Are changes in functional beliefs about smoking a proxy for nicotine withdrawal symptom reduction?
NOT PEER REVIEWED Fotuhi et al concluded in their interesting study of patterns in smokers' cognitive dissonance-reducing beliefs that rationalisations about smoking change systematically with changes in smoking behaviour(1). Moreover, they argue that: i) changes in attitude on quitting are higher for 'functional' beliefs rather than 'risk-minimising' beliefs and ii) if smokers relapse these functional beliefs return to pre-quit levels, iii) that changes in beliefs follow the changes in behaviour (quitting), suggesting that iv) these changes are rationalisations invoked in the service of motivation to reduce cognitive dissonance and that v) smokers are able to reduce dissonance by modifying their beliefs in ways that help to rationalise their continued smoking.
We wish to suggest an alternative understanding. The functional belief items include questions such as "smoking calms you down when you are stressed or upset" and "smoking helps you concentrate better". We propose that these items are not examples of dissonance-reducing attitudes but are representations of smokers' genuine experiences of nicotine withdrawal 'in between' cigarettes or on quitting, i.e. 'stress' and 'poor concentration'(2). In this way they are more a proxy for the physiological states induced by nicotine deprivation rather than attitudes and beliefs per se. Therefore 'risk-minimising beliefs' such as 'the medical evidence that smoking is harmful is exaggerated' and 'you've got to die of something, so why not enjoy yourself and smoke' may more truly represent cognitive dissonance, as they do not overlap with experiences indicating withdrawal symptoms.
A misinterpretation of these withdrawal symptoms by smokers and a commonly held belief that smoking reduces stress will undoubtedly result in the kind of results that the authors report - but should these results really be interpretated as supporting their hypothesis? Once smokers stop smoking, withdrawal symptoms subside over ensuing weeks (3), with 'functional' justifications for smoking naturally receding. They would return when the smoker then recommences to a physiological state of dependency and nicotine deprivation.
The theory of reasoned action holds that attitude changes precede behavioural change (4). The authors conclude that their study shows conversely, for smokers that their changes in attitudes are likely to be a result of their changes in smoking behaviour. This interpretation does not prove causation if these 'cognitive-dissonance' measures are more an indication of the presence of physiological symptoms rather than attitudes and beliefs per se.
We do agree, however, with Fotuhi et al's proposal that public health measures should target smokers' beliefs that smoking reduces stress. This would promote greater understanding about the withdrawal process and link it to why pharmacotherapy can be a useful adjunct to quitting and thereby increase their sense of response and self-efficacy (5).
We have been working in Australia with Indigenous smokers who have a high prevalence of smoking. One of the teaching tools we have developed is a simple visual model to explain to the lay public in the context of a group or personal intervention why smoking increases stress levels, how withdrawal symptoms make smokers more stressed and how nicotine replacement therapy can be efficacious (6).
Resistance to anti-tobacco messages, and cognitive dissonance will most likely continue to plague smokers who do not feel able to quit. Although for Indigenous smokers, knowledge acquisition alone may not be enough to support successful cessation (7), we believe smokers' justifications for smoking may also represent the truth for them of their experiences of withdrawal, and a lack of understanding about nicotine deprivation.
1. Fotuhi O, Fong GT, Zanna MP, Borland R, Yong H-H, Cummings KM. Patterns of cognitive dissonance-reducing beliefs among smokers: a longitudinal analysis from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control. January 3, 2012. doi: 10.1136/tobaccocontrol-2011-050139 2. Parrott AC, Garnham NJ, Wesnes K, Pincock C. Cigarette Smoking and Abstinence: Comparative Effects Upon Cognitive Task Performance and Mood State over 24 Hours. Human Psychopharmacology: Clinical and Experimental. 1996;11(5):391-400. 3. Hughes JR. Tobacco withdrawal in self-quitters. J Consult Clin Psychol. 1992;60(5):689-97. 4. Fishbein M, Ajzen, I. Belief, attitude, attention and behaviour: An introduction to theory and research. Reading, MA: Addison-Wesley; 1975. 5. Witte K, Meyer G., Martell, D. Effective health risk messages: a step- by-step guide. Thousand Oaks, CA: Sage Publications; 2001. 6. Baker F, Gould, GS. Blow Away The Smokes DVD: Quit Cafe Scene starts 13.00min. 2011 [4 July 2012]; Available from: http://www.blowawaythesmokes.com.au 7. Gould G, Munn, J, Watters, T, McEwen, A, Clough, A. Knowledge and views about maternal tobacco smoking and barriers for cessation in Aboriginal and Torres Strait Islanders: a systematic review and meta-ethnography. Nic Tob Res. 2012;under review
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