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I I I I I I I I I I I I I I I I I I Chapter 3 Psychological Analysis of Establishment and Maintenance of the Smoking Habit Daniel Horn, Ph.D. I began studying smoking habits about 30 years ago, primarily be- cause of an interest in the epidemiology of cancer, and continued partly to help me decide whether or not I should continue to smoke. Eventually I became persuaded that I would be better off if I stopped smoking cigarettes, and I acconplished this quite easily by continuing to smoke only a pipe. Because of the publicity asso- ciated with the publication of our American Cancer Society studies on the effect of smoking on health (Fivmond and Horn 1954, 1958), I found myself the target of innumerable personal accounts of how people had given up smoking. Not only would friends and associates do this, but strangers would approach me on the cormsuter trains into Manhattan with detailed accounts of hosw they had accomplished . the feat. Partly because it seemed a waste to ignore this fund of information, I began to move into a more scientific concern about the smoking habit, its developnrnt, and its alteration. #ltaing these sany years I have developed certain prejudices about statements on cigarette smokina. First, I deplore attempts by people who apply their personal standards to others' behavior to ~ characterize it as.•YlloQical" or "Ybnoraal." A fora of behavior that was regularlyeng aged in at saae time by approximately three- fourths of the males in the tinited States born around the time of ttorld War I, as I uras, hardly sserns appropriately characterized as abnormal. It was not until the early 1950's that scientific infor- mation became available which persuaded a majority of us that we would be better off if we did not smoke. Although more than half of us did eventually quit smoking, many of us found that the behav- ior had become so integral a part of our w-Ay of functioning that it was difficult to quit. For some, quitting demanded such an invest- ment of effort that it seemed better to postpone trying to a later, more propitious time, but in the meantime to "hedge one's bet" by seeking a filtered cigarette. W preju3ius also sncompass i}iose %bo feel that anly 2he rare indi- lrldual successfully quits swkiag'. Roughly a siillion adults a year 'l!ave successfully quit seoicinj ia the past few years. _ Durinj the 24

I I I I I I Y I I I I I I I I I I lete 1960's, with the suppvrt of a bomb~mt of aatisa~kin= ara~oeaicements on televis3oa, the na~ber of persons qnittin= reeched as high as 3 or 4 million a year (fiorn 1970, 1979). Since the long term success rate during that period was between one-fourth and one- third of those who were trying to quit, we have had as many as 10 aillion persons trying to quit in a single year. Also, I deplore thosc i& characteriu quittiag smoking as a tor- tured, almost i"sible process. lbr suny people, it is easy; for most it is sames.tere between easy snd diffialt ; and only for a minority is it really difficult. Finally, the demands of the smoking public have pushed the industry into developing and promoting cigarettes that produce lower and lower emissions of hansiful ingredients. These have now been demon- strated to be of lesser degrees of harm than those being used for- rrrly, though they are far from being demonstrated as innocuous. Average tar and nicotine levels, which have been dropping since the early 1950's, have dropped another 10 percent in the past 2 years alone and are now down to 16.6 mg of tar and 1.09 mg of nicotine (Horn, unpublished data), compared to the 42 mg of tar and 3 mg of nicotine in the cigarettes before the 1950's. In addition to those who quit smoking and those who change to cigar- ettes delivering less tar and nicotine, increasing numbers of indi- viduals do not become smokers. lhtil about 2S years ago, cigarette smoking was a habit that was growing rapidly in each successive cohort of males born in the United States. It began to take hold even more rapidly among successive generations of young woocen. This phenomenon has slowed and turned around during the past 25 years. 'fie taking up of smoking by yaaig men is now substantially lower than it used to be, and the growth of the habit among youasg wortkn has probably now peaked, at a level appreciably below the , former peak among men (fbrn et al. 1959; U.S.LHI]V 1972, 1976). 94J1CIM AS A IFJIRNING PROCfSS I bave explored the initiation and establishment of the smokin habit as a learning process partly, no d~bt, because of the assutQt~on that uhat can be learned can be unlearned. This has been basic to the descriptive model of~ rsona_l choice health behavior about rfiieh I have written, sumnarizing- nuch of our resear ?i on =sw -ing (Horn 1976). We have investigated the factors that characterize this class of behavior with the objective of finding out how to maximize its benefits r+hile minimizing its harmful effects. Initiation of the Behavior 1 The initiation of personal choice health behavior is usually ex~lora- tory in nature. Typically, it takes place in rather young people, saretimes in yomg children. It is largely dependent on: first, the availability of opportunity toeng age in~behavior; second, having a fairly high degree of euriosity about the effects of the behavior; and third, in finding it a wy of expressing either con- formity to the behavior of others (such as parents, older siblings 2S

I I I I I I I I I I I I I I I I or age-equals) or rebellion against rdut are seen as tmreasonable proscriptions against the behavior. tharacteristically, the greater the availabilit)Lor the opportiaiity for expressing the behavior, the less is the necessity for a strong eomnitment either to conformity with the behavior of others or to rebellion against proscriptions by others (tiorn et a1.*1959). We lciow that smoking, for example, is awh more comnon in children of parents who are themselves regular smokers, and this is partly be- cavse of the ready availability of cigarettes to children when there is already a smoker in the household and partly because use of cigarettes by older members of the family sets an exanple of accept- able behavior and sti;mulates curiosity about what aiakes the eigar- rette so attractive (iiorn et a1. 1959). When smoking first begins to be widespread in a culture, it tends to be taken up with increasing frequency by successive waves of youig people. Nevertheless, substantial nunbers of older people may turn to it, especially if it can serve as a convenient substi- tute for previously well-established behavior, as was the case with cigarettes replacing cigar and pipe smoking in many male populations between 1910 and 1950. We are seeing a similar phenomenon now in Third World countries wfiere the raaotion of cigarette smoking is increasing rapidly (bckhoim 19783 . Establishment of the Behavior Y}ie establishment of persoral ehoice health behavior can be influ- enced by at least three groups of factors. In the case of cigarette smoking developing as a continuing habit in adolescents, these are, first, the costs/benefits evaluation of the behavior; second, common stereotypes that characterize perception of behavior; and third, psychological factors characterizing both personal structure and personality integration factors, particularly as they reflect the relationship of the individual and his needs to society and its demands. 'Ihe costs that go into the evaluation of the costs/benefit balance aay include the harmful effects on health (boM-pFiysica~an menta ), economic cost, and the harmful effects on society, such as economic or as a form of pollution. The benefits may include positive effects on health (both physical and mental), economic advantages, social utility (especially in terms of the facilitation of personal inter- actions), psychological utility (both in terms of the increase of positive effect or the reduction of negative effect) and benefits to society. 'there a+ay also be quite separate evaluations of a costs/benefits analysis for the individual and a costs/benefits analysis for society, since for some individuals, one of these may be more per- suasive than the other in producing attempts to change behavior. For political leaders, the costs/benefits for society usually take ' pzecedence over the costs/benefits analysis for the individual. 26 O W ~ ~ I . °°

I I I I I I I I I I I I I I I I ffien the behavior which appears to be most logical on the basis of a costs/benefits balance and the actual behavior of the individual are quite different, another set of factors consisting of rational- izations or some other set of beliefs may cane into play to reduce the dissonance between the "logical" behavior and the actual be- havior. In the case of cigarette smoking, the costs for the past twenty or so years have largely reflected the increasing evidence of the harmful effects of smoking on health, but in addition to that, such concerns as esthetic values, the contribution of smoking to various forms of pollution, and economic values related to the financial cost either to the individual or to society, have come into play. Zbe benefits are wide, sanginj from the facilitation of social interaction, which is perceived or appears as ane of the most raiu- able benefits of taking up ssokir~, to the reduction of tension and to the a~sancement of states of p~.asure NAich tend to be a lattr development in tbe appreciation of benefits`7Such comon remarks as "I can always give up smoking before it htrts me," or "I don't really smoke enough for it to do any damage," or "Ihe kind of cigar- ette I smoke (or the way I smoke it) is not very likely to hurt ariyane" are characteristic of beliefs of the individual who per- ceive~s~ potential costs as higher than benefits and yet who continues to tual stereo s tend to develop as a kind of mythology about uing is i e, what smokers are like, and why people smoke. 7hese tend to be superficial and frequently inaccurate systems of beliefs and are likely to be derived either from the exaggerations of advertising on the one hand or the exaggerations of counter- advertisinY by antismoking groups on the other. In general, the greater the role played by superficial and inaccurate beliefs about the behavior, whether positive or negative, the more difficult it is to develop a sound decision-making process on the part of the individual or society as a whole. /lvariety of patterns of s cholo ical forces may enter into the determination of personal choice a behavior, in particular, those that reflect the conflict engendered in individuals by the demands of society and his own inner demands. In the case of smoking behavior and health, we have identified two such factors (Milne and Cel.man 1973). Qie depends on the strength of the conflict perceived by the individual between the satisfaction of his okn needs and the demands imposed on him by society or by its authority figures. 7he second factor is a reflection of the urgency to the individual of nintaining control over his own behavior and over his osai destiny as opposed to being subject either to the control of others or to vagaries of chance as represented by "good luck" or by 'bad W.' lInalement of /lffeet Although the factors that contribute to the establishment of the Wit probably continue for a time to be important in the mainten- 27

I I I I I I I I I I I I 1 I ance of smokin.g behavior, we have found the model developed by Tomkins (1966) and extended by us (}iorn and iwaingrow 1966; Ikard, Green, and Norn 1969) to describe the psychological utility of smoking in terms of its affect management capabilities describes aell the use of smoking even in as young a population as college students. The use of cigarettes to help in the managear.mt of affect, by augmenting positive affective states and reducing negative affect- ive states, is probably developed quickly; and as the number of cigar- ettes used per day increases usually up to the ages of 35 or 40, the individual may shift from using cigarettes for one purpose to using them for assltiple purposes. 'ihis approach to characterizing smoking behavior has been of sax use -in developing educational prograas for altering smoking behavior, as a logical application of this knoaledge carries with it impliations for interfering with the establishment and maintenance of the behav- ior. Our critical need at this point is to identify the co:anon pat- terns that predict establishment of the smoking habit and to find ways of interfering with that process. FOOTNO'IE 1. With minor changes, the sections of this paper on "Initiation of the Behavior" and "Establisfieent of the Behavior" were included in an article by Dr. Horn entitled "A model for the study of personal choice health behaviour," in 'Ihe International Journal of Health Bducation, 19(2):89-98, 1976.5r~rn k-tTen rectoi o t e tiona Clearinghouse for Ssoking and Health, Bureau of Health bducation, Center for Disease Control, Department of Health, Educa- •tion, and Welfare. During 197S and early 1976 he served as a Special Consultant to the World Health Osganization. REFEREVCFS Eckholm, E. Cuttin Tobacco's Toll. Worldwatch Paper 16. Washing- ton, D.C.: Aorf at nstitT ; 1978. 40 pp. Hanmond, E.C., and Horn, D. 'ihe relationship between human smoking habits and death rates. JMiA. 155(1S):1316-1328, 1954. Tiamnond, E.C., and Horn, P. 9aoking and death ntes--report on forty-four months of follow-up of 187,783 men. JAMA. 166(10):1159- 1172, 1958. Horn, D. What's happening to smoking behavior? In: National Con- ference on S+nokin and Health: A Stomof Proceedin s: tiona teragency ci on ing a , 1970. pp. 15-20. Horn, D. A model for the study of personal choice health behaviour. International Journal of Health bducation, 19(2):89-98, 1976. 28

I I I I I I I I F I I I I fiorn, D. fiotir ssuch real progress have we nade in the fight against swkiag? American hazA Association Bulletin, 65(1):6-9, 1979. Horn, D.; murts, F.A.; Taylor, LM.; and Solonxal, E.S. Cigarette smoking among high school students. American Journal of Public Health, 49:1497, 1959. Eiorn, D., and Waingrow, S. Some dimensions of a model for smoking behaviot: change. American Journal of Public Health, 56:21, 1966. riurd, F.F.; Green, D.E.; and Fiorn, D. A scale to differentiate between types of smoking as related to the manaQement of affect. International Journal of Addictions, 4:646, 1969. Kilne, A.M., and Cblman, J.G. Development of a teenager's self- testing kit (cigarette smoking). Final Report. Edvcation and Public Affairs, Washington, D. C., 1973. Tamki.n.s, S.S. Psychological model for smoking behavior. American Journal of Public Health, 56:12 (Part II), 17-20, 1966. U.S.DEP. National Clearinghouse for Smoking and Health. Teena 9!akin --National Patterns: 1968 1970. U.S. Department of a t, uon, an e are ication .(}Si)72-7508, 1972. U.S.ItIDV. National Q earinghouse for Smoking and Health. Teena Snckin --National Patterns: 1972 1974. U.S. Department o a t, ation, an are ication .(NIH)76-931, 1976. AITTIiOR bniel Horn, Ph.D. R. D. 1, Box 182 PrenchtAwn, New Jersey 0882S ~ ~ . ~ ~ ~ ~ ~ J-.6 1 29