British Journal of Health Psychology (2000), 5, 235–248 Printed in Great Britain 235

© 2000 The British Psychological Society

Lung cancer and cigarette use: Cognitive factors,

protection motivation and past behaviour
Nashiba Kanvil and Kanayo F. Umeh*
Department of Psychology, University of Central Lancashire, UK

Objective. To assess relationships between health cognitions and protection motivation

regarding cigarette use and lung cancer.

Design. Cross-sectional questionnaire survey. Variables were intentions (i.e., motiva-

tion) perceptions of susceptibility to and severity of lung cancer, the beneŽts or
effectiveness of not smoking in reducing the risk of lung cancer, barriers to not
smoking, past smoking behaviour, and demographic factors (age, gender).

Method. Two-hundred and seventy-Žve men and women (aged 18–66 years) were
administered and returned the questionnaire. Multiple regression analysis was used to
analyse the data.

Results. Past cigarette use predicted stronger intention to smoke, accounting for 70%
of the variance. Perceptions of susceptibility and barriers increased the variance
explained, but only marginally. Greater perceived likelihood of contracting lung
cancer and stronger perceived barriers to not smoking predicted higher motivation to
smoke.

Conclusions. Results provide limited support for the role of health cognitions in
intended cigarette use, and justify the incorporation of past risk behaviour in social
cognition models applied to cigarette use.

The present study used a cross-sectional questionnaire survey to assess the role of health
cognitions in intentions concerning cigarette use and lung cancer. Protection motivation
theory (PMT; Rogers, 1975, 1983) and the health belief model (HBM; Janz & Becker,
1984; Sheeran & Abraham, 1996) were used as the conceptual frameworks and lung
cancer as the health threat. Before examining the salient features of PMT and HBM, some
epidemiological literature is required on the threat posed by lung cancer.
Lung cancer is a principal cause of premature mortality in present-day western
countries. This condition makes up 15–25% of all cancer cases, 8% in men and 22%
in women (Amler & Dull, 1987). Mortality from lung cancer has risen exponentially in
the past 50 years, especially among women. In 1988 this disease accounted for 24 671
deaths in the UK, approximately 33% of all cancer-related mortality. Mortality rates
*Requests for reprints should be addressed to Dr Kanayo F. Umeh, Social Sciences, Psychology Division, Nottingham
Trent University, Burton Road, Nottingham NG1 4BU, UK.
236 Nashiba Kanvil and Kanayo F. Umeh
among men have declined steadily over the years. However, death among women has
generally been increasing (The Health of the Nation, 1993). Although the onset and
development of lung cancer is not yet fully understood, up to 80% of all lung cancers in
men and 40% of all lung cancers in women living in western countries can be attributed
to cigarette smoking (Amler & Dull, 1987). In the UK, 90% of all deaths from lung
cancer can be attributed to cigarette smoking (Jacobsen, Smith, & Whitehead, 1991).
While the role of cigarette smoking as a behavioural risk factor for lung cancer has been
heavily publicised, increased tobacco consumption, notably in women and young adults
(The Health of the Nation, 1993) suggests that other health cognitions besides risk
awareness may be relevant (Steptoe & Wardle, 1992).
A variety of factors have been implicated in cigarette use, ranging from basic
demographic and personal considerations to complex socio-economic processes
(Murphy & Bennett, 1994). However, the role of health cognitions has been of special
interest to health psychologists (Norman & Conner, 1996). Two theoretic frameworks
used to understand the inuence of cognitive factors on health decision making are the
HBM (Janz & Becker, 1984) and PMT (Rogers, 1983). Both models propose that beliefs
about the seriousness of a health threat (perceived severity), one’s likelihood of contract-
ing the disease (perceived susceptibility or vulnerability), the beneŽts or effectiveness of
recommended preventive action in reducing the threat (perceived beneŽts or response-
efŽcacy), and one’s capacity to perform the preventive behaviour (perceived barriers or
self-efŽcacy), affect a persons motivation to adopt protective action. Motivation to reduce
a threat is strongest when people perceive themselves to be vulnerable to a serious threat,
believe preventive behaviour would effectively avert the threat, and think they are capable
of adopting the behaviour.
Health cognitions have been found to play a key role in cigarette use (see review by
Janz & Becker, 1984). Various experimental studies have demonstrated causal links
between beliefs and smoking intentions (e.g., Maddux & Rogers, 1983; Sturges &
Rogers, 1996) and health beliefs have also been identiŽed as important predictors of
intention measures (e.g., Ho, 1992). However, the predictive strength of health
cognitions has varied across studies (see review by Van der Pligt, 1994). Moreover,
studies assessing the role of cognitive factors speciŽcally in relation to lung cancer are
rare. Weinstein (1988) points out that assessing people’s cognitions, speciŽcally risk
perceptions, without reference to a speciŽc threat, may attenuate cognitive–decision
relationships. There is also a paucity of research assessing health beliefs within the context
of past/current smoking behaviour. Research has shown that behavioural risk status is a
major determinant of health decisions (Steptoe, Sanderman, & Wardle, 1995). There is
increasing evidence that past behaviour may have an independent effect on behavioural
intentions (see review by Sutton, 1994). More importantly, studies suggest that belief –
intention relationships may weaken after past/current action is considered (see review
by Van der Pligt, 1994). Thus, researchers have called for behavioural risk status to be
assessed as a control variable in evaluating the importance of health beliefs (see review
by Norman & Conner, 1996).
The present study addresses these issues, by evaluating the predictive power of HBM
and PMT cognitions in relation to lung cancer and within the context of past/current
smoking behaviour. Although lung cancer is not the only smoking-related health threat,
the disturbing morbidity and mortality rates means that research in this area would have
 Lung cancer and cigarette use 237
signiŽcant beneŽts for health promotion (Jacobsen et al., 1991). In line with past research
(Sutton, 1994), it was expected that past cigarette use would predict stronger intentions
to smoke. Furthermore, it was hypothesized that stronger perceptions of susceptibility to
lung cancer, the severity of lung cancer, the beneŽts or efŽcacy of not smoking in reducing
the threat, and lower perceived barriers to or higher self-efŽcacy for adopting preventive
action, would predict reduced intentions to smoke cigarettes.

Method

Design
The study was based on a cross-sectional questionnaire design. Health cognition research has traditionally
distinguished between intentions to perform a behaviour and actual performance of that behaviour (see
reviews by Eagly & Chaiken, 1993; Rogers, 1975). The use of intention as the criterion variable in the present
study concurs with the view that severity, vulnerability, response–efŽcacy and self-efŽcacy cognitions
primarily arouse protection motivation, the conventional measure of which has been intention (see Maddux &
Rogers, 1983; Rippetoe & Rogers, 1987; Rogers, 1975, 1983; Rogers & Mewborn, 1976). Although
behavioural intention is not a component of the HBM (Janz & Becker, 1984), it is generally accepted as an
essential mediating variable that links health cognitions with action (see reviews by Boer & Seydel, 1996;
Conner & Sparks, 1996). Another issue is that early health cognition research based on PMT assessed health
cognitions as interacting rather than additive constructs (see review by Eagly & Chaiken, 1993). It was
generally assumed that intention to adopt preventive behaviour will not be aroused if the value of any health
cognition is zero (e.g., no perceptions of beneŽts). However, this multiplicative function has not received
consistent empirical support (Boer & Seydel, 1996; Eagly & Chaiken, 1993) and an additive framework was
used in the present research.

Sample
The sample comprised 100 (36.4%) male and 175 (63.6%) female undergraduates (aged 18–66 years,
mean 5 25.97 years) attending the University of Central Lancashire in Preston. This sample was selected
partly on the basis of convenience of access, but also because the formality of a university setting promised a
high response rate. Most of the questionnaires were administered to respondents in their lecture theatres.
Participation was voluntary.

Measures
The questionnaire incorporated 41 statements to which participants responded on 6-point scales, from not
true (1) to very true (6). Based on measures developed by Champion (1984) and Boer and Seydel (1996), most
items related to perceptions of susceptibility or vulnerability to and severity of lung cancer, beneŽts or
efŽcacy of not smoking in reducing the risk of lung cancer, obstacles and difŽculties in not smoking, and
intention to smoke. In addition, respondents indicated their past smoking behaviour (from six alternatives)
and stated their name (optional), age, and gender. A pilot study was initially carried out to on a sample of 20
undergraduates (separate from the main sample) to identify and eliminate problematic items.

Health cognitions. Several aspects of PMT (e.g., advantages of maladaptive behaviour, costs of adaptive
behaviour, fear) and the HBM (e.g., health motivation, cues to action) were not measured. While these factors
may be relevant to smoking, most studies focus on severity, vulnerability and efŽcacy beliefs (Boer & Seydel,
1996), constructs which have substantial precedence in earlier work on persuasion and (together with
barriers/self-efŽcacy beliefs) are considered the essential antecedents of protection motivation (Hovland,
Janis, & Kelley, 1953; Rogers, 1975; Eagly & Chaiken, 1993).
All the health cognition measures were subjected to a principal component analysis, with varimax
238 Nashiba Kanvil and Kanayo F. Umeh
rotation, to determine the existing factor structure in the present sample (Bryman & Cramer, 1994).
Although oblique rotation seems more reasonable when factors are assumed to be related, distinctions
between certain cognitions sometimes seem to be redundant. For example, people don’t always discriminate
between severity and vulnerability cues in their risk appraisals (Umeh, 1998). Orthogonal rotation generates
unique factors and enhance minimizes unnecessary duplication of constructs1 (Tabachnick & Fidell, 1996).
Ten factors were generated with eigen values higher than 1, and contributing 66% of the variance. Item
loadings of .50 and above were used to deŽne the factors (Tabachnick & Fidell, 1996). Details of the number
of items, the Cronbach’s alpha reliability coefŽcient, and descriptive statistics for each factor are shown in
Table 1.

Table 1. Health cognitions measure: Cronbach’s alphas, means and standard deviations
No of Cronbach’s
Measure items alpha Min–Max Mean SD
Health cognitions
Motivation (intention) 5 .96 5–30 12.93 9.47
Barriers 7 .81 7–42 12.75 6.88
BeneŽts 3 .71 3–18 11.20 4.04
Fear 3 .75 3–18 7.61 4.31
Severity 3 .64 3–18 12.05 3.85
Susceptibility 4 .86 4–24 11.07 5.35

The Žrst subset of items consisted of Žve statements reecting motivation to smoke cigarettes in the near
future (I intend to smoke during the next 6 months, I will smoke during the next 6 months, I want to smoke
during the next 6 months, I expect to smoke over the next 6 months, It is likely that I will smoke during the
next 6 months). These items were summed to yield a single intention or motivation to smoke score. Greater and
lower intentions to smoke can be seen to reect, respectively, lower and higher motivation to protect one’s
health (Rippetoe & Rogers, 1987; Rogers, 1975, 1983).
The second group comprised seven items relating to perceived barriers to successful avoidance of cigarette
use (It would be difŽcult for me to avoid smoking, Not smoking would be anti-social, Not smoking is a
problem for me, My friends would disapprove if I didn’t smoke, Not smoking would interfere with my
activities, Not smoking would require starting a new habit, which is difŽcult, I am afraid I will not be able to
avoid smoking). These items reect the HBM’s perceived barriers to preventive action, and also PMT’s
perceived self-efŽcacy (perceived ability to successfully enact the behaviour) and therefore added up to form a
single barriers or self-efŽcacy score.
The third group contained four statements concerning beliefs about one’s likelihood of contracting lung
cancer in the future (My chances of getting lung cancer are great, My physical health makes it more likely
that I will get lung cancer, I feel that my chances of getting lung cancer in the future are good, There is a good
possibility that I will get lung cancer). The sum of these items yielded a single susceptibility score.
The next subset consisted of three items reecting fear of lung cancer (When I think about lung cancer I
feel nauseous, When I think about lung cancer my heart beats faster, I am afraid to even think about lung
cancer). These statements were summed to give a single fear score. Fear tends to be conceptualized as a by
product of vulnerability and/or severity appraisals within the context of PMT (Rippetoe & Rogers, 1987;
Boer & Seydel, 1996).
The Žfth factor comprised three items about the perceived severity of lung cancer (My Žnancial security
would be endangered if I got lung cancer, Problems I would experience from lung cancer would last a long
time, If I had lung cancer my whole life would change). These items added up to a single severity score.

1
The appropriate choice of rotation in principal component analysis remains controversial (Bryman & Cramer, 1994). An
orthogonal solution may be more artiŽcial but it can also help reduce multicollinearity (Tabachnick & Fidell, 1996, p.9).
The present data was also subjected to oblique (oblimin in SPSS) rotation but (as expected) this generated factors that were
much more difŽcult to interpret (Tabachnick & Fidell, 1996, p.674). The SPSS output is available on request.
 Lung cancer and cigarette use 239
Only one item obtained a sufŽciently high loading on the sixth factor (Have you in the past 6 months
received any information on lung cancer?). In view of the reliability problems associated with single item
measures (Eagly & Chaiken, 1993), this factor was subsequently discarded.
The next group comprised four statements related to the perceived utility of preventive action in averting
lung cancer (Not smoking would prevent lung cancer for me, I have a lot to gain by not smoking, Not
smoking would avoid me getting lung cancer, If I do not smoke, I am unlikely to develop lung cancer).
Together, these items proved internally consistent (Cronbach’s alpha 5 0.68). However, deletion of the item
‘I have a lot to gain by not smoking’ improved internal reliability (Cronbach’s alpha 5 0.71), highlighting
the ambiguity in this statement. The three remaining items concur with the HBM’s perceived beneŽts, and
also PMT’s perceived response-efŽcacy. These three statements were therefore summed to yield a single beneŽts
or response-efŽcacy score.
The eighth subset consisted of three items concerning both the perceived seriousness of lung cancer (If I
had lung cancer my career would be endangered, Lung cancer would endanger my marriage—or a signiŽcant
relationship), and fear of lung cancer (The thought of lung cancer scares me). Removal of this last statement,
to obtain a ‘pure’ severity measure, markedly reduced internal consistency (Cronbach’s alpha 5 0.51). The
ninth factor initially contained three statements generally reecting perceptions of vulnerability or
susceptibility to lung cancer (Within the next year I will get lung cancer), cues to action (Have you been
prompted to protect yourself from lung cancer?) and fear (I worry a lot about getting lung cancer). Not
surprisingly, these items proved quite unreliable, yielding a Cronbach’s alpha of 0.58. The Žnal factor
comprised only one item with a sufŽciently high loading (Have you seen any documents on television about
lung cancer?). Due to problems of interpretation and unreliability, these three factors were subsequently
discarded.

Smoking behaviour. Past cigarette use was measured with six options adopted from a recent OfŽce of
Population Censuses and Surveys (OPCS) (1994) survey on smoking: I have never smoked, I have only ever
tried smoking once, I used to smoke sometimes but I never smoke a cigarette now, I sometimes smoke
cigarettes, but I don’t smoke as many as one a week, I usually smoke between one and six cigarettes a week
and I usually smoke more than six cigarettes a week. According to OPCS (1992, 1994) surveys, smoking at
least one cigarette per week is deŽned as ‘regular’smoking. In this regard, the last 2 items were treated as one
category. Since this measure cannot be assumed to represent an interval scale, the last four categories were
converted into dichotomous ‘dummy’ variables with levels coded as either ‘1’ or ‘0’. The Žrst category (i.e., I
have never smoked) was treated as a reference category and coded as ‘0’ for each of the four dummy variables.
Thus, the dichotomy in each dummy variable represented the difference between the reference category
(0) and the given smoking category (1) (e.g., ‘I have never smoked’ 5 0 vs ‘I have only ever tried smoking
once’ 5 1) (Tabachnick & Fidell, 1996).2
Demographic factors assessed were age and gender (1 5 male , 2 5 female ).

Procedure
Questionnaires were administered just prior to (or following) a lecture. Of 300 questionnairesadministered,
275 (90%) were returned.Participants were informed that the exercise was part of a study on beliefs related to
cigarette smoking and that all information provided would be treated in strict conŽdence. Previous research
suggests that such assurances of conŽdentiality encourage valid responses to questions on issues (e.g.,
cigarette use) that evoke socially acceptable answers (Murray & Perry, 1987). Names were not required.
Administration of the questionnaire in lecture halls allowed direct supervision of respondents. The
questionnaire took between 10 and 20 minutes to complete and all returned questionnaires contained
little or no missing data.

2
Dichotomous ‘dummy’ variables restrict predictor–criterion associations to linear relationships in multiple regression.
This is desirable as a nominal variable with three or more categories can have a different shape of relationship (e.g.,
quadratic) which changes arbitrarily with changes in the numbers assigned to each category (Tabachnick & Fidell, 1996).
Linear multiple regression was used in the present analysis, hence the use of dichotomous variables.
240 Nashiba Kanvil and Kanayo F. Umeh
Data analysis
Chi-square analysis was used to compare the frequency of past/current cigarette use across gender and age
(split at the median). Demographic differences in health cognitions and motivation to smoke were tested
using analysis of variance (Tabachnick & Fidell, 1996). Pearson’s correlational analysis was used to assess zero-
order relations between variables. Finally, hierarchical multiple regression was computed to identify key
predictor variables, in accordance with the study hypotheses.

Results

Descriptive data
The prevalence of past/current smoking overall and across gender and age is shown in
Table 2. Almost one-third of the sample (83, or 30.2%) had never smoked. Forty (14.5%)
had smoked only once previously, 45 (16.4%) used to smoke but did not currently smoke,
16 (5.8%) smoked sometimes, while 91 (33.1%) smoked at least one cigarette a week.
There was no signiŽcantly distinguishable pattern across age and gender (x 2 5 2.55 and
5.07, respectively, p > .05). However, older respondents (aged 22–66 years) seemed more
prone to smoke at least once a week, and have smoked previously, whereas younger
participants (aged 18–21 years) appeared more likely to smoke occasionally but less than
one cigarette per week, to have tried smoking only once previously, or to never have
smoked. Men seemed more inclined to smoke at least once a week, smoke sometimes but
less than one cigarette per week, have smoked previously, and to have never smoked,
whereas women appeared more prone to smoke sometimes, and have smoked only once.
Due to low cell frequencies, possible age by gender interactions were not assessed.

Table 2. Prevalence of cigarette use overall and across age (median split) and gender
Age Gender
a a
Sample Young Old Male Female
Smoking status (%) (%) (%) (%) (%)
Never smoked 30.2 32.6 27.5 31.0 29.7
Smoked only once 14.5 15.3 13.7 13.0 15.4
Used to smoke 16.4 14.6 18.3 19.0 14.9
Smoke sometimes 5.8 6.9 4.6 2.0 8.0
At least one cigarette per week 33.1 30.6 35.9 35.0 32.0
Note. Chi-square analyses revealed no signiŽcant patters ( p > .05).
a
Young 5 18–21 years, old 5 22–66 years.

Demographic differentials on all health cognitions are shown in Table 3. Older

participants had stronger perceptions of severity than did younger respondents,
F(1, 274) 5 10.91, p < .001. By contrast, older respondents reported lower levels of
fear compared with younger participants, F(1, 274) 5 5.87, p < .05. No main effects
or age by gender interactions were observed for perceptions of susceptibility, barriers/
self-efŽcacy, beneŽts/response-efŽcacy, and motivation/intention to smoke.
In Pearson’s r correlational analyses (see Table 4), past cigarette use (tried smoking
once, used to smoke, smoke at least one cigarette per week) related to higher perceived
 Lung cancer and cigarette use 241
Table 3. Mean differences on all health cognitions across age (median split) and gender
Age Gender
a
Health cognitions Young Old Male Female SigniŽcance
Motivation (intention) 12.72 13.16 12.68 13.07 –
BeneŽts 11.26 11.13 11.46 11.05 –
Barriers 12.87 12.62 12.60 12.83 –
Fear 8.22 6.95 7.46 7.70 A*
Severity 11.31 12.86 12.28 11.92 A***
Susceptibility 10.81 11.35 10.62 11.33 –
Note. A 5 age main affect; *p < .05, **p < .01, ***p < .001.
a
Young 5 18–21 years, old 5 22–66 years.

barriers to not smoking, motivation to smoke, and susceptibility to lung cancer. Smoking
at least once a week was associated with greater perceived beneŽts of not smoking, fear
and severity of lung cancer. Smoking sometimes but less than one cigarette per week was
related to being female and stronger perceived susceptibility. Previous smoking but
current abstinence was associated with older age and lower perceived beneŽts of not
smoking. Never having smoked was linked with lower perceived barriers to not smoking,
less motivation to smoke, and lower perceived susceptibility to lung cancer. Greater
perceived barriers to not smoking related to stronger perceived beneŽts of not smoking,
motivation, fear, and susceptibility. Stronger perceived beneŽts was associated with
greater fear and perceptions of severity. Motivation to smoke was linked with higher fear
and susceptibility. Greater perceived severity and susceptibility were related to more fear
and (severity only) older age. Finally, fear was associated with younger age (all p values
<.05).

Multiple regression analyses

Table 5 shows results of the hierarchical multiple regression analysis. Age and gender
were entered Žrst (Step 1) to control for demographic differentials, followed by the four
past smoking ‘dummy’ variables (Step 2), and Žnally health cognitions (Step 3). Only
beta coefŽcients signiŽcant at the p < .05 level are reported.
In Step 1, neither age nor gender emerged a signiŽcant predictor of motivation to
smoke (F(2, 272) 5 0.10; p 5 .90).
In Step 2, two aspects of past behaviour predicted intentions; ‘smoke at least one
cigarette per week’ (b 5 .82; t 5 20.65; p < .0001) and ‘sometimes smoke but not as
many as one per week’ (b 5 .12; t 5 3.42; p < .001) were associated with stronger
motivation to smoke in the next 6 months (F(6, 268) 5 104.14; p < .0001). The R2
increased from 0% to 70%, and the F for signiŽcance of R2 change was
F(4, 268) 5 156.05; p < .0001.
Finally, in Step 3, perceived susceptibility to lung cancer (b 5 .17; t 5 4.22;
p < .0001), and perceived barriers to not smoking (b 5 .10; t 5 2.62; p < .01), predicted
motivation to smoke (F(11, 263) 5 65.68; p < .0001). Greater perceived likelihood of
contracting lung cancer and perceived barriers to not smoking, predicted stronger
motivation to smoke. The dummy variable ‘smoke sometimes but not as many as one
 242

Table 4. Pearson’s correlations among health cognitions, past behaviour and demographic measures
1 2 3 4 5 6 7 8 9 10 11 12 13
1) Age –
2) Gender 2 .11 –
3) Never smoked 2 .04 2 .01 –
4) Smoked once 2 .08 .03 2 .27** –
5) Smoked >1 per/week 2 .00 2 .03 2 .46** 2 .30** –
6) Smoked sometimes 2 0.00 .12* 2 .16** 2 .10 2 .17** –
7) Used to smoke <1 per/week .14* 2 .05 2 .30** 2 .18** 2 .31** 2 .11 –
8) Barriers .01 .02 2 .25** 2 .14* .45** .04 2 .16** –
9) BeneŽts 2 .11 2 .05 .06 2 .06 .16** 2 .04 2 .19** .23** –
10) Fear 2 .17** .03 2 .10 2 .04 .20** 2 .06 2 .05 .37** .32** –
11) Intention .02 .02 2 .38** 2 .29** .82** 2 .01 2 .30** .48** .11 .16** –
12) Severity .15* 2 .05 2 .08 .01 .12* 2 .04 2 .04 .11 .20** .12* .04 –
Nashiba Kanvil and Kanayo F. Umeh

13) Susceptibility to lung cancer .06 .06 2 .30** 2 .19** .51** .14* 2 .21** .39** 2 .03 .14* .60** 2 .00 –
*p < .05, **p < .01.
 Lung cancer and cigarette use 243
Table 5. Prediction of motivation (intentions) from demographic factors, health cognitions and
past behaviour
Cumulative R2 SigniŽcance
Predictors Beta R2 change of change
(N 5 275)
Step 1
Age 2 .02
Gender .02
.00 .00 p > .05
Step 2
Age .03
Gender .03
Smoked oncea 2 .04
Smoked one p/weekb .82***
Smoke sometimesc .12***
Used to smoked 2 .05
.70 .70 p < .0001
Step 3
Age .02
Gender .02
Smoked oncea 2 .04
Smoke one p/weekb .69***
Smoke sometimesc .07
Used to smoked 2 .04
Severity 2 .05
Susceptibility .17***
Fear 2 .03
BeneŽts .00
Barriers .10**
.73 .03 p < .001
*p < .05, **p < .01, ***p < .001.
Note. Variables (and associated beta coefŽcients) added in Step 2 and Step 3 are in indicated in bold.
a
Tried smoking once. b Smoked at least one cigarette per week. c Smoke sometimes but not as many as one per week. d Used
to smoke but never smoke now.

cigarette per week’ was no longer signiŽcant at this stage, although ‘smoke at least one
cigarette per week’ remained signiŽcant (b 5 .69; t 5 14.95; p < .0001). The R2
increased by 3%, from 70% to 73%, and the F for signiŽcance of R2 change was
F(5, 263) 5 6.56, p < .001.
Age, gender, ‘only ever tried smoking once’, ‘used to smoke but never smoke now’,
fear, perceptions of severity, and the beneŽts of not smoking, all failed to predict the
criterion.

Discussion
The present study assessed the proposed link between health cognitions and smoking
intentions, in relating to lung cancer and within the context of past risk behaviour.
244 Nashiba Kanvil and Kanayo F. Umeh
Descriptive analyses revealed demographic differences in health beliefs. Financial and
other general life problems seemed more important to older respondents who, by virtue
of their greater responsibilities (e.g., family, marriage, jobs), may view lung cancer as
more severe to the extent that it threatens their lifestyle. Older participants reported less
fear of lung cancer, perhaps because of less cigarette use. Respondents who used to smoke
but don’t smoke currently tended to be older.
Multiple regression showed that only a marginal proportion (3%) of variation in
motivation to smoke can be accounted for by health cognitions. Past behaviour explained
most (70%) of the variance, with cigarette use at least once per week predicting stronger
intentions to smoke. Indeed, the best predictor of future behaviour is usually a measure of
earlier behaviour as people based their judgements about future action mostly on their
past behaviour (Sutton, 1994; Steptoe et al., 1995). Thus, respondents who smoke are
mostly acting on the basis of a smoking history rather than their perceptions of risk and
efŽcacy. It is worth noting that the motivation scale incorporated items assessing both
intention (e.g., I intend to smoke during the next 6 months) and expectation (e.g., It is
likely that I will smoke during the next 6 months). Behavioural expectations amount to
self-predictions about the probability of behaviour, and tend to be based on perceived
skills, resources, and opportunities (Warshaw & Davies, 1985). Thus when asked to
predict future smoking (expectations), respondents probably based their predictions on
their current or recent past behaviour. With intentions the inuence may be reversed in
that reports of current/past smoking may reect smoking intentions. For example, people
smoke at least one cigarette per week because of an intention to do so.
Neither the HBM nor PMT incorporate past behaviour as an integral element. Prior
behaviour is viewed as just any other external variable (e.g., social class, personality)
mediated by health cognitions, and hence not predicting intentions/behaviour directly
(Norman & Conner, 1996). Indeed, smoking cigarettes sometimes, but less than one per
week, was no longer a salient factor after accounting for health cognitions, suggesting
mediation (for example occasional cigarette may increase appraisals which in turn
impinge on motivation to smoke).
The fact that perceived susceptibility and barriers both continued to predict motiva-
tion even after controlling for past smoking is remarkable. After all, several studies have
found that the inuence of risk perceptions may be greatly attenuated when past risk
behaviour and other cognitions are considered (see review by Van der Pligt, 1994).
However, the positive association between susceptibility suggests that respondents may
also used their future behaviour as a basis for assessing personal risk (Van der Velde,
Hooykaas, & Van der Pligt, 1996), lower intentions to smoke resulting in lower levels of
perceived risk. If susceptibility estimates are assumed to reect people’s (future) risk
behaviour, rather than as a precursor of health behaviour (Weinstein & Nicolich, 1993),
the predictive salience of susceptibility should not be surprising. Research suggests that
people at high risk estimate their personal vulnerability as higher than do people at low
risk (Gladis, Michela, Walter, & Vaughan, 1992). For example, someone who does not
plan to smoke will correctly judge their likelihood of contracting lung cancer in the
future as low, whereas a person intending to smoke will accurately assess their
vulnerability as high (Gerrard, Gibbons, Benthin, & Hessling, 1996). Either way, a
strong relationship would obtain between-risk estimates and motivation to smoke,
irrespective of previous smoking behaviour.
 Lung cancer and cigarette use 245
Numerous studies have consistently veriŽed strong relationships between barriers/self-
efŽcacy and smoking decisions (e.g., see review by Schwarzer & Fuchs, 1996). For those
who have a dependence on smoking, overcoming their addiction can prove formidable
and, in some cases, almost impossible (Jacobsen et al., 1993). For both smokers and non-
smokers, strong perceived social pressure to smoke (e.g., ‘My friends would disapprove if
I didn’t smoke’, ‘Not smoking would be antisocial’) are all barriers that exist between any
desire to avoid cancer and staying away from cigarettes. Perceptions of the beneŽts of not
smoking did not seem relevant. Bandura (1989) suggests that the inuence of beneŽts/
response-efŽcacy may be moderated by self-efŽcacy beliefs. Health conscious people who
believe that not smoking reduces the risk of lung cancer may still smoke if they do not
believe they are capable of avoiding cigarette use. Thus, when perceived barriers/self-
efŽcacy is accounted for, the expected beneŽts of preventive action may play a negligible
role in decision making. Research Žndings on this issue are inconsistent (see review by
Schwarzer & Fuchs, 1996).
Perceived severity was not a signiŽcant predictor. In their comprehensive review of
HBM research, Janz and Becker (1984) identiŽed severity as the weakest component, a
view substantiated somewhat by later reviews (e.g., Harrison, Mullen, & Green, 1992). It
has been suggested that severity may not directly predict health decisions, but instead is
mediated by perceived beneŽts. For example, Weinstein’s (1988) ‘precaution adoption
process’ assumes a sequential process, leading to the adoption of preventive action, in
which people Žrst have to appreciate the seriousness of a threat before they consider their
personal vulnerability, barriers and beneŽts. Schwarzer and Fuchs (1996) argue that the
inuence of risk perception in the motivation process tends to be overestimated. Like
Weinstein, they suggest a causal chain in which risk appraisals are distal predictors that
help to stimulate perceptions of the beneŽts of alternative actions and their capacity to
perform them.

Methodological issues
One limitation of both PMT and the HBM is their assumption of a single salient health
threat (Boer & Seydel, 1996; Janz & Becker, 1984) although it can be argued that lung
cancer is the main health risk most people associated with smoking (Gray, 1993). The
measures of susceptibility (e.g., My chances of getting lung cancer are great) were
unconditional in that they were not made contingent on future risk behaviour.
Researchers have identiŽed several problems with such scales (e.g., Ronis, 1992; Ronis
& Harel, 1989; Van der Velde et al. 1996; Van der Pligt, 1998) and recommended the use
of conditional measures (e.g., My chances of getting lung cancer if I continue to smoke are
great). As always, cross-sectional data are merely suggestive and hence need to be
regarded with caution. Longitudinal research examining not just direct relationships but
also possible mediation pathways is recommended. Recent evidence with adolescents
suggests that increases in cigarette use (and other risk behaviours) are accompanied by
increases in perceptions of susceptibility to lung cancer which in turn predicts subsequent
smoking, demonstrating reciprocity between cigarette use and health cognitions
(Gerrard et al., 1996). It may be productive to extend such research to other age
groups and account for the motivation (i.e., intention) which purportedly precedes
behaviour (Rogers, 1975, 1983). It is worth mentioning that only linear relations were
246 Nashiba Kanvil and Kanayo F. Umeh
tested in the present study. Although it is this form of association that is generally
assumed (Baron & Kenny, 1986), quadratic or step functions may also apply (but see
Sutton, 1992). The present Žndings must therefore be interpreted strictly within a linear
context. Questionnaire data also needs to be viewed cautiously given that several biases
may operate to distort the accuracy of self-reports (Conner & Waterman, 1996; but see
Murray & Perry, 1987).

Implications
The present research embedded health cognitions in relation to lung cancer and intended
cigarette use, within the context of past risk behaviour. Stronger perceptions of barriers/
self-efŽcacy predicted higher motivation to smoke, as expected, although the positive
association between susceptibility estimates and motivation may reect accuracy in risk
judgments. The attenuated role of smoking sometimes but less than one cigarette per
week, after accounting for health cognitions, suggests a mediating effect that necessitates
further investigation. Fear of lung cancer, perceptions of lung cancer severity, and the
beneŽts of preventive action, all failed to emerge as direct predictors. Overall,
the contribution of health cognitions was marginal. Past behaviour (i.e., smoking at
least one cigarette per week) accounted for the bulk of the variance, justifying the
inclusion of this factor as a standard part of health behaviour models applied to cigarette
use (Sutton, 1994). These Žndings have disturbing implications for health promotion
efforts. Seeking to develop people’s cognitions about the risk of lung cancer and efŽcacy of
not smoking may be unproductive if individuals intend to behave as they have behaved in
the past (Sutton, 1994). This possibility underscores the notion of targeting health
promotion strategies at younger age groups, before cigarette use is Žrmly acquired and
established. For older groups ‘set-in-their-ways’, interventions can aim at removing social
and other barriers that encourage smoking (Lichtenstein & Glasgow, 1992).

Acknowledgements
The authors would like to thank Dr Derek Rutter and two anonymous reviewers for their contributions to
this paper.

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Received 28 September 1998; revised version received 11 June 1999