Worry about health in smoking behaviour change

Abstract

Many smokers and ex-smokers worry about their health. Given that worry keeps attention focused on the threat, it was expected that worrying about health in smokers would motivate them to quit and in ex-smokers may prevent relapse. Furthermore, worry was expected to influence the process of smoking cessation in interaction with self-efficacy, which is a measure of control over smoking, and with disengagement beliefs, which distorts the threatening meaning of potential motivating information. In the present study 380 smokers and 324 ex-smokers were recruited to join a prospective study with a follow-up of eight months. At T1, smoking/quitting behavior, worry and the other psychological constructs were assessed. At T2 quitting activity in smokers and relapse in ex-smokers were assessed. As expected, smokers who worried about the health effects of smoking reported higher quitting activity at T2. The three-way interactions between worry, self-efficacy and disengagement beliefs in the prospective prediction of quitting activity and relapse were significant: Among smokers with high self-efficacy combined with strong disengagement beliefs, worry led to more quitting activity. Among ex-smokers with low self-efficacy combined with strong disengagement beliefs, worry led to more relapse. The present results suggest new ways of approaching the stimulation of quitting and the prevention of relapse.

Introduction

The phenomenon of worry has been studied primarily in the context of understanding psychopathology (Borkovec, Ray, & Stöbe, 1998), although relevant data have been gathered from normal populations (Davey & Tallis, 1994). In clinical psychological contexts, worry is considered to be an indication or core aspect of psychopathology. Worry is also being studied in health psychology, where it is considered as a mediator of the effects of stress on health. In this context, worry is for example thought to be responsible for sub-optimal recovery from any confrontation with stressors, by keeping the body in a state of prolonged physiological arousal (Brosschot & Thayer, 2002). In this study however, worry is not viewed as a psychopathological phenomenon but as a normal and functional psychological phenomenon with possible physical drawbacks. Taking the functional perspective, the present study develops the application of the construct of worry in health psychology. More specifically it focuses on the role of worry in the psychology of health behaviour change. As a cognitive mechanism that serves the crucial goal of keeping the mind aware of potential threat (Tallis & Eysenck, 1994), worry might play a specific if not crucial role in changing behaviour that potentially damages somatic health.

Changes in health behaviour are desirable whenever a link is revealed between specific health behaviours and specific diseases (Green & Kreuter, 1985), for example the link between smoking behaviour and serious diseases, such as cardiovascular diseases and several types of cancer (Doll, Peto, Wheatly, Gray, & Sutherland, 1994). Consequently, smokers are abundantly exposed to health education information that has been developed to motivate and support smoking cessation, through mass media campaigns and through the diffusion of smoking cessation guidelines in health care organisations and practices. A significant portion of the efforts aimed at making smokers quit smoking is devoted to the communication of information on the detrimental health effects of smoking (Glynn, Boyd, & Gruman, 1990). Thus, smokers and ex-smokers—who have been exposed to tobacco smoke in the past—have been extensively confronted with knowledge about the threats to their health. It would therefore not be surprising and in line with adaptive reactions to threat, that smokers and ex-smokers continue to think or worry about it as long as it is useful, that is, as long as the threat is present. Worry can partly be conceptualised as “an attempt to engage in mental problem-solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes” (Borkovec, Robinson, Pruzinsky, & DePree, 1983). As other authors (Tallis & Eysenck, 1994) have indicated, worry has a ‘prompt’ function, causing the organism to constantly direct attentional resources to current concerns, and preparing the organism to action. As such, worry might motivate and support smokers in planning and implementing a quit attempt. It is reasonable to expect that the more often a smoker is made aware of the hazards of smoking, the more likely it is that a smoker will try to quit. Smoking-related worry seems to be an adequate measurement of this ‘prompting’ frequency. However, smoking-related worry may not always lead directly to a ‘behavioural solution’ (not smoking) that would decrease the real health threat. In fact, it often instigates a potentially maladaptive ‘cognitive solution’, for example, distortion or denial of the threatening content. Thus, by taking account of a person’s preference for the behavioural versus cognitive solutions, the effects of worry on quitting activity can be mapped out. The construct of self-efficacy, or the belief in the personal ability to exert the required coping behaviour, may be useful at this point. In the case of quitting smoking, self efficacy refers to a person’s judged capability to be able to refrain from smoking. High self-efficacy may guide worriers to the behavioural solution, that is, to attempt to quit or to stay abstinent. The construct of disengagement (Bandura, 1986, Bandura, 1996), on the other hand, represents the distortion or denial of the meaning of the threatening information. Strong disengagement beliefs may lead worriers to choose the cognitive solution to cope with the health threat, which may hinder the quitting process.

In the present study, smoking cessation was divided into two major phases: The motivational phase in which smokers still smoked but were working towards a quit attempt and the action phase in which ex-smokers tried to remain non-smokers. We expected that worry would influence the quitting process in the motivation phase as well as in the action phase, possibly in interaction with self-efficacy and disengagement beliefs. More specifically, firstly, it was expected that 1) ex-smokers would worry to a lesser degree than smokers because they had removed the threat successfully (quit smoking); 2) ex-smokers would have higher self-efficacy than smokers because they had shown that they could refrain from smoking and 3) ex-smokers would no longer adhere to disengagement beliefs. Secondly, it was expected that in smokers as well as in ex-smokers, more frequent worry and higher self-efficacy would support the quitting process, whereas higher levels of disengagement beliefs would inhibit a constructive quitting process. Importantly, we expected that worry, because of the ‘prompting’ function discussed above, would predict quitting activity to a greater extent than the expected negative physical outcomes of smoking. In other words, worry would stimulate quitting more than mere threat. Thirdly and finally, it was expected that the effects of worry on the quitting process would partly depend on self-efficacy and disengagement beliefs. Specifically, we expected a three-way interaction to occur, in such a way that worry helps quitting when self-efficacy is high and disengagement beliefs are low.