The Effectiveness of Different Treatment Methods to Curb Smoking Addiction

Abstract

Smoking has been a prevalent issue in Singapore, and is highly detrimental to the public

and the smokers. The Health Promotion Board (HPB) is interested in treatments that target the

reduction of smoking. Hence, the HPB has conducted a study to test the effectiveness of 3

treatments - aversion therapy, tapering off and immediate stopping. We hypothesised that

aversion therapy would be the most effective treatment and female smokers would be more

inclined to quit smoking than male smokers. A longitudinal study over a period of 2 months was

conducted. Participants were randomly selected and questionnaires were given to participants pre

and post experiment to determine their desire to smoke both at home and at work. After running

ANOVA test, we found out that the most effective treatment to curb smoking addiction is

aversion therapy and tapering off. Results have also shown that female smokers were less likely

to quit than males possibly due to concerns about appearance. Smoking is also more likely to

decrease at the workplace than at home. This could be due the social stigma associated with

smoking. As such, aversion therapy can be implemented by HPB as a measure to effectively

reduce smoking addiction in Singaporeans.

 Introduction

Background & Purpose.

Smoking is known to be a cause of many diseases such as cancer, increased risk for

coronary heart disease, stroke and chronic obstructive lung disease. Smoking is prevalent

amongst people of all ages. Many smokers turn to cigarettes to alleviate stress (Epstein, et al,

1988) and even adolescents could have been peer pressured into smoking during their rebellion

years (Baker, et al, 2004). Once introduced to smoking, smokers find it difficult to quit due to the

nicotine addiction developed overtime. Strong withdrawal symptoms also prevents smokers from

successfully quitting smoking (Baker, et al, 2004). Thus, should the pervasiveness of smoking

decrease, the morbidity and mortality from diseases caused by smoking would be greatly

reduced. As such, the HPB conducted this study to effectively assist smokers to quit smoking

with the most effective treatment methods.

Our research aim is to determine which is the most effective treatment method in curbing

smoking addiction while taking into consideration the gender and location.

There are three types of treatment methods to curb smoking addiction in therapy centres.

They are: tapering off, immediately stopping, and aversion therapy. Eventually, the ideal result

would be to quit smoking completely. The tapering off method refers to reducing the number of

cigarettes smoked per day, and changing the nicotine content from high to low. Doctors would

be available to advise addicts and may prescribe nicotine patch or chewing gum to decrease the

amount of nicotine consumed ("Tapering Off Method.", n.d.). However, the success rate of

tapering off method differs between low nicotine dependent and high nicotine dependent

smokers (Sach., et al, 1991). While treatment effect was significant for the low nicotine
dependent smokers, it was not so significant for the high nicotine dependent smokers as they

were more likely to slip up and relapse.

The second method would be immediate stopping. This cost effective method would

require smokers to stop any form of nicotine intake immediately, relying only on their own

motivation to quit. As seen in Law & Tang (1995), after being advised to quit smoking in a

doctor consultation, 2 percent of smokers quit and did not relapse for a year, showing its

effectiveness.

Lastly, the aversion therapy is a form of psychological treatment whereby one is exposed

to the pleasurable stimulus of smoking a cigarette while simultaneously subjected to an

unpleasant stimulus such as administering electric shocks, rapid smoking or covert sensitization

(Hajek., et al, 2001). Russell and Armstrong (1976) illustrated that electric aversion was highly

effective in reducing or stopping smoking for over 6 weeks.

Hypothesis.

Hypothesis 1 is that the aversion therapy would be the most effective method for quitting

smoking as by administering an unpleasant stimulus when smoking, one would be conditioned to

associate smoking with the unpleasant stimulus. This reduces the appeal of smoking and could

hence extinguish ones smoking addiction. Whereas the tapering off and immediate stopping

treatments would not be able to curb smoking as effectively due to higher dependency on ones

motivation to quit and the lack of a conditioned response towards smoking.

Hypothesis 2 that the treatment methods would be more effective in reducing the desire

to smoke at home than at work. Since the consequences of passive smoking is significantly

damaging to family members health (Kalucka, 2006), the considerations for ones family could

override the temptation to smoke, leading to a lower rated desire to smoke at home. There could
also be a higher rated desire to smoke at work due to social smoking or job stress (Ayyagari,

2010).

Hypothesis 3 is that women would be more likely to successfully quit smoking as

compared to men. This is because women generally appear to be less nicotine-dependent than

men (Beslau, Kilbey & Andreski, 1994; Fagerstrom et al., 1996).

Method

Participants.

Participants were chosen through convenience sampling from the group of callers who

dialled in to QuitLine, a counselling service initiated by HPB in aiding smokers to quit

smoking. Participants consisted of 38 callers (18 males and 20 females) aged 24-46. This group

of people were selected as they were smokers who explicitly expressed a desire to quit. This

would also remove the possible confound of participants willingness to quit smoking.

Design.

This study uses a mixed design. Between subjects factors are the 3 treatment conditions

and gender. The within subject factors are the location of home and work.

Procedure.

A longitudinal study over a period of 2 months were conducted. Participants were

randomly assigned into the three different treatment conditions - tapering off (n = 8),

immediately stopping (n = 14) and aversion therapy (n = 16) for the experiment. They were

given two surveys to rate their desire to smoke at home and work on a 10-point scale, whereby a

larger value indicates a stronger desire. The survey were completed before and after the

treatment is administered.
 For the tapering off condition, participants' initial cigarette intake per week was

recorded. Participants were asked to cut down on their individual cigarette intake by 12.5% with

each week. By the end of the 2 month experiment, their cigarette intake level should be zero.

For the immediately stopping condition, participants were asked to withhold their

cigarette intake for the entire experiment period.

For the aversion therapy condition, participants were given a remote-controlled electric

shock device to administer a mild electric shock to themselves whenever they feel an urge to

smoke.

Analysis Plan.

Statistical method

Firstly, the scores of pretreatment desire to smoke at home and at work was averaged to

yield a combined pretreatment desire to smoke. The same was done with post treatment scores to

yield a combined post treatment desire to smoke. A one-way between-subjects ANOVA was

conducted twice to find out if there was a significant difference between the means of the 3

treatment conditions for both pre and post experiment.

Least Significant Difference (LSD) Test was conducted to determine which treatment

condition contributed to the significance found in the one-way ANOVA. Bonferroni procedure

was conducted to control the familywise type I error rate at = .05.

Pre and post treatment difference was calculated by subtracting the desire to smoke at

home post treatment from the desire to smoke at home pretreatment to yield home difference

(Home before - Home after). The same was done for the scores of desire to smoke at work to

yield work difference. (Work before - Work after).

 Next, two-way between-subject ANOVA was conducted 2 times to find out if a treatment

effect and gender effect were present. Each ANOVA used a different variable as the dependant

variable to test for location effect as well as a general treatment effect. Also, LSD Test was

conducted to determine which treatment condition was the most effective in the reduction of

desire to smoke.

Lastly, a repeated measures ANOVA was conducted to find out if there is a location

effect between work and home.

Statistical Assumptions

For the convenience of the data analysis, we have made 2 statistical assumptions - the

independence of observations and normality. This indicates that the samples are randomly

selected from the population such that observations are independent of each other and the data

are drawn from normal distribution within each population. The homogeneity of variance can be

seen from the results in Levenes Test for Equality of Variances conducted which was found to

be not significant (p = .486 > .05) and (p = 0.349 > 0.05) respectively.

Results

A one-way ANOVA was conducted between the combined pretreatment desire to smoke

and treatment conditions. Results showed that there was no significant difference between the 3

treatment conditions pre experiment, p = .810. In the tapering off condition, M = 6.31, SD =

1.44, immediately stopping condition, M = 5.96, SD =1.29 and aversion therapy, M = 5.88,

SD = 1.83. This shows that the randomization was successful.

Next, one-way ANOVA was conducted between combined post treatment desire to

smoke and treatment conditions. Results showed a significant difference between the 3 treatment

conditions post experiment, p = .020. In the tapering off condition, M = 5.00, SD = .963,
immediately stopping condition, M = 5.82, SD = .868 and aversion therapy, M = 4.56, SD =

1.45. Post hoc LSD Test was then conducted. Bonferroni Procedure was used to control the

familywise error rate to be no greater than FW = .05. Since we are only comparing 2 pairs,

aversion therapy and immediately stopping, aversion therapy and tapering off, * = .05/2 = .025.

The post-hoc comparison test reflected that participants who underwent aversion therapy

condition (M =4.56) had significant difference in their desire to smoke as compared to

participants in the immediately stopping condition(M = 5.82) (p = .006 < .025). At this stage,

aversion appears to be the most effective method since the participants in this condition has an

average of lower desire to smoke.

Next, a two-way ANOVA with home difference as dependant variable was conducted and

found a significant main effect in gender (p = .000 < .05). 41.4% of the dependent variable can

be attributed to the gender effect. ( = .414) However, the results did not show any main effect in

both the treatment (p = .091 > .05) and the interaction effect (p = .521 > .05). Since there was no

significant results found for treatment, post hoc was not conducted.

Another two-way ANOVA with work difference as a dependent variable was conducted.

Results showed that there is a main effect for gender (p = .047 < .05) with 11.8% of the

dependant variable can be attributed to the gender effect ( = .118) and treatment (p = .012 <

.05) with 24.1% of the work difference can be attributed to the treatment effect ( = .241).

However, no interaction effect was found (p = .162 > .05). Comparing 2 pairs, aversion therapy

and immediately stopping, aversion therapy and tapering off, LSD Test and Bonferroni

Procedure were conducted and found that there was no significant difference between aversion

therapy and tapering off (p = .631 > .025) but there was a significant difference between aversion
therapy and immediate stopping (p = .021 < .025). Looking at the post hoc results, there was also

a significant difference between tapering off and immediately stopping (p = .018 < .05).

To confirm the effect of location on the effectiveness of the treatment, we ran a repeated

measures ANOVA for both work and home conditions. A significant difference was found

between the difference in desire to smoke at work and the desire to smoke at home (p = .003 <

.05). 21.3% of the difference in desire to smoke is explained by the location factor (eta sq =

.213). This further supports that the treatment is more effective in reducing participants desire to

smoke at work rather than at home.

The Levenes test was conducted in all the analysis and were found to be not significant

which proves our assumption of homogeneity of variance.

Discussion

Evaluation & Interpretation of results.

In general, aversion therapy and tapering off methods have no significant difference. This

suggest that both treatments are equally effective.

Male smokers have shown a reduced desire to smoke at home and at the workplace.

Although females have shown a decrease in desire to smoke at work, there is an increase in

desire for them to smoke at home (Mhome_diff = -.737, Mwork_diff=.933). This might suggest that

females chose to smoke at home instead of at work.

One possible reason why female smokers were more likely to continue smoking than

males could be due to concerns with their physical appearances. They believe that smoking can

lead to weight loss and enhance their physical attractiveness (Waldron, 1991) and quitting

smoking usually causes weight gain (Spring., et al, 1991). As such, females who are often more

concerned with their appearances than males (Pliner., et al, 1990) would be more reluctant to quit
smoking. It was also reported that women were less likely to cease smoking compared to men as

they were less confident in their ability to quit (Satcher., et al, 2001). These explain the

significant gender difference in which females are more persistent in their smoking habits,

disproving hypothesis 3.

Our results also show that treatments only shown significant effect for reducing desires to

smoke at work but not at home, contrary to our hypothesis 2. A plausible explanation why people

smoke at home instead of work would be to escape the social stigma labelled with smoking.

People tend to have negative societal perceptions towards smokers thus discouraging them from

smoking in public. This leads to an increased preference in smoking at home to steer away from

outsiders judgements. In addition, the recent increase in smoking bans at workplaces and public

places may reduce smokers desires to smoke at work and in public locations (Robert Wood

Johnson Foundation, 2011), hence increasing desire to smoke at home, as it is a convenient

location that is not banned from smoking in Singapore yet.

Implications.

Since aversion therapy and tapering off are the most effective treatment, implemention

can be considered to curb smoking addiction. Although, this treatment effect only applies for

males, the application of our findings would still aid a major population of smokers. Also, we

found out that the treatments are most effective at work which suggest that the treatments can be

introduced to reduce smoking at workplace.

Adequacies/ Limitations.

The small sample size of 62 participants may not be representative of the smoking

population, hence there is low external validity as it may not be generalisable. Additionally,

since participants were randomly selected from the sample pool of people who called the
QuitLine hotline, they would be more willing and motivated to quit smoking as compared to

smokers who did not call. This may then result in a possible confounding bias whereby results

for the treatments are more favourable than they actually are.

In addition, the 2 month experiment period is too short to determine whether participants

will quit smoking entirely. A relapse may occur, causing them to return to their usual smoking

habits. Hence, a longer duration of the study should be conducted instead to access the

effectiveness of the treatment over a longer period of time to increase the generalisability of the

study.

Another limitation is the unequal group sizes in the different treatment groups. There are

twice as many participants in the aversion therapy condition than those in the tapering off

condition. It might cause possible confounds, and unequal treatment groups might cause biases

in the results, tilting the results towards a specific direction.

Further Research.

Further research can focus on reducing desire to smoke at home. Currently, there is a

relatively wide online database on home remedies to quit smoking, however they are not

scientifically proven. Looking into such home remedies makes it easier for smokers to curb

their smoking addiction from home as it increases accessibility to more treatment methods. For

instance, using Black Pepper Essential Oil was suggested to reduce ones desire to smoke (Lis-

Balchin, 2006). Such suggestions, if proven true, could aid in future comparisons in effectiveness

of home remedies as well.

We can also look into treatments targeted towards females to reduce smoking, such as

focusing and promoting more on specialised treatments that include dietary advice should the

female smokers be concerned with weight gain issues. For instance, study conducted on 281
female smokers found that high intensity exercise assists cognitive-behavioural smoking

cessation program, allowing cessation to last in the long term. This exercise not only helps to

improve ones exercise capacity, but also delays weight gain - one of womens worry when

curbing their smoking addiction (Marcus, et. al., 1999). Treatments that focus on motivational

and behavioral influences can also be crafted to target smoking addicts (Baker., et al, 2004).
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