Research Korner: Social Cognition

Cigarette Smoking

Social Cognition   Introduction             Smoking continues to be a problem among many individuals worldwide. An attempt to decrease availability to those less than 18 years of age resulted in a law that requires proof of age to purchase cigarettes. Cigarette smoking by women is also a growing health concern. However, enforcement is far from being met. In many public places, smoking is allowed and even minor aged individuals can smoke. The decision to smoke may be reflective of self-concept issues and may be culturally influenced. Awareness of risk factors is essential for implementation of preventive health care in a variety of health care settings. This paper will discuss the situation of Susan, a 45 year old single female who tried to quit cigarette smoking many times but failed. She has become frustrated and thinks she might never give up smoking. This discussion will focus on schemas, the self, and attribution theory, and relate it as factors that might be responsible for Susan’s failure to quit smoking and her thoughts and feelings in response to this situation.   Smoking Cessation Programs             Success in response to public health education is more likely in professional and managerial persons and in those best able to intelligently appreciate the risks associated with smoking. Unfortunately, most smokers do not usually stop smoking until the onset of ill health. Withdrawal effects, possibly related to nicotine deprivation, include depression, anxiety, irritability, insomnia, and weight gain. Hypnosis, aversion therapy, group therapy, and special smoking withdrawal clinics have helped individuals break their smoking habit, but the overall value of these aids is uncertain. Persons unable to stop cigarette smoking should be encouraged to change to a less dangerous method of smoking such as using pipes or cigars, or filter-tipped cigarettes with a low tar and nicotine content. The risk may be also reduced by smoking fewer cigarettes, inhaling less, leaving a longer stub, and taking fewer puffs/cigarettes (2005).             Motivated by health concerns, spurred on by social pressure, and aided by efficacious treatments, many smokers have managed to stop smoking. For a certain group of smokers, however, this outcome has been short-lived, as within months, weeks, or even days for some, a relapse to smoking occurs. Indeed, it has been documented that 1 year after a quit attempt, about 90% of would-be ex-smokers will have gone back to smoking (1999). Various organizations have put up campaigns against smoking. Yet not all of them do work. Governments alone cannot set up a successful campaign against smoking. Thus we see many private organizations that also help in campaigns against smoking.             Susan’s case is just one of the many cases about individuals who wish to stop smoking yet aren’t able to. Their need to smoke may be attributed to factors related to the self. Susan will probably need professional help regarding her smoking problem and an understanding of self is needed for a successful treatment.   Psychotherapeutic Approach             Because women's lives are more punctuated, sociobiologically speaking, than are men's -- by menarche and menopause, by the monthly cycle of ovulation and bleeding, by pregnancy and childbirth, and by the accompanying assaults of these life changes on body image -- looking at women as a block may blur differences in women's smoking cessation needs across the life cycle. The special needs of women at different life stages will require much more attention if smoking cessation programs are to be maximally helpful to women smokers. Nevertheless, sufficient research has been done in a few aspects of the female life cycle to offer at least some guidance to the clinician (1999).             In Susan’s case, she would need a psychotherapeutic approach to her smoking problem. A psychotherapeutic approach for smoking cessation uses cognitive, supportive, and expressive therapeutic techniques that are generally delivered in an active, directive therapeutic style ( 1999). This approach will focus in an individual’s self-concept and views regarding smoking. Why people smoke and smokers' views about smoking are issues that have attracted much attention within the last few years. Some researchers have focused on the role of peers and of parents. Other researchers have asked smokers to attribute their smoking to different reasons--for example, pleasure, relaxation, or weight control. These researchers have often been guided by attribution theory and, specifically, by the fundamental attribution error. When this theory has been applied to smokers, researchers have predicted that smokers would attribute their own smoking to external causes (e.g., peers, advertisements, pleasure), whereas nonsmokers would attribute people's smoking to internal causes ( 1994). The therapy is change oriented, sequenced, and time limited.             The organizing principle of this therapeutic approach is the assumption that cigarette smoking is maintained by the (emotionally dependent) patient's tendency to use cigarettes in the service of denying painful feelings. The consequence of this self-medicating tendency, which is sustained by the psychoactive nature of nicotine, is a learned and practiced inability to recognize feelings and to respond adaptively to the stressful, emotionally arousing events, large or small, of everyday life. The emotionally dependent smoker will often be emotionally unaware, constricted in emotional experience, and lacking in appropriate coping mechanisms (1999). The protection motivation theory also supports the psychotherapeutic approach to the problem of smoking. Protection motivation theory states that health information (e.g., cigarette health warnings) elicits both appraisal of the threat and appraisal of coping techniques; both cognitive processes involve (a) either maladaptive or adaptive responses and (b) variables that increase or decrease the probability of those responses. People use the threat-appraisal process to evaluate the variables associated with the potentially harmful (maladaptive) response. Intrinsic rewards and extrinsic rewards increase the probability of the maladaptive response; severity of and personal vulnerability to the danger decrease the probability of the maladaptive response. By using the coping-appraisal process, a person evaluates his or her ability to cope with and avert the threat (adaptive response). The efficacy of the response and one's ability to perform it increase the likelihood of the adaptive response, whereas response costs decrease the probability of the adaptive response (1998). In the case of smoking, the likelihood of smoking is decreased by (a) belief in the severity of the diseases caused by smoking, (b) belief in one's vulnerability to those diseases, (c) belief that smoking cessation is an effective way to avoid the diseases, and (d) belief that one can successfully stop smoking. On the other hand, the likelihood of cigarette smoking is increased by intrinsic rewards (e.g., physical satisfaction), extrinsic rewards (e.g., peer approval), and the costs of an adaptive response (e.g., enduring withdrawal symptoms). This would mean that aside from smoking being affected by emotions, it is also affected by cognition. According to this model, the increased likelihood of an adaptive response (not smoking) depends primarily on four cognitive perceptions. Severity, personal vulnerability, self-efficacy, and response efficacy enhance the persuasive effects of health warnings by eliciting protection motivation, an intervening variable that arouses, sustains, and directs activity for self-protection. Strong beliefs about these four variables arouse protection motivation; consequently, individuals are more likely to change their attitudes and subsequently to adopt the health behavior which is smoking cessation in this case (1998).             A key concept underlying this psychotherapeutic approach for the hardcore smoker dependent on emotion and cognition is the notion that it is not negative affect itself but rather the inability to cope with negative affect that presents an impediment to sustained abstinence. This explanatory model is rooted in the emotionally dependent smoker's history of conveniently using cigarette smoking as a "psychological tool" with which to self-medicate painful feelings. Although the long-term benefit of using smoking to cope with negative feelings is questionable, the pharmacology of nicotine, a drug with multiple psychoactive effects, and the pharmacokinetics of smoked nicotine do make it plausible that feelings of anxiety, depression, or anger are attenuated at the time the cigarette is smoked. Although short-lived, this balming quality of smoking behavior is reinforcing, leading to its repetition whenever such negative affects are experienced, and ultimately to a state of emotional dependence on smoking. It is possible that this process begins early in the person’s smoking career, as suggested by the evidence that the relationship between being a regular smoker and depression starts as early as during the adolescent years (1999).             Following this line of thinking, the therapeutic challenge presented by the emotionally dependent smoker can be conceptualized on multiple levels. The presenting complaint is persistent, compulsive smoking, with an inability to sustain abstinence. With a high level of motivation, a pharmacological agent, and behavioral counseling, Susan may actually be able to stop on a given quit day.             Just as in the case of Susan, most smokers seemed torn: On the one hand, they saw smoking as extremely bad and were harsher about themselves than they were about others; on the other hand, they believed they could not change their smoking behavior because they perceived themselves as psychologically addicted. To change their habit, they would need to participate in programs that present adequate alternatives for relaxation and address psychological addiction ( 1994).             Promoting a positive self-concept in older adults like Susan is therefore essential, but it is especially important for those experiencing disability or frailty. Conducting a life review or participating in a reminiscence group, recording an oral history, or arranging a photo scrapbook of meaningful life events are examples of activities that can be suggested to Susan to help her feel a sense of self-worth about the life lived, as well as help take her mind off cigarette smoking ( 2001).             Potential threats to the self-esteem of older adults such as Susan may arise from the institutional environments where they receive their care. These threats can include dependence, devaluation, depersonalization, functional impairments, and lack of control over one’s environment. These threats could create stress in the individual and thus they resort to smoking as release and due to these factors have a hard time quitting smoking even if they desperately want to. Susan’s difficulty in stopping smoking is somehow related to her self-concept. Self-concept may be negatively affected in older adults secondary to a number of life changes, including health problems, declining socioeconomic status, spousal loss or bereavement, loss of social support, and decline in achievement experiences (2001).   Conclusion             There is a counseling approach for emotion and cognition dependent smokers, broadly defined as that subset of smokers whose inability to stop smoking is determined by emotional and cognitive factors. Despite Susan’s strong wish to stop smoking and multiple attempts to do so, her efforts are stymied by the emergence of distressful and painful feelings that they attempt to alleviate through smoking cigarettes. Severity, personal vulnerability, self-efficacy, and response efficacy enhance the persuasive effects of health warnings about smoking cessation by eliciting protection motivation, an intervening variable that arouses, sustains, and directs activity for self-protection within the individual. Strong beliefs about these variables can arouse protection motivation; consequently, Susan will be more likely to change her attitudes and subsequently to stop smoking.

Cigarette Smoking

Social Cognition Introduction Smoking continues to be a problem among many individuals worldwide. An attempt to decr...