Elsevier

Preventive Medicine

Volume 49, Issues 2–3, August–September 2009, Pages 219-223
Preventive Medicine

Do risk-minimizing beliefs about smoking inhibit quitting? Findings from the International Tobacco Control (ITC) Four-Country Survey

https://doi.org/10.1016/j.ypmed.2009.06.015Get rights and content

Abstract

Objective

To replicate findings that risk-minimizing and self-exempting beliefs lower quit intentions, and to extend this by testing their capacity to prospectively predict smoking cessation.

Method

13,324 adult (≥ 18 years) cigarette smokers from the USA, Canada, UK, and Australia from one of the first three waves (2002–2004) of the International Tobacco Control 4-Country survey were employed for the predictive analysis where beliefs measured in one wave (1–3) of a cohort were used to predict cessation outcomes in the next wave (2–4).

Results

Both types of belief were negatively associated with both intention to quit in the same wave and making a quit attempt at the next wave. When taken together and controlling for demographic factors, the risk-minimizing beliefs continued to be predictive, but the self-exempting belief was not. Some of the effects of risk-minimizing beliefs on quit attempts seem to be independent of intentions, but not consistently independent of other known predictors. There were no consistent predictive effects on sustained cessation among those who made attempts to quit for either measure.

Conclusions

Countering risk-minimizing beliefs may facilitate increased quitting, but this may not be so important for self-exempting beliefs.

Introduction

In western countries most smokers accept that smoking is harmful and regret ever having started (Fong et al., 2004). However, many also profess beliefs that minimize or discount the harms (Chapman et al., 1993, Oakes et al., 2004), sometimes called self-exempting beliefs, but perhaps better thought of as rationalizations. Oakes et al. (2004) identified four classes of such beliefs. ‘Bulletproof’ beliefs, the archetypal self-exemptions in that the problem does not apply to me (e.g., “I think I must have the sort of good health or genes that means I can smoke without getting any of the harms”); and three types of risk-minimizing beliefs, that is, beliefs that the harms are not as great as some think, either absolutely or relatively: ‘Skeptic’ beliefs which discount the harms of smoking (e.g., “The medical evidence that smoking is harmful is exaggerated”); ‘Jungle’ or normalizing beliefs (e.g., “Smoking is no more risky than lots of other things people do”); and ‘Worth-it’ beliefs (e.g., “You've got to die of something, so why not enjoy yourself and smoke”). All four beliefs were inversely related to intentions to quit (Oakes et al., 2004), with the Worth-it beliefs having the strongest relation. Similar beliefs have also been associated with reduced interest in quitting (Peretti-Watel et al., 2007).

Rationalizing beliefs are theorized as psychological mechanisms to reduce perceptions of vulnerability or susceptibility to harm, which is postulated as a key motivator of behaviour change in theories like the Health Beliefs Model (Rosenstock, 1974, Abraham and Sheeran, 2005) and Protection Motivation Theory (Rogers, 1983, Norman et al., 2005), and as such help create an optimistic bias that reduces the psychological need to act, that is, reduce cognitive dissonance (Weinstein, 1988). The other type of beliefs that theoretically should reduce the likelihood of quitting are functional beliefs in the value of smoking (Yong and Borland, 2008). However, unlike these experience-based beliefs, rationalizing beliefs do not have a tangible reality to ground them, and thus may be less stable. Oakes et al. (2004) questioned whether rationalizing beliefs are primary inhibitors of quitting or merely convenient defenses that are discarded when the cognitive dissonance is resolved by quitting (Diclemente et al., 1991, Carter et al., 2001). Collectively expectancies beliefs should affect the likelihood of quitting either independently or in interaction. This is clearly so for making quit attempts, but less so for predicting success among those who try (Borland et al., 1991, Hyland et al., 2006, Segan et al., 2002, West et al., 2001).

This paper uses data from the International Tobacco Control Policy Evaluation Project (ITC) Four-Country survey to explore the power of these beliefs to predict quitting activity prospectively. We report three replications of the findings.

The aims are:

  • a.

    To explore socio-demographic correlates of those who hold these beliefs and how they relate to intentions to quit.

  • b.

    To test the predictive strength of these beliefs on quitting, controlling for psychosocial factors known to affect quitting.

  • c.

    To examine the stability of the beliefs as a function of interest in quitting.

Section snippets

Participants

13,324 adult smokers from the first three waves (2002–2004) of the ITC cohort survey carried out in four English-speaking countries: Canada, USA, UK and Australia (9058 recruited in Wave 1; 1714 at Wave 2; and 2552 at Wave 3). Cooperation rates were high for a survey of this kind (78%). Retention from waves 1 to 2 was 6764 of 9058 (74.7%); from waves 2 to 3 it was 5827 of 8478 (68.7%); and from waves 3 to 4 it was 5979 of 8379 (71.4%).

The ITC project is a longitudinal study designed to evaluate

Results

The three risk-minimizing beliefs were moderately inter-correlated and formed a reliable scale (alpha = 0.65, 0.63, 0.66 for the three replications). The results we report are on the scale rather than treating the beliefs individually because in preliminary work the results were stronger and more consistent when combined, consistent with them measuring a common underlying factor (see Table 1). The self-exempting belief predicted quite differently so was kept separate, although it was moderately

Discussion

The results confirm earlier work that rationalizing beliefs are related to intentions to quit, and that these beliefs are most strongly held among older smokers and those from more disadvantaged backgrounds (Oakes et al., 2004, Peretti-Watel et al., 2007). This study shows that risk-minimizing beliefs independently predict quit attempts, with those holding the beliefs being less likely to make quit attempts. However, the self-exempting belief (Oakes et al.'s Bulletproof belief) operates in a

Conflict of interest statement

The authors declare that there are no conflicts of interest.

Acknowledgments

This research was funded by grants from the National Cancer Institute of the United States (R01 CA 100362), the Roswell Park Transdisciplinary Tobacco Use Research Center (P50 CA111236), Robert Wood Johnson Foundation (045734), Canadian Institutes of Health Research (57897 and 79551), National Health and Medical Research Council of Australia (265903 and 450110), Cancer Research UK (C312/A3726), and Canadian Tobacco Control Research Initiative (014578), with additional support from the Centre

References (20)

  • OakesW. et al.

    "Bulletproof skeptics in life's jungle": which self-exempting beliefs about smoking most predict lack of progression towards quitting?

    Prev. Med.

    (2004)
  • Peretti-WatelP. et al.

    Risk denial about smoking hazards and readiness to quit among French smokers: an exploratory study

    Addict. Behav.

    (2007)
  • AbrahamC. et al.

    The health beliefs model

  • BorlandR. et al.

    Predicting attempts and sustained cessation of smoking following the introduction of workplace smoking bans

    Health Psychol.

    (1991)
  • CarterS. et al.

    Finding the strength to kill your best friend — smokers talk about smoking and quitting

    (2001)
  • ChapmanS. et al.

    Self-exempting beliefs about smoking and health: differences between smokers and ex-smokers

    Am. J. Public Health

    (1993)
  • DiclementeC.C. et al.

    The process of smoking cessation: an analysis of the precontemplation, contemplation and preparation stages of change

    J. Consult. Clin. Psychol.

    (1991)
  • FongG.T. et al.

    The near-universal experience of regret among smokers in four countries: findings from the international tobacco control policy evaluation survey

    Nicotine Tob. Res.

    (2004)
  • HylandA. et al.

    Individual-level predictors of cessation behaviours among participants in the International Tobacco Control (ITC) Four Country Survey

    Tob. Control

    (2006)
  • NormanP. et al.

    Protection motivation theory

There are more references available in the full text version of this article.

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