to
sh~J
hopeless dream.
that the promise of a better life is not just a
It will demonstrate to the student.t.hat it is possible
to allay further damage and even reverse some that has already taken
place in given instances. if one was to stop smoking.
80
By using grpahs. pictures--showing
unh~althy
and healthy
su~jects--and
other factual information (on slides) the presentation will aim to evoke
a posttive behavioral change, i.e. the cessation or the reduction of the
number of cigarettes used.
Y~nally,
a list of suitable jstop smoking programs' will be presented.
A behavioral char.ge will have taken place if the student simply enrolls
in one of the programs listed or any other with similar purposes, though
the long range ojbective is the cessation of cigarette smoking.
.
.
..
81
Instructional Design:
Specific Content
1. List of diseases which are known to be potentiated through the use of
cigarettes;
a) Cardiovascular disease - as stated in a 1976 document, put out by
.
.
Health Education and Welfare (DHEW), Center for Disease Control (CDC),
in an extensive study
~nvolving
more than a million person-years of ·
experience, there has been conclusive evidence that cigarette smoking
1a one of the three major risk factors in the devleopment of both non-fatal and fatal
~JocaFdial
infarction.
Thus the following are other diseases of the blood vessels which are
affected by smoking as seen in this otudy;
--- strongly associated with increased risk of contracting
peripheral vascular disease
a~
well as death from arteriosclerotic
$neu!Ysm of the aorta.
---it bas been
establ~shed
that the
~~re
one smokes the greater the
progression of ''hardening of the arteries" of the aorta and. o:ther
coronary arteries-vessels that supply the heart muscle.
---increases the risk of the survivor of a heart attack of
havin~
,!_reeur!ence.
---during experimentation, it was shown that those in the presence of
cisarette smoke or carbon monoxide were prone to experience angina and
.sl!!!.dication of t:he calve muscles much mo·re rapidlv.
The nicotine
cowponent of the cigarette is also associated with the above.
---For those who both smoke and have diabetes. the risk of having
ischemic: vascular diseas*:_; closing off of the small vessels to the tissue
1c appreciably greater, than in those who do not smoke.
~those
terms or phrases underlined will be listed on the slides
-:•.•
82
_,_
Non-Cancerous Respiratory Diseases
In the last 15 years the follovdng was learned about the relationship
between cigarette smoking and the enhancement of diseases of the
respiratory system, not including the cancers which are well known
results of smoking: 2
---greater chance of contracting chronic bronchitis and emphysema
· and dying of these diseases than non-smokers •
.;.--poor function of the pulronary system as measured in tests- this can
subsequently lead to poor oxygenation of the blood.
--som.e studies have shown evidence that smoking may induce imbalance
or
certain
~~
lead to tissue damage.
--alteration of the immune system, lowering resistance to disease.
~mpounds
the risk of contracting various disease for those living
in areas with high
L~cidences
of air pollution.
c) Effect on Prescription MedicationsJ
---can alter the prireary effects of the drug-leading to lessening of
its benefits.
--can induce the metabolism of certain drugs, rendering them less effective, e.g. as vitamin C.
---may cause a decline in the effective antibody levels after vaccination
for such things as the
nu virus.
--may affect the results of various laborato!"'J tests. ·
the immediate effects of cigarette smoking are as follows:
1) one study dealing with the amount of nicotine in the blood
pla.SQ!l reveals that the levels of this chemical increases rapidly
83
-6dl~ing
the smoking of a cigarette and declines first rapidly as the
body's tissue absorbs some of it and then more slowly as shovm on
this graph- (see page 16, The Health Consequences of Smoking).
Y.'hen one realizes that nicotine has the following effects on the body;
the release of certain compounds which leads to increased heart rate
blood pressure and speed of contraction of the heart.
It can also
cause :heart rhythm problems and constriction of the airways in the lung.
The first graph demonstrates the difference in blood pressure readings
obtained from the non-smoker and smoker, during rest, smoking and
wo~k.
The next graph demonstrates the same comparisons for heart rate in the
non-smoker vs. the smoker.
One sees that-there is a significant difference between these measurements
in the non-smoker ar1d smoker,
leadir~
to poorer performance and a greater
stress on the cardiovascular system of the smoker.
(A Teacher's Guide
..
figures J&lt). 4
tb demonstrate the higher incidence of disease and death in the smoker
one can look at the following comparisons:
lc
the overall death ratio, as of the 1979 appraisal, for all smokers
is about 1. 7 compared to r.on-smokers.
This mean that for every 100
people that die, 70 additional people succu."!!b from diseases related
cigarette smoking.
~o
This ratio increases with the amount smoked; thus
& two pack a day smoker has a death ratio of 2.0 -
mea.~ng
ever,y 100 deaths in nonsmokers there will be 200 smokers
that for
tl~t
succumb.
)} the actual number of deaths, excess of non-smokers, attributable
to cigarette smoking increases with age.
5
84
-74)
from detailed data of two recent studies, the excess death rate for
smokers is noted to be greatest for the 45-54 year age group for
6
men and women.
Therefore this smoking death rate is
pre~ature
mortality.
The following facts will lend creedance ·to the belief that cigarette
sm:>klng leads to or increases the risk of one contracting a variety
of diseases:
1) Current smokers tend to report more acute and chronic conditions
e.g. chronic bronchitis, emphysema, and influenza.
2) Those individuals who had smoked reported a 14% higher incidence of
acute conditions, such as the common cold- with a
JJ% excess of lost
Qaj·s at work as compared with male non-smokers.
J)
Smokers have a) 1. 7
Heart Disease, b)
tim~s
.greater chance of contracting Coronary
a 1. 5 greater chance of' developing hypertensive
Heart Disease and c) a 2.6 times greater chance of developing other
Circulatory Diseases. 7
(See a bar graph with the above information.)
Which do you value most, your health and significant others or the
pleasure you gain from smoking?
These are values-something we must
chose between and subsequently adjust our behavior to the path that
we decide \llXm.
Studies r.ave sho?.n th:lt there is HOPE for the former
fimoker, B especia.lly in those individuals who are suffering from dise~ses
which are potentiated by the immediate effects of cigarette smoke.
For instance, & tendency was noted that a higher proportion of former
smokers and those who have never smoked, assess their own health as
excellent when compared to smokers.
85
-8Just being able to make this statement is a sign of personal confidence
and indicates a feeling of self vrorth.
Most studies show a reduction in risks of mortality in former smokers.
In fact, after abstaining from cigarettes for ten years, the risk of
death !rom coronary heart disease approaches that of the nonsmoker.9
As pointed out in the earlier slides, showing the immediate effects of
cigarette smoking, if an individual with peripheral vascular disease
was to stop smoking, the degree of impairment might be lessened.
S~ply,
look around at your fellow patients, who are inflicted with
such maladies and find out how many of them have stopped smoking.
You will probably find that very few have and that they continue to
S\\ff'er from the same problems with little relief'.
It' you have :hope for yourself and for others, then the least you can do
is experiment on yourself'.
changes for the better.
Se if by not sm.:>king, your disorder
By doing this you will not only have done
yourself' a service, but you will also have served as an exaruple for
others.
the f'inancial and social benefits become self evident:
--no rore wanton spending on cigarettes, you can save as much as
$JO
k
month lf you are a two pack smoker- using the money instead for
entertainment or anything else that would help one gain more pleasure
tram life in a healthful manner.
---greater earnings from fewer lost days at work.
---able to participate in physical activities which you were precluded
86
·-9from due to the advcrze effects of ::;;noking.
(slides illustrating these activities and achievement.s with brief
captions emphasizing key W·:Jrds).
ln this .ll".aze of statistics, which has been presented, lies various
implied statements.
-~-in
It can be summarized in the following way:
certain diseases smoking causes immediate impact on bodily
functions, which in the presence of existing circulatory disease may
lead to increased symptoms, e.g. pain, shortnass of breath, etG.
--continuous use of cigarettes may expedite the disease process.
7hus, if one discontinues smoking; the disease
p~ocess
might be
slowed.
-the ability to perform
compromised by smoking.
~xercise,
at ones peak level, may be
it is also held that exercise, done on a
regular basis, may lead to cardiac fitness
~,d
studies are
~,derway
to see it" this would have an effect on those individuals with current
cardiovascular disease.
·.
--'t~Jlwn
one becomes capt:lve to a certain disease, there are two routes
to follow; one the road of least resistance or two change ones
·lifestyle to i.n a manner which will be condudve to reducing the
errects or the disease.
Surely) the cesse tion of S'l".Oking is "the first
step to improving ones chances of living a oore fulfilling and
health!'ul life.
Once this is accomplished, the individual can further
improve his/her chances of improved health through proper diet and
oxarcise.
87
Today. there are a number of methods available to stop smoking.
A list of classes offered will be provided - it is up to you to choose
which cethod best fits your needs and then :.eriroll in one.
Audience
tbe audience that this presentation is designed for is the in patient
.ac the Sepulveda V.A. Medical Center.
Therefore, visual and narrative
W!di.a is the chosen design, emphasizing lay termlnology and broad
factUal information.
APPENDIX D
SCRIPT
88
89
Rtchard J. Katz
·Script:
Smoking Education fat• the Circulatory..:Impaired Veteran
Narrat1on Idea
~~
Stop Sm_Qking-promote good
· 1) Title:
health
Title: This Brief Presentation Could
Have a Positive Effect en Your Health.
2} The following diseases will be
displayed on a slide; a) Heart
Attack, b) Peripheral Vascu1ar
Otsease, c) Hardening of the
Arteries, Angina and d) diabetes
You have probably beer, to 1d many
t1mes and on many dlfferent occas icos
3) Picture of an Intensive Care
The bulk of material seems to be on
smor.ings relationship to lung Cancer.
Did you ever wonder >'lhy you shou1d
stop smok.ing, besides fm· the reason
al~ady stated?
Un1t and a ha 1 h1ay in the hospital •
(CO}
~)
Repeat of the slide w1th the
The illnesses 1 isted have t\~O things
in common, one, they are all diseases
affecting the circulatory system and
two they all are thought to be wade
worse by the smoking of cigarettes.
Yes, srroking is one of the three
leading risk factors in Heart disease.
it also has the effect of reducing
the blood flow through vesse1 constriction thus it can aggravate the
symptoms of those suffering with
peripheral vascular disease, Angina
and diabetes.
~
Thus, that feeling of tightness in the
calve or chest. shortness of breath,
painful and cold limbs-all symptorns
of the aforementioned illnesses can
be intensified by the mere use of
11st of
dis~ases.
(see 2)
sertes of pictures-a clave,
pressing against their
ch~st. and someone squeezing their
fest.. (CU) (studio)
· S}
that you should stop smoking because
it is bad for you.
s~one
cigarettes.
6) A picture of a cigarette
burn1ng.
FollO'iJEd
(C~)
(Studio)
by a picture of a patient
in a hospital bed in a
darkened room.
( boS.9l till }
(LS)
Cigarettes like medications are technically drugs. But. unlike medicines
which when used wisely. they have no
therapeutically positive value. Thus.
snvk1ng cigarettes is 1ike taking
bad medicine, expecially when you are
afflicted by fl1ness. which cigarettes
are known to mlke worse. Would you
knowingly take a drug that could
1tens1fy your illness?
90
Visual
Narration Idea
7) A picture of a patient walking
slowly dovm the hall. with a tonk
of oxygen. (LS) (Hospital)
15 years of research has sho\'m the
relationship between cigarette use and
the enhancement of: chronic bronchitis,
e~hysema and consequent I y ~or_
.E!J monary function; in other vmrds
gasping for air. The air is presentthe 1ung can't handle it effectively,
as in a norma 1 person.
8) A list of non-cancerous
respiratory diseases.
A picture of Air Pollution
and one of a cigarette
burning (CU) iw~~diately
~)
following.
10) A picture of an individual
sneezin'], \·iith a handkerchief in
hand t:n number of cold remedies
1n the fm·eground. ( Cll)
Some studies have shown that smoking
compounds the risk of contracting
various diseases for those living
1n areas with a high incidence of
air pollction.
One question that we all ask ourselves-
is why did I get that cold or flu
while someone else in close proximity
didn't. Part of this has to do \·lith·
ones natural immunity or resistance.
Cigarette smoking might cause an
alteration of the immune system,
thereby making one more susceptible
to disease.
11) Two. slides spaced about 15
seconds apart. The first being
a conglorr:eration of prescription
vials, (CU), emphasizing the
bottles and not th~ labels. The
Many people require medications as
part of their daily regiment. In
some cases it helps to maintain an
individual in a steady state. Studies
have indicated that smoking can alter
the primary effects of a drug-leading
to lessening of its benefits. Why
defeat the purpose of taking it in
the first piace? Also, evidence has
shown that the results of various
laboratory tests can be affected by
the use of cigarettes. It \'IOU 1d seem
that these are crucial reasons to give
up CIGAnETTE SI·10KH!G particularly
whe:t one is ill.
12) A slide of a graph showing
the effects of cigarette smoke-the
Nicotine a chemical in cigarette smoke,
has an immediate effect on the blood.
2nd will be a bunch of slips
containing results of medical
hb tests. (CU)
nicotine component-will be projected.
A graph showing the difference in
heart rates of the nonsmoker and
smoker and blood pressures.
rluring rest. smoking, and work.
91
-Jv·lsual
Narration Idea
Quickly show a picture of a heart
(cartoon) showing stress on it.
(art work)
Nicotine has the following effects on
the body; r·elease certain substances
which leads to increased fi.R., 8.P.
and the speed th~t the· heart contracts.
13) The fol1ov1ing slides will
A survery indicated that for those
individuals who had smoked a 145;
higher incidence of acute conditions
and a 33% excess of lost days at v1ork
was reported as compared with male
nonsmokers.
14) A bar graph will be projected
~r.orbidity ratios
for smokers.
Smokers have a 1. 7 grea te.- chance of
contracting coronary hea1·t disease, a
1.5 greater chance of developing high
blood pressure and a 2.6 tirr:es greater
chance of developing other circulatory
include in this sequence; a)
a picture of a hospital bed
(LS). b) a pictur·e of a check
empasizing the vJOrds PAY CHECK
with an X through it.
'nth data on
~1seases.
15) A picture of a construction
on a lift. A picture of
a cigarette in front of poster
with the words, in large letters,
High Blood Pressure, Heart Disease,
end Circu1atory disorders.
t~rker
When one undertakes a dangerous or
risky job one generally is compens:1ted
for the added risks. Me the benefits
one derives from cigarette smoking
worth the risks? You have been told
the risks. as vividly displayed on the
bar graph, nm>~ try to think of the
benefits.
16) A (LS) showing a family.enjoying
· a picnic on a sunny day, in a
grassy field.
Other slides showing p1easant scenes,
indicating a bright outlook.
17) A series of (LS's), blurring
the identity of the individual
showing patients in wheelchairs.
beds and walking ·in wards, smoking
cigarettes.
do you value more, your health
and ability to be with your loved ones
or the pleasure you derive from srr.oking.
Studies have shown that there is hope
for the former smoker, especially in
those who are suffering from diseases
made worse by the immediate effects of
cigarette smoke. As pointed cut in
the eurlier slides, showino the effects
of cigarette smoking, if you r1ere to
stop smoking. the degr~e of damage might
be lessened.
~lhich
Simply look around at your fellow
patients. who are aff1 i cted with many
of the illnesses which were just discussed and find out how many of them
have stopped smoking.
You will probably find out that very
few have and th<~t they cont1nue to
suffer- from the sJme prob 1er.1s with
little relief.
92
Visual
Narration Idea
18) A series of slides (CU) showing
If you ha~e hope for yourself and
others, then at least experiment on
yourself by.trying to reduce and
eventually give up smoking.
See, if by not smoking. your disorder
improves. By doing this you ~>Jill
not only have done yourself a service,
but also have served as an example
for others.
packs of cigarettes being tossed
1n the trash. Only the hands.
cigdrette pack and trash can will
be shown.
19) A slide of paper money and
coins (CU) will be shown. Next
a slide illustrating night-life,
mvie theaters. etc. will be sho\'m.
The social benefits of not smoking
should be evident. They include, the
savings o not spending money on
c1 garettes. If one smokes tHo packs
a day one could save as much as $30
a month by not smoking. This money
could go towards activities v1hich
provide pleasure such as: movies~
restaurants ot· other social ventures.
Also one can save rr.oney in view of the
statistics which shov1 Jess lost work
days in nonsmokers when compared with
smokers.
20) Several slides in sequence
!hawing people :-iding bicycles in
the.park, playing baseball and
basketball alona with other
leisure activities. (CU)
21) The first slide will be of· the
seen in an advertisement in a
magazine showing a healthy person
advocating smoking. This will be
. fOllowed by a scrie3 of pictures
showing middle age and older people
~rtaking in physical activities.
ty~
22) A slide w111 be shown with
the follo•11ing ·.vord; DISEASE
Immediate Symptoms:
PAIN
SHORTNESS-OF-BREATH
A caricature of 'sick'lungs
w111 be shown.
(art v.'Or·k)
Good health can also mean
ability to participate in
activities l'lhich you l'lere
precluded from due to the
effects of smoking.
greater
leisure
previously
adverse
Why is it that those pictures one sees
in the magazines of healthy-looking
people smoking only use young people.
Even though many of them probably don't
smoke it is to show an association of
youth and vigor with cigarettes.
Obviously you are a case in point against
this misrepresentation by virture of
your illness. There are many people wno
are middle age and beyond who are just
as healthy-1ooking and perform ably.
Though unlike the w.agazine pictures
they don't smoke.
In this maze of statistics which you
have heard and seen lies some important
truths. First~ cigarette smoking can
cause or increase the risks of contracting various diseases. Secondly,
it can give you ilrmediate symptoms,
i.e. pa1n and shortness-of-breath and
lastly it can prevent one from performing at ones full capacity by
virtue of limiting the function of ones
lungs.
93
Narration Idea
Visual
A caricature of a healthy
~art will be pr~jected.
·(Art Work}
23) A picture of an individual
"behind bars (LS) follm-ted by
a picture of the individual
walking out of the prison
cell with the door open.
. (Ar't Work)
· 24; A !.eries of
~lides
will be
shown of the follm·ting:
a cigarette (CU) with an X drawn
across it.
A pictur·e of a patient walking
down the step of entrance to the
hosp1tal. (f.!S) emph~sizing the
s·lgn of the has pita 1 and the
pi\tient. To add to the effectiveness 5everal different slides demonstrating this action will be sho\'m
1n succession. accompanied to
stirring music in the background.
Repeat of the eal"l ier· pictures
showing spor·ting activities and
Since~ 1t is felt that exercise done
on a regular basis can he1p achieve
cardiac fitness, how can one \'Jho smokes
possibly perform at a level necessary
to derive these benefits.
When one becomes captive to a certain
disease, there are two routes to follow: .
one is the road of least resistance or
two 1s to change ones lifestyle in a
manner which will reduce the effects
of the disease.
Surely, the cessation of cigarette
smoking is the first step to improving
your chances of living a more fulfilling
and healthful life.
p1c:nicing.
?.5) A sl fde ~1il1 be shown containing a list of approved techniques
and classes to help people stop
Slrlolld ng •
Today. there are a number of methods
available to help ycu stop smoking.
But first it is necessary for yo•J
to exercise the good judgement und
s&y to yourself that where there is
hope and desire there is a way.
If you feel this way or have the least
inclination towards this thought.
then seek out one of the stop-smoking
courses on the list which you will be
provided with.
26} A (LS) of medical professionals.
We can only help you if you are will fnq
to help yourself. Please take some
responsibility for your health and
welfare; 1t is )~ur right.
APPENDIX E
COMPUTER PROGRAMS
94
95
Mann-Whitney U-Test
( DIH AC40>,B<40>,N<2>
-··-·------
" E NI£.fL.N" ; I{ • T NPII I N 00
--.
10 PRINT "ENTER SAMPLE";K
15 FOR 1=1 TO N<K> STEP 4: INPUT B<I>,B<I+1>,BCI+2>,BCI+3>: NEXT I
s...E.J:l!LK:=__!._ID......2:..__2 P I N I
~~B~;;:r~1~~~J~r~~~~~~~=~~-1~~~-~~y~y~<~¥~~-~~~--3-5-------------------------30 BCJ>=Y1: BCJ+1>=X1
~EXL_~~XT I~:~P~R~I~N~T-----------------------------------------
40 IF K=2 THEN SO
45 FOR 1=1 TO N<1>: A<I>=B<I>: NEXT I
SO NE~X~T~K~-----------------------------------55 X1,X2-1
60 Y1,Y2=0
..A5._;tF X1>=N< 1) THF"N 70: FOR ~{=Xl+l TO N< 1 >
68 IF.ACX1><A<K> THEN 69: Y1-Y1+1
69 NEXT ~{
70 IF X2>=NC2) THEN 75: FOR K=X2+1 TO NC2)
72 IF BCX2><B<K> THEN 73: Y2=Y2+1
•· 73 NEXT ~{
. 75 Z='f2/2
80 l;8(X2~-)~+~1~:~I~F~X~1~>~N~<~l~>~T~H~E~N-=8~S~:-I~=-A~<~X~1~)~----------------------85 J=B<X2>: IF I<>J THEN 90: Z=<Y1+Y2+1)/2
90 IF I<J THEN 95: R=R+<X1+X2+Z-1>*<Y2+1>: X2~X2+Y2+1
95 IF I>J THEN 100: X1-X1+Y1+1
100 ~F X2<=N<2> THEN 60
105 Yl=N<1>*N<2>+N<2>*<NC2)+1)/2-R: Y2=N<1>*NC2>-Yt
110 IF Yl<=Y2 THEN 120: Y1=Y2
i20 PRINT : PRINT "U=";Y1
130 END
96
Spearman-rho Correlation
.10 DIM A(20),8(20),T(20J,Tt(:0>
19 PR1NT
20 PRINT •rNPUT NO. OF SUBJECTS";
30 I NPIJT N "~--,--,~~~
A<N>: Mf'l"ff!:EDIH tHN)
SO MAT A=ZER:MAT ~=ZER
60 PRINT •INPUT FIRST SET";
70 MAT I NF·TJT f1
80 PRINT "INF'UT SECOND SET";
90 MAT INPUT B
9SFOR ~(;;;l·~T~O~N~:=P~R""'IN'"'"'T AOD;: NEXT f(: PRINT
96FOR K=l TO N:PRINT BCKJ; :NEXT K:PRINT
100 02=0
110 FOR !=1 TO N
120 D=A<I>-B<I>
130 D2=D2+<D1'2>
140 NEXT I
150 R=1-((D2~6)/((Nt3)-N))
160 PRINTUSING 170.R
170 X CORRELATION COEFFICIENT r<s>=~N.#HH
175 SELECT PRINT 005
220 PRINT "INPUT NO. OF TIED GROUPS IN FIRST VARIABLE";
230INPUT G1
240 IF G1=0 THEN 280
250 HAT REDIM T<G1)
260 PR I NT--;;-IN PUT~~:;..;W::-.--::O~F:-::T:-::Ic-:::E~D--s-=-c-:::-0R=-·E""S:::-:F""'·E=-=R=-·'"'G""'R""·O"'"U""P~at'""4-:F=I=-=R=-=·8::-::T:o--:-V.ARI A8 LE " ;
·270 MAT INPUT T
280 PRINT "INPUT NO. OF TIED GROUPS IN SECOND VARIABLE•;
290 INPUT G2
300 IF G2=0 THEN 350
310 HAT REOIM T1<G2>
320 PR I NT " I NPUT No=-•.:._o""'F::--:T""I"""E,.,D,...-,S-::C-::0-R~E"='S~PE=-R=-·-G::-:Ro-c·o""'U-:-:P:--:0-H--SE._,.C-O..,...N-.O~lJ-A-::F'"":1-A_.G..,..L"""E-:-"-;330 HAT INPUT Tl
40FA'r-.f.~EDIM
340 T4=:0
IF Gi=O THEN 400
FOR I= 1 TO Gl
350
360
370
380
390
400
410
420
430
440
450
~~0
470
480
~90
T4=T4+({(T(G1it3)-J(G1))/12}
T2=<<Nt3-N>/12>-T4
NEXT I
T2=<<Nt3-N)/12)-J4
TS=O
IF G2=0 THEN 470
FQF: I =•..._..t.T"'-O_G,_::?':'-·:-:-~:--:----------------------TS=TS+<<<T1CG2)t3>-T1(G2))/12>
T3=((Nt3-N)/12>-TS
NEXT I·---------::---------------------T3=<<Nt3-N)/12>-TS
R2=<<T2+T3>-02)/(2~SQR<T2*T3>>
PRINLUSING 500 R2
500 X CDF:RECTED FO:.R':-',.:.:T::-:I:-:E:-:S:--r-:<-s-:-)-=-c:H-c:lt• .,-:-it"'"'"itU:-:---------------501 PRINT
505 SELECT PRINT 005
510 COTO 1.9
_______
,
--·-···-··-
..