were reporting abstinence. However, self-reports were not validated,
and if one assumed that nonresponders were smoking, the success rate
based on all subjects completing treatment would be only 23 percent
(22 of 96). Some success has been noted utilizing contingency
contracting as a maintenance aid within a broad-spectrum program
(210). In sum, as a single technique, contingency contracting appears
able to initiate some behavioral changes, and when used in combination
with other procedures, to prevent relapse.

Other Self-Control Strategies

Several other techniques or procedures have been modified for
treatment of smoking behavior. Systematic desensitization was one
procedure that was adapted for use with smokers under the rationale
that reducing the need for stress-related cigarettes would aid subjects
in coping with cessation. Again, while the technique was theoretically
attractive, long-term abstinence rates were unimpressive (96, ZOO, 205,
215, 263, 301, 426). Similarly, a direct test of meditation proved to be
equivocal (287).

In a similar vein, the suggestions of Homme (163) have produced a
number of treatments attempting to increase self-control over
smoking. Homme focused on "covert operants" which were designed to
be incompatible with smoking behavior. He also reinforced non-
smoking alternatives. However, only temporary treatment effects
were produced in control trials (125,188,199,212), despite some clinical
demonstrations (416). Several other studies tried some combination of
techniques along these lines with only minimal success (38, 120, 282).

Aversion Strategies

Techniques designed to reduce the probability of smoking through the
use of aversive stimuli have been very commonly utilized in behavioral
research projects. The theoretical underpinnings of individual proce-
dures remain only partially delineated, and different theoretical
positions-such as operant vemus classical conditioning perspectives
(12, 14, 106)-can result in varying treatment predictions (26, 226).
Possibly due in part to this lack of theoretical precision, early research
on aversive strategies produced mixed results (107, 135, 201, 279, 313.
326, 327, 435, 436, 437). Continuing refinements and evaluations have
led to more elaborate combinations that appear more effective.

Aversive control procedures can most easily be categorized according
to the major stimuli used: electric shock, covert sensitization, or
cigarette smoke. All but two studies (242,434) reporting minimal long-
term results for taste aversion fit easily into these categories. The
three major stimuli have rarely been used in combination with each
other, but more recently have been included in multicomponent
packages that include aversion and self-control strategies. For clarity,

19-22


the research on the aversive control procedures applied in isolation will
be examined first.

Electric Shock

Previous reviews (24, 200, 230) of early studies (201, 279, 313, 435)
concluded that it was most likely that laboratory administered shock
was ineffective because humans were too capable of discriminating
between shock and no-shock situations. Thus, in spite of encouraging
case study data (338), controlled experiments have failed to produce
impressive long-term results (20, 32, 64, 220, 350, 394) or even
superiority over attention-placebo controls (20, 64, 350). The nondiffer-
ential results from contingent and noncontingent shock conditions in
ihe study by Russell and his collaborators (350) suggested that
"traditional conditioning processes do not contribute significantly to
the clinical response of human subjects to electric aversion therapy for
cigarette smoking" (p. 103).

Some positive results are noteworthy, however. Berecz (PI, 22) has
presented interesting case study data suggesting that shocking
imaginal urges rather than actual smoking may be more effective.
Chapman and his colleagues (58) combined daily shock sessions with
intensive self-management training to produce reported abstinence in
6 of 11 (54.5 percent) of the participants at a 1Zmonth follow-up.
Dericco, et al. (85) produced a clear treatment effect for electric shock
therapy. Sixteen of twenty (80 percent) of the subjects receiving shock
were abstinent at 6-month follow-ups with validation by informants.
The treatment involved sessions 5 days per week for several weeks,
with higher than normal shock intensities and the additive influence of
other treatment factors. Thus, these results do not refute the basic
conclusion of past reviewers that shock augmented by other procedures
may produce an effective treatment package, although as a sole
treatment it fails because the effects often do not generalize outside
therapy( 200,226,230).

Covert Sensitization

Cognitive processes have been commonly employed to produce aversion
by pairing smoking with vivid images of extreme nausea or other
unpleasant stimulation. This procedure of covert sensitization showed
promise in case studies (57, 416), but experimental studies involving
various types of control conditions or treatment comparisons have
failed to produce either meaningful levels of long-term abstinence or
superiority over controls (14, 118, 212, 236, 245, 268, 280, 315, 355, 384,
4.26, 431, 447). However, it has been suggested as a maintenance
strategy (29), and variants of the technique have been utilized in the
more elaborate multicomponent treatments to be discussed later.

19-23


Cigarette Smoke Aversion

The choice of cigarette smoke as the aversive stimulus in smoking-
treatment may be particularly appropriate because: (1) the reinforcing
aspects of almost any stimulus are reduced if presented at sufficiently
increased frequency or intensity, and (2) the aversion affects many of
the endogenous cues that characterize smoking (26,226). Several main
versions of this approach have been used: satiation (that is, doubling or
tripling the daily consumption of cigarettes) prior to abstinence; and
aversive conditioning through either smoking with warm, stale smoke
blown into the face, or rapidly smoking with inhalations every 6
seconds.

Early research using artifically produced warm, stale smoke to
affect aversion showed impressive initial results (436) followed by total
failure during follow-up (437). Other early studies also produced
minimal or no long-term successes (107,135). However, in a subsequent
study with the warm, smoky air apparatus, Schmahl and his colleagues
(362) produced both 100 percent termination abstinence and an
impressive 57 percent (16 of 28) abstinence rate at 6month follow-up,
verified by random checks with informants. In the treatment, subjects
were required to smoke rapidly (inhaling every 6 seconds) and
continuously while facing into the blown smoke until further smoking
could not be tolerated. Sessions were scheduled until the subject was
abstinent a minimum of 24 hours and felt confident in maintaining
abstinence (mean of about eight sessions).

A well controlled replication against a normal-paced, smoking
attention-placebo control found 60 percent (18 of 30) abstinence among
three experimental conditions at 6month follow-ups, but only 30
percent (3 of 10) abstinence in the control (229); this was again verified
by random checks of informants. As the rapid-smoking-only condition
was as successful as the more involved procedures, abandonment of the
inconvenient smoke blowing apparatus was recommended (229).
Subsequent early research by Lichtenstein and his colleagues was also
highly effective (226). The logic and supporting data for the procedure
have been considered in more detail by Lichtenstein and Danaher (226).

Owing in part to the early effectiveness, convenience, and simplicity
of the rapid smoking procedure, it became increasingly popular (72,
226). Subsequent results are mixed and variable (72), however. A
multiyear follow-up of the early studies has shown that some relapse
did occur over the intervening years (232). Danaher (72) recently has
comprehensively reviewed the existing data on- the procedure and
documented that termination and follow-up abstinence rates varied
widely in subsequent research, with some studies reporting minimal or
no (0 to 29 percent abstinence) long-term successes (94, 122, 127, 206,
215, 409), others with moderate (30 to 49 percent abstinence) success
(28, 31, 104, 202, 207, 209, 276, 292, 325, 452), and a few approximately
replicating the follow-up data of early studies (71, 94, 144, 246).

19-24


Danaher (72) has attempted to clarify these data by highlighting the
departures from original treatment procedures by the use of group
presentation (94, 127, 206, 209, 215, 246, 276, 292, 325, 452), limiting the
number of sessions (usually to six) (123, 127, 202, 276, 292, 325),
offering treatment on a rigid or fixed schedule (28, 71,94,123,127,202,
276, 292, 325, 409), and omitting the contingently warm, supportive
treatment context (94, 206, 207, 209). The most impressive recent
outcome data have been produced with multicomponent approaches
combining aversion and self-control procedures (28, 31, 94, 144, 246).
Nevertheless, it is important to note that several multiple case studies
and controlled studies on the rapid smoking procedure failed to
demonstrate any improvement with the addition of self-control
procedures (70, 71,123,292).

Thus, the rapid-smoking procedure appears to be a potentially very
effective but complex intervention, dependent both upon the subject's
active revivification of the aversion (12, 226, 246) and upon critical
elements in the format, including a warm, personal client-therapist
relationship offering social reinforcement and positive expectations
(72, 88, 226, 246) and flexible or individualized treatment scheduling to
insure total abstinence prior to treatment termination (72, 226).
Numerous nonreplications and one direct test (276) have demonstrated
that the production of only physiological aversion and conditioning
effects are insufficient to produce long-term abstinence.

Satiation

Early research (436, 437) on the satiation technique was encouraging,
with a 63-percent reported abstinence at Cmonth follow-up. The
success was partially replicated in a slightly modified, marathon
format (24O), but the weight of evidence on the procedure has been
negative since that time. Controlled studies were unable to replicate
the impressive cessation data or even to demonstrate superiority to
control groups (59, 211, 408). Other comparative tests have also
produced negative results (32, 207, 242, 249, 280). While the procedure
as a sole treatment may have questionable effectiveness, more recent
studies (28, 31, 80, 210), combining satiation with multicomponent
treatment packages, have reported more impressive results.

Medical Risks of Aversive Smoking

Because the smoke-aversion procedures were developed to induce a
degree of physiological discomfort by excessive smoking, the cardiopul-
monary stress of increased nicotine and carbon monoxide exposure has
been noted with concern, especially with regard to rapid smoking (156,
164, 165, 223). A number of studies have been undertaken to quantify
the impact of rapid smoking on the cardiovascular system (73, 78, 79,
144, 174, 261, 354); much of the data has been summarized by

19-z-5


Lichtenstein and Glasgow (228). Recent studies by Hall and associates
(144, 354) and Miller and associates (261) have documented that the
rapid smoking procedure produces an acute and dramatic effect upon
vital signs (respiratory rate, heart rate, and blood pressure), blood
gases, and COHb saturations, which make the procedure contraindicat-
ed for individuals with potential or active cardiovascular or pulmonary
diseases. Adequate medical screening of potential treatment partici-
pants has been strongly recommended (144,156,223,261,354).

Data have yet to be published on the relative risks of other smoke-
aversion procedures. If heavy-smoking subjects double or triple their
daily smoking consumption during the satiation procedure, notable
acute effects on the cardiovascular system may also occur. It should be
noted that in excess of 35,000 participants have been exposed to the
rapid-smoking procedures, with an informally reported morbidity rate
from nonspecific complications of about 0.023 percent and no reported
mortality (228). Yet, until the relative risks of procedures have been
adequately researched, all the smoke aversion procedures should be
used with appropriate screening and monitoring (144, 156, 228, 261,
354).

Less Stressful Alternatives

The identification of the relative risks of the rapid smoking procedure
has stimulated the development of smoke aversion interventions that
involve less physiological stress. Because of the pattern of 20 to 30
percent long-term abstinence with a common normal-paced attention-
placebo condition (71, 123, 202, 206, 207, 209, 211, 229), which self-
control training seemed to enhance (71). initial clinical demonstrations
have been undertaken combining normal-paced "focused" smoke
aversion within broad, multicomponent treatment packages (74, 141).
Preliminary demonstration data showed that a &month abstinence
could be produced in approximately 50 percent (5 of 10) of the
participants (141). A controlled test of a rapid-puffing-sans-inhalation
procedure produced somewhat less optimistic results with only 6 of 21
(29.6 percent) of the participants who started treatment reporting
abstinence at the 3-month follow-up; this was verified by random
checks of informants (292). A recent report by Tori (417) found that a
smoke-induced taste-aversion technique involving limited smoke
inhalation produced reported abstinence in 17 of 25 (68 percent) of the
participants versus 6 of 10 (60 percent) in a ragd smoking condition at
a 26week follow-up. Unfortunately, assignment to treatment was not
random, abstinence reports were not validated, subjects were treated
on a fee basis, and a variety of adjuncts including hypnosis were
utilized as maintenance boosters. Nevertheless, this and other early
data (74, 141, 292) on alternatives to rapid smoking involving similar
treatment formats, rationales, and nonspecifics, but markedly reduced

19-26


physiological stress, appear encouraging and worthy of additional
controlled research.

As noted above, the research on techniques and procedures derived
from learning theories and models has been mixed and often
inconclusive. As recommended by early reviewers of the behavioral
literature (24,366), treatment packages combining multiple techniques
are beginning to emerge. These comprehensive programs utilize some
combination of the behavioral self-control techniques, and many also
integrate aversive control procedures. The technology in this area is
still developing; the early mixed results are to be expected. Still, recent
reviews have uniformly concluded that the data from this emerging
trend in programming are clearly encouraging (16,29, ZX, LGj).

Treatment packages using behavioral self-control strategies alone
have not produced notably effective results. Several complex programs
have produced minimal long-term effects (48, 104, 115, 255, 381, 382).
The later successes of Pomerleau and associates (308) and Brengel-
mann (44, &) only came with refinements based on systematic
developmental research. The most recent successful reports (28, 31, 44,
45, 210, 246, 308) thus appear to be a product of practical and in-depth
knowledge of the problem which guides the application of the diverse
elements in the treatment programs. Early and more recent successes
(28, 31, 39, 44, &, 58, 80, 94, 140, 142, 210, 246, 308, 407) suggest that
planned extended contacts plus adaptation of techniques to individual
needs are necessary for long-term success.

In a carefully evaluated clinical demonstration, Pomerleau and
associates (308) reported success in 61 of the first 100 participants with
32 remaining abstinent (these were verified by urinary nicotine assays
at l-year post-treatment). Brengelmann (42, 45) has refined his
complex treatment package (42) to the point where current results
with treatment-by-mail are equal to face-to-face therapy, with 55 to 67
percent of the participants who complete treatment (86 percent
reported completion rate) reporting abstinence at termination and 57
percent of those responding to follow-up reporting continued, but
unverified, abstinence. Although the success rate based on the
assumption that nonresponders were smoking would be 23 percent, the
efficiency of the approach is clearly encouraging.

Other multicomponent treatments utilizing an aversion procedure to
help induce cessation have also produced initially mixed but encourag-
ing data. The early multiple case study of Chapman and associates (58)
with electric shock plus extended self-management training is an
often-cited example of this tJF of approach. In recent clinical
evaluations of delivery formats, Best and associates (28. ~1) have also
documented the potential efficacy of a multicomponent program
involving aversive smoking (satiation and rapid smoking) plus

19-27


behavioral self-control training. Abstinence rates at 6 months, verified
by informant reports, have varied from 35 to 55 percent, with the best
results in a take-home version involving minimal personal contact. In a
controlled study of satiation plus self-control training, Delahunt and
Curran (30) demonstrated the superiority of the multicomponent
treatment over controls and individual components. Six-month absti-
nence data showed five out of nine subjects (56 percent) for the
combined treatment, but only 0 to 22 percent for individual compo-
nents and controls; self-report validity was enhanced by collected but
unanalyzed saliva for thiocyanate assays. Elliott's (94) package of rapid
smoking, self-control strategies, covert sensitization, and systematic
desensitization likewise produced abstinence, verified by a bogus
marketing survey, in 45 percent (9 of 20) of the participants at 6-month
follow-up, versus 17 percent for rapid smoking only and 12 percent for
attention-placebo control. McAlister (246) demonstrated that his
multicomponent rapid-smoking package was equally effective at 3-
month follow-up presented either in person (56 percent or 5 of 9
abstinence) or over television (62.5 percent or 5 of 8 abstinence), with
self-reports validated by thiocyanate assays.

These very positive findings are tempered somewhat by several less
successful combinations of self-control and aversive smoking proee-
dures (27, 71, 123, 292). The analytical study of the multicomponent
approaches by Flaxman (104) provided some data on the complexity of
the issues involved. Although the study indicated that subjects who
abruptly quit on a selected date after self-control training reported the
best &month abstinence data either with subsequent aversive smoking
(5 of 8 or 62.5 percent) or only supportive counseling (4 of 8 or 50
percent), gradual reduction strategies, especially for male subjects,
were markedly less effective with or without aversive smoking.
Though the cell frequencies were small and the abstinence data
unverified, the results suggest that successful response to multicompo-
nent treatments may be the product of many only partially understood
variables.

Treatment Innmatims

Older (371) and more recent (119) survey data clearly indicate that
most smokers who are motivated to quit are less interested in formal
programs than in do-it-yourself methods. The broadening of the mode
of service delivery- of behavioral treatments is thus another encourag-
ing trend. A study by Dubren (90) suggested that brief interventions
by television can produce small but meaningful abstinence rates on the
order of 9 to 10 percent. He also demonstrated that taped telephone
messages can be used to extend the intervention and support
maintenance (91). McAlister's (246) experimental demonstration of the
potential of the media-only treatment group was impressive. Rosen
and Lichtenstein (339) evaluated a program independently developed

19-28


by the employer. They reported encouraging results using the resulting
monetary contingency technique. These preliminary studies suggest
that the best of the behavioral technology could be made available
effectively by media or at the worksite to those smokers unwilling to
attend formal programs.

The basics of successful clinical programs have also been reduced to
self-study books (310, 72~). Consistent with the growing trend toward
self-administered treatments (I',$), multicomponent treatments based
on behavioral self-control strategies with or without aversive smoking
techniques (310, 72aj are now available in self-study formats. Although
initial tests of the self-study approach to smoking cessation are mixed
(28, 31, 123, 202), their availability should facilitate further testing of
programs similar to the successful self-managed clinic reported by Best
and associates (28,31).

Controlled Smoking

Most smokers want to reduce their risks from smoking (4.9, 347); this is
evidenced by the dramatic changes that have occurred in the types of
cigarettes being smoked (151, 270, 287. 34.5). Filter cigarettes are now
the norm, and both the tar and nicotine content of the American
cigarette have declined significantly (279, 412). These natural trends
and apparent high interest among smokers in safer smoking have
stimulated only preliminary interest in the development of interven-
tions to maximize the reduction of risks (4.9,287,347). Frederiksen and
associates (10&112), however, have pursued the topic and have
experimentally demonstrated that exposure level can be controlled not
only by rate of smoking and strength of cigarette, but also by altering
the topography of the habit. They demonstrated that modifying the
topography of smoking involves changing how much smoke is inhaled,
how many puffs per cigarette are taken, and how much of each
cigarette is smoked (109, 110, 112). Although the technology is still in
the clinical-developmental stage, and the long-term stability of the
changes will need to be verified, initial single-case demonstrations are
encouraging and merit more emphasis. Data from the stimulus control
studies suggest that reduction in exposure may be limited by the floor
effect of 10 to 12 cigarettes per day (8,10,23,59,104,139,221,242,313,
377).

The controlled smoking technology may be useful to other groups of
individuals. Physiological monitoring of ex-cigarette smokers who shift
to pipes and cigars has documented that inhalation does occur (81, 82,
351). Because the inhalation may mur at an unconscious level and can
lead to tobacco exposures as great as cigarette smoking, such smokers
may need specific behavioral training to control the topography of
their new habits. Similarly, some smokers who shift to lower tar and
nicotine cigarettes to reduce their risk may also require the controlled

19-29


smoking t,echnology to avoitl increases in rate or attempts to
~cmlw~s~ie I)! altering the smoking tol)ography.

Maintenance of Nonsmoking

Both early (&`:j, B/O, NS) and more recent (2fj, Z!), JO, 226, 245, ,706, ,?68,
37t;i) reviews of the smoking intervention literature have focused on
the need to devote more energy to developing Ibrocedures to assure
long-term, robust behavior change. The continuing problems of
nonreplications and minimal treatment effects have, however, kept
most researchers searching for new or more effective cesmtim
strategies. Yet past research has clearly indicated that most smokers
motivated to quit relapse shortly after treatment termination (170,
17'1). Thus all interventions should recognize that the production of the
initial cessation is only the start of treatment (26, 226, 24.5, 306j.
Detailed procedures to aid the recent ex-smoker learn the skills needed
to solidify the behavior change should become an integral part of all
treatments.

Existing attempts to add maintenance programming to various
treatments have proven somewhat ineffective (306). When offered
booster sessions or telephone support if problems arise, most partici-
pants fail to make use of the services (27; 380). Experimental tests of
the booster treatment approach generally have shown equivocal results
(84, 202, 32.5). Paradoxically, supportive phone calls during or after
treatment seem to lead to significantly poorer long-term results (28,
84, 380). It has been suggested that maintenance programming must
be offered in a fashion that will enhance rather than distract from self-
attributions of success (29,203).

Some initial positive finding;; are available, however. Dubren (90)
reported some success utilizing tape-recorded telephone reinforcement
messages during the follow-up of a televised smoking clinic. After
some initial negative and inconsistent results (206), Lando (21oj
demonstrated, but was unable to replicate, that the long-term
effectiveness of an aversive smoking program may be enhanced by a
broad-spectrum, contingency-contracting program. Seven maintenance
sessions over a Bmonth period produced abstinence, validated by
informant reports, in 76 percent (13 of 17) of the maintenance group
subjects at 6-month follow-up, versus only 35 percent (6 of 1'7) of the
controls given cessation treatment only. Case study data support the
maintenance-contracting conceI& (222). Recent dissertation data also
appear to provide some encouraging findings regarding maintenance
programming (84).

Attempts to add on maintenance procedures have generally been
ineffective (27, 31, .&P, 606, 292, :%G). However, several effective
programs appear to have integrated into the total treatment package
extended contacts and training in the behavioral skills (28, 44, ..$.5, 58,
210, 308). These factors may be required to maintain abstinence. More


research is needed to define what types of maintenance procedures are
needed and when and how they can be most effectively administered
(306).

Research has begun to clarify the personal and situational factors
which support smoking and which may induce ex-smokers back into
the habit (30, 97, 110, 111, 243, 2Fi6, 349, 359). Individual difference
factors have been overemphasized in the analysis of relapse, however,
compared to situational factors (29). Betrospective analyses of
individual differences that may be related to successful cessation have
generally suggested that older males with lighter smoking habits and
from higher social classes tend to be more successful (92,126,1&9, 233,
271, 323, 389, 390), but the magnitude of these differences has been
small (29). Several studies have suggested that individuals who report
using smoking to control negative affect or who have higher levels of
anxiety also appear more susceptible to relapse (89, 105, 179, 180, 292,
370, 375, 389, 390, 399, 400). Efforts to utilize broad individual
differences to maximize treatment effectiveness have been mixed and
generally inconclusive (27, 32, 33, 53, 205, 212, 292). Given that broad
smoking topographies (1, 29, 2 76, 177, 256, 34.9) and personality tests
(27, 179) lack sufficient specificity, Best and Bloch (29) have suggested
that emphasis should be placed on locating interactions between finer
variations in the individual's situational cues and smoking patterns (30,
97,110,111,243) and responsiveness to treatment modalities.

McAlister (2.45, 246) has outlined several other important areas that
should be addressed in maintenance programming. Smokers need to be
given a positive set regarding withdrawal symptoms and their ability
to deal with them. Some data suggest that misattribution-type therapy
can be helpful in achieving this goal (16, 2.~5). Since most smokers,
especially women, believe they will gain weight if they quit (27'1), fear
of the documented weight gain after cessation (37, SO, 62, 122) should
be directly countered (24.5). The role of negative self-evaluations and
common rationalizations (76) also requires further clarification (13,
245). McAlister (24.5) has suggested that specific plans be formulated to
aid ex-smokers confront their predicted problem areas.

Research interest in the important area of maintenance program-
ming is beginning, but many issues remain to be defined and tested.
Preliminary data suggest that multicomponent programs are more
effective when extended contacts are planned into the program and,
diverse techniques are individualized to meet the special needs of all
participants. Given the concern over smoking among women (65, 162,
214,335), their special needs should be addressed.

19-31


General Overview of Data

Status of Methodology

As stated at the beginning of this section, there have been great
improvements in the quality of data on smoking cessation methods in
recent years (26,226, .X8,376), especially in several research clinics (81,
82, 178, 283, 381, 382), large-scale coronary prevention trials (101, 265,
266, 324, 441), and in the behavioral research area (26,29, 226). Yet the
validity of the self-report data remains a critical concern. Since the
validity of reported abstinence has been questioned by physiological
measures in up to 20 percent of clinic participants (47, 82, 178, 231), it
appears that many individuals may be reporting their commitment and
expectations of success rather than their current smoking behavior.
Ohlin and associates (283) revealed that, of the 19.2 percent (25 of 189)
of the reportedly abstinent subjects who had COHb levels above a 0.8
percent nonsmoking cutoff at treatment termination, none was
reporting abstinence at Bmonth follow-up. With the current state of
unverified self-report data, one must interpret cautiously even the
commonly cited relapse curves (170,171).

Random assignment to experimental conditions and the use of one or
more control conditions have become much more common, especially in
the behavioral research areas. Broad generalizations of the data
continue to be made about the general efficacy of procedures with
little regard for the interactive effects of age, gender, social class, or
smoking topographies of successful participants. The small samples of
almost all comparative research relegate these sources of possible
interaction to the error variance. This, plus wide variability in the
actual application of supposedly identical procedures, makes compari-
sons across individual studies difficult.

The continuing pattern of nonreplication and the lack of clear
superiority of treatments over appropriate controls further suggest the
need to balance these advances in research methodology with a
practical and clinical sensitivity to the complexity of the problem (7, 43,
224, 225, 304). The guidelines offered by several comprehensive clinics
(43, 224, 304, 372, 375, 379, 380, 381, 383, 440) should serve to direct
initial clinical testing of procedures. As McAlister (245) has outlined,
procedures should first be intensively piloted with single individuals or
small groups. The technology for the use of quasi-experimental (56,
393) with other methods should make it possible to conduct multiple
case studies with adequate statistical validity (108, 158u, 293, 415).
When clinically refined, the treatment techniques can be tested against
appropriate controls, especially attention-placebo controls (24, 56, 226,
251, 272). When the format and techniques are well understood and
documented, they can be replicated by other researchers in diverse
settings (245,304, 398).

19--a


Although behavioral research has been advancing in experimental
rigor, less progress has been made in public service and proprietary
clinics. Objective and controlled evaluations are still needed in these
settings. Though the treatment focus of these clinics makes classical
experimental designs unattractive, alternative quasi-experimental
designs should be investigated, since the technology exists to provide a
degree of control in almost any field or applied setting (56,393). If such
evaluations were undertaken, a wealth of data would be available to
guide more controlled research (398).

Most researchers now seem at least aware of the need to conduct
long-term follow-ups of all participants. While various professional and
financial constraints tend to limit this process, follow-ups of at least 6
months are becoming common. Innovative suggestions, such as
obtaining the name of a contact who will know the future whereabouts
of the participant, have been offered to aid in tracking participants
during follow-up (232). The public service and proprietary clinics are
only beginning to recognize their responsibility in this area, and little is
known about the long-term efficacy of these programs.

In summary, the research on smoking-modification strategies over
the past 15 years clearly indicates that past recommendations
regarding adequate methodology still need to be heeded (24, 26, 226,
251, 272, 366, 376). Researchers also need to become more aware of
social contingencies such as clinical zeal, publication pressures, and
dissertation timetables which have led to poor adherence to these
guidelines (225). Data on the reliability and validity of self-reports of
smoking behavior now strongly suggest that unverified, global self-
reports should no longer be accepted as the only outcome data.
Objective techniques for measuring smoking exposure can be devel-
oped to validate and supplement self-report data. While great
advances in methodology have been made in the past 15 years (26,226,
376), new technical and design approaches now under study should
serve to improve further the quality of the data collected in the future.

Implications of the Data

In light of the amount of research conducted over the past 15 years, it
is remarkable that we have so little outcome data on the wide variety
of treatments being offered and recommended. Equally astounding is
how little we know about the millions of smokers who have quit on
their own. As noted in other sections, it has been estimated that 95
percent of the 29 million smokers who have quit since 1964 have done
so on their own (270). Various surveys have revealed that the
cumulative quit rates for various age groups, social classes, and
occupations are impressive (92, 121, 133, 1.49, 271, 323, 421). The
sporadic and marginal quality of outcome data on treatment programs,
however, makes it impossible to conclude how this broad social
phenomenon has affected clinical and research programs. Survey data

lY--33


have shown that only a third or less of smokers motivated to quit are
interested in formal programs (119, 371), and only a small minority of
those who do express an interest actually attend programs when they
are offered (19.5, 270). It thus appears that objective outcome data that
are available may be based on a small minority sample of smokers at
large.

Objective data are lacking on most of the smokers who have been
willing to attend formal programs. Public service clinics continue, but
the lack of objective outcome data precludes the evaluation of their
efficacy. Similarly, proprietary programs remain virtually unmoni-
tored and unevaluated in an objective fashion. Smoking counseling by
medical or health care personnel seems to be highly effective with
symptomatic smokers (227, 338), but the efficacy of such an approach
for other smokers has yet to be adequately evaluated. The data from
the large scale coronary prevention trials (101, 265, 266, 324, 441)
should help clarify some issues regarding medical counseling and
smoking cessation among higher risk individuals, but the nonspecific
treatment focus of these projects will limit the conclusions that can be
drawn.

Controlled research has yet to produce a clearly superior interven-
tion strategy. However, the rapidly accumulating and improving
research data now suggest that multicomponent interventions offered
by intervention teams with practical knowledge regarding the smoking
problem are the most encouraging. In part, the added effectiveness of
some programs may be due to the skills of the intervention team to
present the available techniques as both credible and attractive to the
participants (173, 175). It is important to recognize that improved
success in recent studies may also be influenced by changes in social
norms regarding smoking. More integration of diverse perspectives,
including pharmacological, behavioral, medical, and social aspects of
the smoking habit, should enhance the multicomponent treatment
approach. It is encouraging to note that more research emphasis has
begun to be focused on maintenance programming. Apparently the
multicomponent programs enable participants to gain the new skills
needed to deal with their individual problems in adjusting to the new
nonsmoking lifestyle. Many issues remain to be researched, however,
and special programs may be required to deal with the needs of
smokers with personal or environmental factors that encourage
recidivism.

Recommendations for Future Research

Objective Measures of Smoking
An adequate technology to validate self-report smoking data is
critically needed. When physiological assessments have been done,
inaccuracies in self-reported abstinence are common. Inaccuracies in

19-34


rate estimates among the continuing smokers cannot, however, be
accurately evaluated with existing technology. If reliable physiological
measures of smoking rate were available, the effects of various
procedures in producing not only abstinence but meaningful and
enduring reductions in smoke exposure could be objectively verified.
Basic pharmacological and biological research is needed to formulate
such objective measures of smoking.

Maximizing Unaided Cessation

The phenomenon of smoking cessation optside formal programs
remains largely unexplored. Almost all successful ex-smokers quit on
their own, but little is known about how to maximize this process.
Existing survey data suggest that most smokers who are motivated to
quit are not interested in aWnding formal programs. Most smokers
report being interested in do-it-yourself quit methods or procedures.
Therefore, precise information is needed regarding what types of
treatments smokers view as credible, useful, and attractive. Controlled
research is needed to evaluate the most cost-effective programs to
make attractive and effective programs available to smokers who
desire to quit. As treatments are refined in controlled research, they
need to be translated into formats which are appropriate for testing
with general population groups.

Development of Maintenance Strategies

The research on methods to assure that smokers who successfully quit
have the behavioral skills and social supports needed to maintain and
solidify the behavior change is currently at a very primitive stage.
More basic research is needed to clarify the topography of smoking and
relapse behavior so that the specific needs of various types of smokers
can be fulfilled. Procedures and programs to aid smokers achieve
cessation must be refined; past experience shows that the production
of high rates of initial abstinence does not insure a noteworthy level of
long-term abstinence. Different classes and types of smokers may
require different levels of maintenance assistance. Specific smoking
topography variables that predict such needs should be defined.
Existing research on maintenance programming indicates that the
maintenance procedures should be integrated into the treatment
package rather than added on as an option at the end of the treatment.
The development of maintenance strategies should be viewed as an
integral part of the intervention package and should be evaluated
accordingly.

Evaluation of Existing Programs and Procedures
As should be clear from the review of existing data, methodologically
sound evaluations of all forms of smoking inter\-ention are still greatly


needed. The increased rigor in the behavioral research area has begun
to produce some tentative suggestions regarding effective strategies.
However, the more promising multicomponent treatment packages
pose new, more complex issues for evaluation. Alternative methods of
effectively presenting the most effectual programs to the general
public need to be explored and properly evaluated. In addition, the
most attractive of the behavioral programs should be experimentally
tested relative to other existing intervention strategies in order to
produce relative outcome data for evaluation.
The potential efficacy of smoking cessation and reduction counseling
by physicians and health care professionals also should be experimen-
tally evaluated. The existing technology derived from behavioral and
social psychological research should be integrated into interventions
appropriate for use in medical settings.
All public service clinics and proprietary programs should be
subjected to rigorous and continuing evaluation. Such programs must
recognize their responsibility to the smoking public to present objective
evaluations of long-term effectiveness. In addition, proper evaluations
should lead to refinements in treatment procedures. As effective
treatment strategies are developed and objectively evaluated within
research programs, they should be translated into clinic formats for
utilization and evaluation within the gener4 population.


Modification of Smoking Behavior: Reierences

(1) ADESSO, V.J., GLAD, W.R. A behavioral teat of a smoking typology. Addictive
  Behaviors 3: 35-38,1978.

(2) AMERICAN CANCER SOCIETY. Stop Smoking Program Guide. San Francis-
   co, American Cancer Society, California Division, 1971,178 pp.
(9) AMERICAN CANCER SOCIETY. Task Force on Tobacco and Cancer-Target
   5. Report to the Board of Directors. American Cancer Society, Inc., 1976,82 pp.
(4) ANDER, S. Who gives up smoking after a myocardial infarction? In:
   Richardson, R.G. (Editor). The Second World Conference on Smoking and
   Health. London, Pitman Medical, 1971, pp. 175-178.
(5) AUGER, T.J., WRIGHT, E., JR., SIMPSON, R.H. Posters as smoking
   deterrents. Journal of Applied Psychology 56(Z): 169-171, April 1972.
(6) AXELROD, S., HALL, R.V., WEIS, L., ROHRER, S. Use of self-imposed
   contingencies to reduce the frequency of smoking behavior. In: Mahoney, M.J.,
   Thoresen, C.E. (Editors). Self-Control: Power to the Person. Monterey,
   Brooks/Cole Publishing Company, 1974, pp. 77-85.
(7) AZRIN, N.H. A strategy for applied research. Learning based but outcome
   oriented. American Psychologist 32(2): 140-149, February 1977.
(8) AZRIN, N.H., POWELL, J. Behavioral engineering: The reduction of smoking
  behavior by a conditioning apparatus and procedure. Journal of Applied
   Behavior Analysis l(3): 193-290, Fall 1968.
(9) BAER, P.E., FOREYT, J.P., WRIGHT, S. Self-directed termination of exceaaive
  cigarette use among untreated smokers. Journal of Behavior Therapy and
   Experimental Psychiatry 8(l): 71-74, March 1977.
(10) BAKEWELL, H.A. The relevance of goal-setting in a smoking reduction
  program. Doctoral dissertation, University of Utah, 1972,119 pp. Dissertation
   Abstracts International 33(3): 1280-B, September 1972. (Univemity Microfilms
   No. 7224,574).
(11) BALL, K.H. Cigarettes and the prevention of heart disease. Rehabilitation 25(1-
   2): 17-20,1972.

(18) BANDURA, A. Principles of Behavior Modification. New York, Holt, Rinehart
   and Winston, Inc., 1969,677 pp.

(18) BANDURA, A. Self-efficacy: Toward a unifying theory of behavioral change.
   Psychological Review 84(2): 191-2151977.
(14) BANDURA, A. Social Learning Theory. Englewood Cliffs, New Jersey,
   Prentice-Hall, Inc., 1977,203 pp.

(15) BARBARIN, O.A. III. A Comparison of Overt and Symbolic Aversion in the
   Self-Management of Chronic Smoking Behavior. Doctoral dissertation,
   Rutgers University, State University of New Jersey, 1975,128 pp. Dissertation
   Abstracts International 36(5): 2457-B-2458-B, November 1975. (University
   Microfilms No. 7524,655).

(16) BAREFOOT, J.C., GIRODO, M. The misattribution of smoking cessation
  symptoms. Canadian Journal of Behavioral Science 4(4): 358-363,1972.
(17) BARIC, L, MACARTHUR, C., SHERWOOD, M. A study of health education
  aspects of smoking in pregnancy. International Journal of Health Education,
   Supplement to Volume 19(2): 1-17, April-June 1976.
(18) BARKLEY, R.A., HASTINGS, J.E., JACKSON, T.L., JR. The effects of rapid
   smoking and hypnosis in the treatment of smoking behavior. International
   Journal of Clinical and Experimental Hypnosis 25(l): 7-17, January 1977.
(19) BARYLKO-PIKIELNA, N., PANGBORN, R.M. Effect of cigarette smoking on
  urinary and salivary thiocyanates. Archives of Environmental Health 17(5):
   739-745, November 1968.

19-37


(20) BEAVERS, M.E. Smoking Control: A Comparison of Three Aversive Condition-
  ing Treatments. Doctoral dissertation, University of Arizona, 1973, 64 pp.
  Dissertation Abstracts International 34(6): 2919-B-2920-B, December 1973.
  (University Microfilms No. `73-28,782).

(22) BERECZ, J.M. Reduction of cigarette smoking through self-administered
  aversion conditioning: A new treatment model with implications for public
  health. Social Science and Medicine 6(l): 57-66, February 1972.
(22) BERECZ, J. Treatment of smoking with cognitive conditioning therapy: A self-
  administered aversion technique. Behavior Therapy `i'(5): 641-648, October
    1976.

(28) BERNARD, H.S., EFRAN, J.S. Case histories and shorter communications.
  Eliminating versus reducing smoking using pocket timers. Behavior Research
  and Therapy lo(4): 399491, November 1972.
(24) BERNSTEIN, D.A. Modification of smoking behavior: An evaluative review.
   Psychological Bulletin 71(6): 418-440,1969.
(25) BERNSTEIN, D.A. The modification of smoking behavior: A search for
  effective variables. Behavior Research and Therapy 8(2): 133-146, June 1970.
(26) BERNSTEIN, D.A., McALISTER, A. The modification of smoking behavior:
  Progress and problems. Addictive Behaviors l(2): 89-1021976.
(27') BEST, J.A. Tailoring smoking withdrawal procedures to personality and
  motivational differences. Journal of Consulting and Clinical Psychology 43(l):
   l-8, February 1975.

(28) BEST, J.A., BASS, F., OWEN, L.E. Mode of service delivery in a smoking
  cessation programme for public health. Canadian Journal of Public Health 68:
   469473,1977.

(29) BEST, J.A., BLOCH, M. On improving compliance: Cigarette smoking. In:
  Haynes, R.B., Sackett, D.L. (Editors). Compliance. Baltimore, Johns Hopkins
  University Press, 65 pp. (to be published).
(90) BEST, J.A., HAKSTIAN, A.R. A situation-specific model for smoking behavior.
   Addictive Behaviors, 3(2): 79-92,1978.
(31) BEST, J.A., OWEN, L.E., TRENTADUE, L. Comparison of satiation and rapid
  smoking in self-managed smoking cessation. Addictive Behaviors, 3(2): 71-78,
    1978.

(82) BEST, J.A., STEFFY, R.A. Smoking modification procedures for internal and
   external locus of control clients. Canadian Journal of Behavioral Ski-
  ence/Revue Canadienne de Science du Comportement 7(2): 155-165, April 1975.
(35) BEST, J.A., STEFFY, R.A. Smoking modification procedures tailored to subject
  characteristics. Behavior Therapy 2(2): 177-191, April 1971.
(34) BIBIN, L.J. An Investigation of the Effectiveness of Covert Role Playing Using
  a Suggestion Oriented Relaxation Technique to Assist Smokers to Stop
  Smoking. Doctoral dissertation, United States International University, 1975,
  229 pp. Dissertation Abstracts International 36(4): 1900-B, October 1975.
  (University Microfilms No. 7522,652).

(35) BIRNBAUM, A.P. Smokers Differential Response to an Enriched Treatment
  Procedure as a Function of Motivation for Smoking. Doctoral dissertation,
  Southern Illinois University, 1975,156 pp. Dissertation Abstracts International
  36(12): 6350-B. June 1976. (University Microfilms No. 7613,221).
(86) BLACKBURN, H. Progress in the epidemiology and prevention of coronary
  heart disease. In: Yu. P.N., Goodwin, J.F. (Editors). Progress in Cardiology,
  Volume 3. Philadelphia, Lea & Febiger, 1974, pp. l-36.
(97) BLITZER, P.H., RIMM, A.A., GIEFER, E.E. The effect of cessation of smoking
  on body weight in 57,632 women: Cross-sectional and longitudinal analyses.
  Journal of Chronic Diseases 30(l): 415-429, July 1977.

19-38


(38) BOVILSKY, D.M. A Comparison of Confrontational and Non-Directive Group
   Experiences in Influencing Smoking Behavior. Doctoral dissertation, Columbia
   University, 1972, 154 pp. Dissertation Abstracts International 36(5): 2459-R
   2460-B, November 1975. (University Microfilms No. 7525,652).
(39) BOZZETTI, L.P. Group psychotherapy with addicted smokers. Psychotherapy
   and Psychosomatics 20(3/4): 172175.1972.

(40) BRADSHAW, P.W. The problem of cigarette smoking and its control.
   International Journal of the Addictions 3(2): 353-371,1973.
(41) BRANTMARK, B., OHLIN, P., WESTLING, H. Nicotinmntaining chewing
   gum as an anti-smoking aid. Psychopharmacologia 31(3): 191~2091973.
(42) BRENGELMANN. J.C. Manual on Smoking Cessation Therapy. Facts and
   Suggestions for the Treatment of Smoking. Geneva, International Journal of
   Health Education, 1975,71 pp.

(49) BRENGELMANN, J.C. The organization of treatment for the cessation of
  smoking. In: Steinfeld. J., Griffiths, W., Ball, K., Taylor, R.M. (Editors).
   Proceedings of the Third World Conference on Smoking and Health, New
   York, June 25, 1975. Volume II. Health Consequences, Education, Cessation
   Activities, and Social Action. U.S. Department of Health, Education, and
   Welfare, Public Health Service, National Institutes of Health, National Cancer
   Institute, DHEW Publication No. (NIH) 77-1413,1977, pp. 655-663.
(44) BRENGELMANN, J.C., SEDLMAYR, E. Experimente zur behandlung des
   rauchens (Experiments for the treatment of smoking). Schriftenreihe des
   Bundesministers fuer Jugend, Familie und Gesundheit, Band 35. Stuttgart,
   Verlag W. Kohlhammer, 1976,165 pp.

(4.5) BRENGELMANN, J.C., SEDLMAYR, E. Experiments in the reduction of
  smoking behavior. In: Steinfeld, J., Griffiths, W., Ball, K., Taylor, R.M.
   (Editors). Proceedings of the Third World Conference on Smoking and Health,
   New York, June 25, 1975. Volume II. Health Consequences, Education,
   Cessation Activities, and Social Action. U.S. Department of Health, Education,
   and Welfare, Public Health Service, National Institutes of Health, National
   Cancer Institute, DHEW Publication No. (NIH) 77-1413, 1977, pp. 533-543
(46) BRITISH MEDICAL JOURNAL. Do people smoke for nicotine? British Medical
   Journal 2(6994): 1641-1042, October 22,1977. (Editorial)
(47') BROCKWAY, B.S. Chemical validation of self-reported smoking rates. Behavior
   Therapy, 6 pp. (to be published).

(48) BROCKWAY, B.S., KLEINMANN, G., EDLESON, J., GRUENEWALD, K.
   Non-aversive procedures and their effect on cigarette smoking. Addictive
   Behaviors 2(2): 121-1231977.
(4.9) BROSS, I.D.J. Less harmful ways of smoking. In: Wynder, E.L., Hoffmann, D.,
  Tori, G.B. (Editors). Proceedings of the Third World Conference on Smoking
   and Health, New York, June 25, 1975. Volume I. Modifying the Risk for the
   Smoker. U.S. Department of Health, Education, and Welfare, Public Health
   Service, National Institutes of Health, National Cancer Institute, Publication
   No. (NIH) 761221,1976, pp. 111-118.

(50) BROZEK, J., KEYS, A. Changes of body weight in normal men who stop
   smoking cigarettes. Science 125(3259): l293, June 14.1957.
(51) BURNS, B.H. Chronic chest disease, personality, and success in stopping
   cigarette smoking. British Journal of Preventive and Social Medicine 23(l): 2%
   27, February 1969.

(52) BURT, A., THORNLEY, P., ILLINGWORTH, D.,WHITE, P., SHAW, T.R.D.,
   TURNER, R. Stopping smoking after myocardial infarction. Lancet l(7352):
   304306, February 23,1974.

(53) BURTON, D. Consistency versus internality as initiators of behavior change.
   International Journal of the Addictions 12(4): 553563.1977.

19-39


(54) BUTTS, W.C., KUEHNEMAN, M., WIDDOWSON, G.M. Automated method
  for determining serum thiocyanate, to distinguish smokers from nonsmokers.
  Clinical Chemistry 20(10): 1344-X348,1974.
(55) CALIFORNIA MEDICAL ASSOCIATION. The Smoking Study. A report of the
  attitudes and habits of California physicians with respect to cigarette smoking.
   California Medicine 199(4): 339344, October 1968.
(56) CAMPBELL, D.T., STANLEY, J.C. Experimental and Quasi-Experimental
  Designs for Research. Chicago, Rand McNally & Company, 196fI,84 pp.
(57) CAUTELA, J.R. Treatment of smoking by covert sensitization. Psychological
   Reports 28(2): 415-429,1970.

(58) CHAPMAN, R.F., SMITH, J.W., LAYDEN, T.A. Elimination of cigarette
  smoking by punishment and self-management training. Behavior Research
   and Therapy 9(3): 255-264,197l.
(59) CLAIBORN, W.L., LEWIS, P., HUMBLE, S. Stimulus satiation and smoking: A
  revisit. Journal of Clinical Psychology 28(7): 4X-419,1972.
(60) COCHRAN, N.N. A Methodological Analysis of Two Self-Control Procedures:
  Self-Monitoring and Thought-Stopping Applied to Smoking Behavior. Doctor-
  al dissertation, University of Mississippi, 1976, 137 pp. Dissertation Abatraots
  International 37(l): 5826&5827B, May 1977. (University Microfilms No. 77-
   11,181).

(61) COHEN, S.I., PERKINS, N.M., URY, H.K., GOLDSMITH, J.R. Carbon
  monoxide uptake in cigarette smoking. Archives of Environmental Health
   22(l): 55-69, January 1971.

(62) COMSTOCK, G.W., STONE, R.W. Changes in body weight and subcutaneous
  fatness related to smoking habits. Archives of Environmental Health 24(4):
   271-276, April 1972
(63) CONRAD, F.G. Smoking-withdrawal clinics. New England Journal of Medicine
   285(l): 69, July 1,1971.

(64) CONWAY, J.B. Behavioral selfcontrol of smoking through aversive condition-
  ing and self-management. Journal of Consulting and Clinical Psychology 45(3):
   348357, June 1977.

(65) CORTINES, C. Chronic disease and other aspects of women's smoking in the
  United States. In: Steinfeld, J., Griffiths, W., Ball, R, Taylor, ELM. (Editors).
  Proceedings of the Third World Conference on Smoking and Health, New
  York, June 25, 1975. Volume II. Health Consequences, Education, Cessation
  Activities, and Social Action. U.S. Department of Health, Education,
  and Welfare, Public Health Service, National Institutes of Health, National
  Cancer Institute, DHEW Publication No. (NIH) 77-1413, 197'7, pp. 293-297.
(66) CRASILNECK, H.B., HALL, J.A. Clinical hypnosis: Application in smoking and
   obesity problems. Dallas Medical Journal 62(6): 29fXUl2, June 1976.
(67) CRASILNECK, H.B., Hall, J.A. Hypnosis in the control of smoking. In: Clinical
  Hypnosis: Principles and Applications. New York, Grune and Stratton, 1975,
   pp. 167-175.

(68) CROOG, S.H., RICHARDS, N.P. Health beliefs and smoking patterns in heart
  patients and their wives: A longitudinal study. American Journal of Public
   Health 67(10): 921830, October 1977.

(69) CUDAHY, H.H. A Comparison of Two Operant Methods in the Treatment of
  Smoking. Doctoral dissertation, University of Utah, 1975, I27 pp. Dissertation
  Abstracts International 36(6): 3029-B, December 1975. (University Microfilms
   No. 7528,866).

(70) CURTIS, B., SIMPSON, D.D., COLE, S.G. Rapid puffing as a treatment
  component of a community smoking program. Journal of Community
   Psychology 4(2): 186193, April 1976.

19-40


(71) DANAHER, B.G. Rapid smoking and self-control in the modification of smoking
   behavior. Journal of Consulting and Clinical Psychology 45(6): 1663-16'75,
     December 1977.
(72) DANAHER, B.G. Research on rapid smoking: Interim summary and recommen-
    dations. Addictive Behaviors 2(2): 151-X6,1977.
(7m) DANAHER, B.G., LICHTENSTEIN, E. Become an ex-smoker. Englewood
    Cliffs, N.J., Prentice Hall, 1978,226 pp.
(78) DANAHER, B.G., LICHTENSTEIN, E., SULLIVAN, J.M. Comparative effects
   of rapid and normal smoking on heart rate and carboxyhemoglobin. Journal of
   Consulting and Clinical Psychology 44(4): 556563, August 19'76.
(74) DANAHER, B.G., SHISSLAK, C.M., THOMPSON, C.B., FORD, J.D. A smoking
   cessation program for pregnant women: An exploratory study. American
    Journal of Public Health, 63(g): 8963931978.
(75) DASTUR, D.K., QUADROS, E.V., WADIA, N.H., DESAI, M.M., BHARUCHA,
   E.P. Effect of vegetarianism and smoking on Vitamin BIZ, thiocyanate, and
   folate levels in the blood of normal subjects. British Medical Journal 3(5321):
   269-263, July 29,1972.

(78) DAVIDSON, H.A. Rationalizations for continued smoking. New York State
   Journal of Medicine 64: 29933691, December 15,1964.
(77) DAVISON, G.C., ROSEN, R.C. Lobeline and reduction of cigarette smoking.
   Psychological Reports 31(2): 443456, October 1972.
(78) DAWLEY, H.H. Jr., DILLENKOFFER, R.L. Letter to the Editor. Minimizing
  the risks in rapid smoking treatment. Journal of Behavior Therapy and
   Experimental Psychiatry s(2): 174, August 1975.
(79) DAWLEY, H.H. JR., ELLITHORPE, D.B., TRETOLA, R. Aversive smoking:
  Carboxyhemoglobin levels before and after rapid smoking. Journal of
   Behavior Therapy and Experimental Psychiatry 7(l): 13-15, March 1976.
(80) DELAHUNT, J., CURRAN, J.P. Effectiveness of negative practice and self-
  control techniques in the reduction of smoking behavior. Journal of Consulting
   and Clinical Psychology 44(6): 1692109'7, December 1976.
(81) DELARUE, NC. The anti-smoking clinic: Is it a potential community service?
   Canadian Medical Association Journal 163(S): 1164-65, 1163, 1171-1172, 1192,
   May $1973.

(82) DELARUE, N.C. A study in smoking withdrawal. The Toronto smoking
  withdrawal study centre-description of activities. Canadian Journal of Public
   Health, Smoking and Health Supplement 64(2): S5-S19, March/April 1973.
(88) DENSEN, P.M., DAVIDOW, B., BASS, H.E., JONES, E.W. A chemical test for
  smoking exposure. Archives of Environmental Health 14(6): 365-374, June
    1967.

(84) DERDEN, R.H., JR. The Effectiveness of Follow-up Strategies in Smoking
   Cessation. Doctoral dissertation, University of Pittsburgh, 1977, 294 pp.
   Dissertation Abstracts International 33(5): 2359-B-2369-B, November 1977.
   (University Microfilms No. 7723,532).

(85) DERICCO, D.A., BRIGHAM, T.A., GARLINGTON, W.K. Development and
  evaluation of treatment paradigms for the suppression of smoking behavior.
  Journal of Applied Behavior Analysis lO(2): 173-181, Summer 1977.
(88) DICKEN, C., BRYSON, R. Psychology in action. The smoking of psychology.
   American Psychologist 33(5): 594-567, May 1978.
(87) DICKSON, C.R. The Effects of Self-Monitoring on Smoking Rate. Doctoral
  dissertation, University of Nevada, Reno, 1971,102 pp. Dissertation Abstracts
  International 32(5): 5436-B, March 1972. (University Microfilms No. 729565).

1941


(88) DITTRICH, R.A. An Investigation of Therapeutic Instructions, Progress
   Feedback, and Patient Expectation in Relation to Treatment Outcome.
   Doctoral dissertation, University of Oregon, 1975, 59 pp. Dissertation
   Abstracts International 36(7): 3597-B-3593-B, January 1976. (University
   Microfilms No. 76922).

(89) DUBITZKY, M., SCHWARTZ, J.L. Ego-resiliency, ego-control, and smoking
   cessation. Journal of Psychology 70: 2'7-33, September 1963.
(90) DUBREN, R. Evaluation of a televised stop-smoking clinic. Public Health
  Reports 92(l): 81-34, January/February 1977.
(91) DUBREN, R. Self-reinforcement by recorded telephone messages to maintain
   nonsmoking behavior. Journal of Consulting and Clinical Psychology 45(3):
   353-369, June 1977.

(82) EISINGER, R.A. Psychosocial predictors of smoking recidivism. Journal of
   Health and Social Behavior 12: 355362, December 1971.
(83) EJRUP, B. A proposed medical regimen to stop smoking. The follow-up results.
   Swedish Cancer Society. Yearbook 3: 463473,1963-65.
(91) ELLIOTT, C.H. A Multiple Component Treatment Approach to Smoking
   Reduction. Doctoral dissertation, University of Kansas, 19'76,122 pp. Disserta-
   tion Abstracts International 33(2): 393-B-394-B, August 19'77. (University
   Microfilms No. 77-16,272).

(95) ELLIOTT, R., TIGHE, T. Breaking the cigarette habit: Effects of a technique
   involving threatened loss of money. Psychological Record 18: 593-513, 1963.
(96) ENGELN, R.G. A Comparison of Desensitization and Aversive Conditioning as
   Treatment Methods to Reduce Cigarette Smoking. Doctoral dissertation,
   Washington State University, 1969,86 pp. Dissertation Abstracts Intemation-
   al 36(2): 1357-B, September 1969. (University Microfilms No. 69-14447).
(97) EPSTEIN, L.H., COLLINS, F.L., JR. The measurement of situational influences
   of smoking. Addictive Behaviors 2(l): 47-53,1977.
(98) EVANS, M.W. The Avdel smoking project. Health Education Journal 32(3): 76
   81,1973.
(99) EVANS, RI., HANSEN, W.B., MITI'ELMARK, M.B. Increasing the validity of
   self-reports of smoking behavior in children. Journal of Applied Psychology
   62(4): 5215231977.

(100) EYRES, S.J. Public health nursing section report of the 1972 APHA smoking
   survey. American Journal of Public Health 63(10): 346-352, October 1973.
(101) FARQUHAR, J.W., MACCOBY, N., WOOD, P.D., ALEXANDER, J.K.,
   BREITROSE, H., BROWN, B.W., JR., HASKELL, W.L., McALISTER, A.L.,
   MEYER, A.J., NASH, J.D., STERN, M.P. Community education for cardiovas-
   cular health. Lancet l(3623): 11921195, June 4,1977.
(ZO.t?) FERNO, 0. The development of a chewing gum containing nicotine and some
   comments on the role played by nicotine in the smoking habit. In: Steinfeld, J.,
   Griffiths, W.,Ball, K., Taylor, R.M. (Editors). Proceedings of the Third World
   Conference on Smoking and Health, New York, June 2-5, 1975. Volume II.
   Health Consequences, Education, Cessation Activities, and Social Action. U.S.
   Department of Health, Education and Welfare, Public Health Service,
   National Institutes of Health, National Cancer Institute, DHEW Publication
   No. (NIH) 77-1413,1977, pp. 569-573.

(103) FERNO, O., LICHTNECKERT, S.J.A., LUNDGREN, C.E.G. A substitute for
   tobacco smoking. Psychopharmacologia 31(3): 201~2@4,1973.
(104) FLAXMAN, J. Quitting smoking now or later: Gradual, abrupt, immediate, and
   delayed quitting. Behavior Therapy 9(2): 269-270, March 1978.
(10.5) FRANCISCO, J.W. Modification of Smoking Behavior: A Comparison of Three
   Approaches. Dcctaral dissertation, Wayne State University, 1972, 87 pp.
   Dissertation Abstracts International 33(11): 5511-B-5512B, May 1973. (Uni-
   versity Microfilms No. 7312,511).

19-42


(106) FRANKS, C.M. Behavior Therapy Appraisal and Status. New York, McGraw-
   Hill Book Company, 1969,780 pp.

(107) FRANKS, C.M., FRIED, R., ASHEM, B. An improved apparatus for the
   aversive conditioning of cigarette smokers. Behavior Research and Therapy
   4(4): 301-308, November 1966.

(108) FREDERIKSEN, L.W. Single- designs in the modification of smoking.
    Addictive Behaviors l(4): 311-319,1976.

(109) FREDERIKSEN, L.W., EPSTEIN, L.H., KOSEVSKY, B.P. Reliability and
   controlling effects of three procedures for self-monitoring smoking. Psycho-
   logical Record w(2): 255-264,1975.

(110) FREDERIKSEN, L.W., FRAZIER, M. Temporal distribution of smoking.
    Addictive Behaviors. 2(3): 18'7-192,1977.

(111) FREDERIKSEN, L.W., MILLER, P.M., PETERSON, G.L. Topographical
   components of smoking behavior. Addictive Behaviors. 2(l): 55-61,19'77.
(112) FREDERIKSEN, L.W., PETERSON, G.L., MURPHY, W.D. Controlled smok-
   ing: Development and maintenance. Addictive Behaviors l(3): 193-196, 1976.
(113) FREDRICKSON, D.T. Cigarette smoking: Questions patients ask doctors (Part
   I and II) Chest 58(2 and 4): 147-15l369-372, August and October 1970.
(114) FREDRICKSON, D.T. The community's response to substance misuse. New
   York City Smoking Withdrawal Clinic. International Journal of the Addictions
   3(l): 81-89, Spring 1968.

(115) FREDRICKSON, D.T. How to help your patient stop smoking-Guidelines for
   the office physician. Diseases of the Chest 54(3): 196202, September 1968.
(116) FREDRICKSON, D.T., MCALISTER, A., DANAHER, B.G. Giving up smoking:
   How the various programs work. Medical World News 17(a): 52-57, November
    1,1976.

(I 17) FRITZ, R. Erfahrungen mit dem "Fuenf-Tage-Plan zur Raucherentwohnung"
   (Experiences with the "five-day plan to quit smoking"). Zeitachrift fuer
   Allgemeinmedixin 50(13): 628-630, May 10,1974.
(118) FUHRER, R.E. The Effects of Covert Sensitization with Relaxation Induction,
   Covert Sensitization Without Relaxation Induction, and Attention-Placebo on
   the Reduction of Cigarette Smoking. Doctoral dissertation, University of
   Montana, 1971, 133 pp. Dissertation Abstracts International 32(11): 6644-E
   6645-B, May 1972. (University Microfilms No. 7213,449).
(119) GALLUP OPINION INDEX. Public puffs on after ten years of warnings.
   Gallup Opinion Index (Report No. 108): 2@21, June 1974.
(2.80) GARDNER, R.M. A Test of Coverant Control Therapy to Reduce Cigarette
  Smoking: A Comparative Study of the Effectiveness of Two Different
   Strategies with a Direct Test of the Effectiveness of Contingency Manage-
   ment. Doctoral dissertation, University of Louisville, 1970,95 pp. Dissertation
   Abstracts International 32(05): 3091-B, September 1971. (University Micro
   films No. 71-29,132).

(121) GARFINKEL, L. Cigarette smoking among physicians and other health
   professionals, 1959-1972. CA-A Cancer Journal for Clinicians 26(6): 373-375,
    November/December 1976.

(I%?) GARVEY, A.J., BOSSE, R., SELTZER, C.C. Smoking, weight change, and age.
   A longitudinal analysis. Archives of Environmental Health 28(6): 32'7329,
    June 1974.

(123) GLASGOW, R.E. Effects of a Self-Control Manual, Rapid Smoking, and
   Amount of Therapist Contact on Smoking Reduction. Doctoral dissertation,
   Univemity of Oregon, 1977, 137 pp. Dissertation Abstracts International
   38(19): 5914-B, April 1978. (University Microfilms No. 7802521).
(124) Gmf$GOW, R.E., ROSEN, G.M. Behavioral bibliotherapy: A review Of wif-help
  behavior therapy manuals. Psychological Bulletin 85(l): l-23 January 1978.

19-Q


(1.85) GORDON, S.B. Self-Control with a Covert Aversive Stimulus: Modification of
  Smoking. Doctoral dissertation, West Virginia University, 1971, 73 pp.
  Dissertation Abstracts International 32(8): 4352-B-4359-B, February 1972.
   (University Microfilms No. 725154).

(f 26) GORDON, T., KANNEL, W.B., DAWBER, T.R., MCGEE, D. Changes aasoai-
  ated with quitting cigarette smoking: The Framingham Study. American
   Heart Journal 90(3): 322-323, September 1975.
(127) GORDON, W.M. The Effects of Instructions to Abstain, Rapid Smoking, and
  Individually Tailored Treatment on Chronic Smoking Behavior. Doctoral
  dissertation, Rutgers University, State University of New Jersey, 1976,43 pp.
  University Microfilms, Inc., Ann Arbor, Michigan, July 1976. (Univemity
   Microfilms No. 7616,402).

(l.38) GRAHAM, S., GIBSON, R.W. Cessation of patterned behavior: Withdrawal
   from smoking. Social Science and Medicine 5(4): 319-337, August 1971.
(f29) GREEN, L.W. Diffusion and adoption of innovations related to cardiovascu1ar
  risk behavior in the public. In: Enelow, A.J., Henderson, J.B. (Editors).
  Applying Behavioral Science to Cardiovascular Risk. Pmcaedings of a
   Conference. American Heart Association, Inc., 1975, pp. 34-108.
(180) GREEN, P. The mass media anti-smoking campaign around the world. In:
  Steinfeld, J., Griffiths, W., Ball, K., Taylor, R.M. (Editors). Proceedings of the
   Third World Conference on Smoking and Health, New York, June 2-5, 1975.
   Volume II. Health Consequences, Education, Cessation Activities, and Social
   Action. U.S. Department of Health, Education, and Welfare, Public Health
   Service, National Institutes of Health, National Cancer Institute, DHEW
   Publication No. (NIH) 77-1413,1977, pp. 245253.
(fn) GREENBERG, I., ALTMAN, J.L. Modifying smoking behavior through
   stimulus control: A case study. Journal of Behavior Therapy and Experimental
   Psychiatry 7( 1): 97-99, March 1976.

(18.2) GREENE, R.J. Modification of smoking behavior by free operant conditioning
   methods. Psychological Record 14(2): 171-178, April 1964.
(188) GREENE, S.B., AAVEDAL, M.J., TYROLER, H.A., DAVIS, C.E., HAMES,
  C.G. Smoking habits and blood pressure change: A seven year follow-up.
   Journal of Chronic Diseases 30(l): 401-413, July 1977.
(f84) GREENSPUN, I.F. Modification of Smoking Behavior Through Commitment
  Enhancement. Doctoral dissertation, State University of New York at Stony
   Brook, 1974,153 pp. Dissertation Abstracts International 35(g): 4650-B, March
   1975. (University Microfilms No. 7w71).
(1.95) GRIMALDI, K.E., LICHTENSTEIN, E. Hot, smoky air as an aversive stimulus
   in the treatment of smoking. Behavior Research and Therapy 7(3): 275232,
   September 1969.
(186) GRITZ, E.R., JARVIK, M.E. Pharmacological aids for the cessation of smoking.
   In: Steinfeld, J., Griffiths, W., Ball, K., Taylor, R.M. (Editors). Proceedings of
   the Third World Conference on Smoking and Health, New York, June 2-5,
   1975. Volume II. Health Consequences, Education, Cessation Activities, and
   Social Action. U.S. Department of Health, Education, and Welfare, Public
   Health Service, National Institutes of Health, National Cancer Institute,
   DHEW Publication No. (NIH) 77-1413,1977, pp. 575591.
(187) GUILFORD, J.S. Group treatment versus individual initiative in the cessation of
   smoking. Journal of Applied Psychology 56(2): 162167, April 1972.
(188) GUILFORD, J.S. Sex differences between successful and unsuccessful abstain-
   ers from smoking. In: Zagona, S.V. Studies and Issues in Smoking Behavior.
   Tucson, University of Arizona Press, 1967, pp. 95102.
(189) GUTMANN, M., MARSTON, A. Problems of s's motivation in a behavioral
   program for reduction of cigarette smoking. Psychological Reports 20(4): 119%
    1114, June 1967.

19-44


(I@) HACKETT, G., HORAN, J.J. Behavioral control of cigarette smoking: A
   comprehensive program. Journal of Drug Education 7(l): 71-79,1977.
(241) HACKETT, G., HORAN, J.J. Focused smoking: An unequivocably safe
   alternative to rapid smoking. Journal of Drug Education 8(3): 261-265, 1978.
(f@) HACKETT, G., HORAN, J.J., STONE, C.I., LINBERG, S.E., NICHOLAS, W.C.,
   LUKASKI, H.C. Further outcomes and tentative predictor variables from an
   evolving comprehensive program for the behavioral control of smoking.
   Journal of Drug Education 7(3): 225229,1977-78.
(I&?) HALL, J.A., CRASILNECK, H.B. Development of a hypnotic technique for
   treating chronic cigarette smoking. International Journal of Clinical and
   Experimental Hypnosis X(4): 283-289, October 1970.
(144) HALL, R.G., SACHS, D.P.L., HALL, SM. Medical risk and therapeutic
   effectiveness of rapid smoking. Behavior Therapy, 28 pp. (to be published)
(I&) HALLAQ, J.H. The pledge as an instrument of behavioral change. Journal of
   Social Psychology 98: 147-148, February 1976.
(f46) HAMMEN, C.L. Factors which Affect Self-Controlling Responses in Smoking
   Cessation. Doctoral dissertation, University of Wisconsin, 19'71, 123 pp.
   Dissertation Abstracts International 32(6): 3636-B, December 1971. (Universi-
   ty Microfilms No. 71-23304).

(l/T) HAMMER, 0. 5 Jahre Bad Nauheimer Raucher-Entwohnungstherapie und
   Nichtraucher-Training. (Five years of the Bad Nauheim nicotine withdrawal
   therapy and nonsmoker's training). Muenchener Medixinische Wochenschrift
   llqll): 565-568, March 15,1974.

(148) HAMMER, O., ADOLPH, E., HAMMER, R. Gruppentherapie "Frei von
   Rauchen." Zweijaehrige erfahrungen mit dem Bad Nauheimer 5Tage-Plan.
   (Group therapy "Free of Smoking". Two years' experience with the Bad
   Nauheimer 5day-plan). Muenchener Medixinische Wochenachrift lI2(28):
   1329-1335, July IO, 1970.

(f&4) HAMMOND, E.C., GARFINKEL, L. Changes in cigarette smoking. Journal of
   The National Cancer Institute 33(l): 49-64, July 1964.
(250) HAMMOND, E.C., GARFINKEL, L. The influence of health on smoking habits.
   Study of Cancer and Other Chronic Diseases. National Cancer Institute
   Monograph 19: 269285,1966.

(f5f) HAMMOND, EC., GARFINKEL, L., SEIDMAN, H., LEW, E.A. "Tar" and
   nicotine content of cigarette smoke in relation to death rates. Environmental
   Research X?(3): 263-274, December 1976.
(152) HAMMOND, E.C., PERCY, C. Ex-smokers. New York State Journal of
   Medicine 58: 29562959, September 15,1958.
(155) HANDEL, S. Change in smoking habits in a general practice. Postgraduate
    Medical Journal 49: 679-681, October 1973.
(154) HARLIN, V.K. The influenos of obvious anonymity on the response of school
   children to a questionnaire about smoking. American Journal of Public Health
    6x4): 566574, April 1972.

(1.55) HARRIS, M.B., ROTHBERG, C. A self-control approach to reducing smoking.
   Psychological Reports 31(l): 165-166, August 1972.

(156) HAUSER, R. Rapid smoking as a technique of behavior modification: Caution in
   selection of subjects. Journal of Consulting and Clinical Psychology 42(4): 625,
   August 1974.

(257') HAY, D.R., TURBO'M', S. Changes in smoking habits in men under 65 years
   after myocardial infarction and coronary insufficiency. British Heart Journal
    32: 73%740,1970.

jf58) HEPPER, N.G.G., CARR, D.T., ANDERSEN, H.A., FONTANA, R.S., ROSE
   NOW, E.C., III, HANSON, C. Antismoking clinic: Report of an experience and
   comparison with published results. Mayo Clinic Proceedings 45(3): 189-196,
    March 1970.

19-45


(Is&) HERSEN, M., BARLOW, D.E. Single Case Experimental Designs: Strategies
   for Studying Behavior Changes. New York, Pergamon Press, 19'76, 374 pp.
(159) HIGBEE, K.L. Fifteen years of fear arousal: Research on threat appeals: 1953-
    1963. Psychological Bulletin 72(6): 426444, December 1939.
(160) HILDEBRAND, G.I. Improving the adult community through hospital based
    smoking education and cessation programs. In: Steinfeld, J., Griffiths, W.,
    Ball, K., Taylor, R.M. (Editors). Proceedings of the Third World Conference on
    Smoking and Health, New York, June 2-5, 1975. Volume II. Health
    Consequences, Education, Cessation Activities, and Social Action. U.S.
    Department of Health, Education, and Welfare, Public Health Service,
    National Institutes of Health, National Cancer Institute, DHEW Publication
    No. (NIH) 77-1413,1977, pp. 233-233.
(161) HILDEBRANDT, D.E. The Impact of Commitment and Technique Training on
   Smoking. Doctoral dissertation, Northern Illinois University, 1975, 256 pp.
   Dissertation Abstracts International 36(4): 1919-B, October 1975. (University
    Microfilms No. 7523,120).
(162) HILL, H. Situational analysis: Women and smoking. In: Steinfeld, J., Griffiths,
    W., Ball, K., Taylor, R.M. (Editors). Proceedings of the Thii World
    Conference on Smoking and Health, New York, June 25, 1975. Volume II.
    Health Consequences, Education, Cessation Activities, and Social Action. U.S.
    Department of Health, Education, and Welfare, Public Health Service,
    National Institutes of Health, National Cancer Institute, DHEW Publication
    No. (NIH) 77-1413,1977, pp. 291-292.

(168) HOMME, L.E. Perspectives in psychology: XXIV. Control of coveranm, the
   operants of the mind. Psychological Record 15(4): 591511, October 1935.
(164) HORAN, J.J., HACKETT, G., NICHOLAS, WC., LINBERG, S.E., STONE, C.I.,
   LUKASKI, H.C. Rapid smoking: A cautionary note. Journal of Consulting and
   Clinical Psychology 45(3): 341-343, June 1977.
(165) HORAN, J.J., LINBERG, S.E., HACKETT, G. Nicotine poisoning and rapid
   smoking. Journal of Consulting and Clinical Psychology 45(3): 344347, June
     1977.
(f 66) HORN, D. An approach to office management of the cigarette smoker. Diseases
   of the Chest 54(3): 293-209, September 1963.
(167) HORN, D. Epidemiology and psychology of cigarette smoking. Chest 59 (5,
   supplement): 22%24S, May 1971.

(168) HUNT, W.A. (Editor). Learning Mechanisms in Smoking. Chicago, Aldine
   Publishing Company, 1970,237 pp.

(169) HUNT, W.A. (Editor). New approaches to behavioral research on smoking.
   Journal of Abnormal Psychology El(2): 197-198, April 1973.
(170) HUNT, W.A., BARNETT, L.W., BRANCH, L.G. Relapse rates in addiction
   programs. Journal of Clinical Psychology 27(4): 455-453, October 1971.
(171) HUNT, W.A., BESPALEC, D.A. An evaluation of current methods of modifying
   smoking behavior. Journal of Clinical Psychology 39(4): 431433, October 1974.
(172) HUNT, W.A., MATARAZZO, J.D. Habit mechanisms in smoking. In: Hunt,
   W.A. (Editor). Learning Mechanisms in Smoking. Chicago, Aldine Publishing
   Company, 1970, pp. 65-196.

(173) HYND, G.W., CHAMBERS, C., STRATTON, T.T., MOAN, E. Credibility of
   smoking control strategies in non-smokers: Implications for clinicians.
   Psychological Reports 41(2): 593-596, October 1977.
(174) HYND, G.W., O'NEAL, M., SEVERSON, H.H. Cardiovascular stress during the
   rapid-smoking procedure. Psychological Reports 39(2): 371375, October 1976.
(175) HYND, G.W., STRATTON, T.T., SEVERSON, H.H. Smoking treatment
   strategies, expectancy outcomes, and credibility in attention-placebo control
   conditions. Journal of Clinical Psychology 34(l): 182139, January 1973.

19-46