Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. 5, 145±154 (1998)

Changes in Confidence and Craving

During Smoking Reduction
Kieron O'Connor* and Robert Langlois
Centre de recherche Fernand-Seguin, HoÃpital Louis-H. Lafontaine,
Montreal, Canada

This article reports two studies designed to explore patterns of change

in confidence about not smoking during gradual smoking reduction. In
the first study, trends in self-reported smoking, craving and confidence
were measured over baseline, 10 attendance sessions and at 2-month
follow-up in a group receiving situationally tailored coping strategies,
and two comparison groups receiving either a uniform coping strategy
(relaxation therapy) or no systematic coping strategy. The coping
strategy group showed a more consistent increase in confidence, but all
groups were able to cut out smoking, situation by situation, without
corresponding increases in craving in other situations. In a second
study, 60 smokers were assigned to one of three gradual reduction
groups emphasizing: self-efficacy or behavioural coping skills, or a
third control programme. Confidence in not smoking increased during
treatment in the self-efficacy and behavioural coping groups, and
initial situational differences in confidence had flattened out post-
treatment. Higher confidence at follow-up correlated significantly with
lower saliva cotinine level. In conclusion, situational reduction can
be accomplished systematically and is associated, in some subjects,
with an overall increase in confidence in coping with no smoking.
# 1998 John Wiley & Sons, Ltd.

INTRODUCTION smoking may become more attractive, as a con-

sequence of fewer cigarettes being smoked (Sobell
Health facts dictate cessation as the goal of choice
et al., 1990). An alternative view is that the smoker
for smokers. But, at the outset many smokers do not
may find reducing a less aversive way of quitting
consider this a realistic goal, and may fear the
(Hughes et al., 1984). Although there have been
commitment and the effects of abrupt cessation
studies showing comparable outcome in graded
(Owen et al., 1992). One obvious possibility is for
versus abrupt cessation (Glasgow et al., 1989), there
these smokers to cut down rather than stop com-
have, to our knowledge, been no studies examining
pletely and, with the increasing social margin-
cognitive changes relevant to quitting, during the
alization of smoking, more and more smokers are
actual process of smoking reduction. Clinically, for
becoming (or, are being forced to become) light
example, we have noted that successfully cutting
situation or period specific smokers. However, a
down may increase the smoker's confidence in the
major objection to smoking reduction as a means to
ability to cope with not smoking. If such confidence
cessation is that relapse is more likely and that
was greater after, than before, reduction, this result
could suggest that self-efficacy about coping with
*Correspondence to: K. O'Connor, Centre de recherche quitting had also increased. Self-efficacy (Bandura,
Fernand-Seguin, HoÃpital Louis-H. Lafontaine, 7331 Hochel-
aga, MontreÂal, QueÂbec, Canada H1N 3V2. 1982) has been reported as a main predictor of both
adherence and abstinence during a cessation pro-
Contract grant sponsor: Conseil QueÂbeÂcois de la Recherche
Sociale; Contract grant number: RS-1421-1653.
gramme (O'Leary, 1985; Yates and Thain, 1985).
Contract grant sponsor: Fonds de la Recherche en Sante du West and Schneider (1988) reported that lower self-
QueÂbec. efficacy was correlated with higher craving during

CCC 1063±3995/98/030145±10$17.50
# 1998 John Wiley & Sons, Ltd.
146
cessation, and, according to Marlatt and Gordon
(1985), self-efficacy is a central factor that can have a
major influence in relapse.
But, confidence in not smoking could be affected
by perceived ability to cope with not smoking, and
so self-efficacy may also depend on what the smoker
does whilst reducing and, in particular, whether
coping strategies are adopted or not. There seem to
be wide variations in the use of coping strategies,
particularly during the early phases of cessation or
fading (Shiffman, 1982, 1984, 1989). Coping with
craving might be managed more effectively during
reduction, with the help of coping skills than
without such skills, as has been shown in the case
of preventing relapse after abrupt cessation (Hall
et al., 1984; Bliss et al., 1989; Stevens and Hollis,
1989).
In the present two studies, changes in cognitive
appraisals of confidence about not smoking, whilst
gradually reducing smoking, were examined along-
side concomitant changes in craving to smoke, and
self-report changes in arousal. The first study
examined whether specific coping strategies were
necessary to increase levels of confidence in not
smoking whilst reducing, and the second study
evaluated the impact of a cognitive intervention,
specifically targeting self-efficacy.
The specific hypothesis of the first study was that
a group applying coping strategies would show a
linear increase in confidence and a decrease in
craving during gradual reduction, and that neither a
uniform coping approach which took no account of
coping specificity, nor an approach which gave no
coping training at all, would show a consistent
trend in confidence or craving.
STUDY 1
Method
Recruitment
Subjects were recruited via an internal advertise-
ment in a local hospital inviting staff who
were smokers to participate in a free 10 weeks
smoking cessation programme. The programme was
announced as suitable for those who wanted to cut
down smoking gradually. Thirty-three smokers
were randomly assigned to three groups of 11. The
groups were matched for age, sex, length of habit,
motivation and type of situational preference,
personality scores of extraversion and neuroticism
(measured by the Eysenck Personality Question-
naire) (Eysenck, 1980). Age: active coping, xÅ 42.0
# 1998 John Wiley & Sons, Ltd.
K. O'Connor and R. Langlois
(SDn718.8); uniform coping (relaxation), xÅ 39.4
(SDn717.5); control, xÅ 40.5 (SDn7111.9). Cigarettes
per day: active coping, xÅ 32.1 (SDn7114.3); uni-
form coping, xÅ 29.8 (SDn719.4); control, xÅ 27.1
(SDn7110.7). Motivation to participate was assessed
by initial interview, and rated on a scale of (0±10),
on the basis of realistic expectations about the
programme, commitment to attend meetings and
do homework exercises, and the absence of illness,
difficulties or stress likely to impede participation:
active coping, xÅ 7.2 (SDn711.2); relaxation,
xÅ 7.3(SDn710.9); control xÅ 7.2 (SDn711.3).
Measures
Number of Cigarettes Smoked per Day
The number of cigarettes smoked per day was
evaluated using a daily self-monitoring procedure.
Cards were specially printed for this purpose listing
a column for trigger situation, time, and craving
rating (1±5). The cards fitted into the cigarettes
packets. A baseline measure of 1 week's monitoring
was taken at 1 month, and at 1 week before the
first session. Subjects continued self-monitoring
throughout the 10 weeks. Smoking status was also
evaluated by self-monitoring for a 1-week period at
post-treatment, and at two follow-up sessions:
2 months and 6 months post-treatment. An hier-
archy of high craving cues and situations was
constructed individually for each smoker.
At baseline, after each group session throughout
treatment, and at post-treatment, and at follow-up,
subjects completed the following three question-
naires measuring: craving, confidence and arousal.
Self-Report Craving Questionnaire
This questionnaire listed 12 categories of everyday
smoking cues and situations. These were: after a
meal, when drinking alcohol, taking a work break,
when relaxing, when involved in a pleasurable
activity, when watching TV, when bored, when
conversing, when doing complicated work, when
waiting for something, when emotionally stressed,
when concentrating. Subjects were requested to rate
desire to smoke in each situation from 0 (never
smoke) to 100 (smoke always).
Confidence About Not Smoking Questionnaire
This questionnaire listed the same 12 items of the
Situational Questionnaire but subjects had to rate
from 0 (uncertain)±100 (certain) their degree of
confidence in being able to not smoke in the
different situations. (The scale was adapted from
the format validated by Condiotte and Lichtenstein,
1981; O'Connor and Langlois, 1992).
Clin. Psychol. Psychother. 5, 145±154 (1998)
Confidence During Smoking Reduction
Thayer Stress Arousal Questionnaire
This was a 38-item adjective checklist which has
been psychophysiologically validated (Thayer,
1967; Mackay, 1980). The responses were divided
into four categories of high and low stress, and
high and low arousal items. High stress and low
arousal items included mood items reflecting mood
correlates of withdrawal (e.g. irritation, depression,
stress) as given in Hughes and Hatsukami (1986).
Treatment
Two weeks were spent on preliminary exercises
to enhance awareness of cues for smoking, and to
acclimatize the smoker to the rationale of the
programme, and to the plan of graded cessation.
The format of all treatments was a group format.
The smoking group leader (RL) was the same for all
groups and was independent and impartial with
regard to treatment modality. All groups consisted
of 10 weekly, 90 min reunions, followed by two
follow-up sessions at 2 and 6 months post-treat-
ment. In each of the three groups, a gradual
reduction approach was adopted. The experimental
group (A) involved tailoring active coping strategies
according to the smoking situation analysis. The
person was encouraged to cope with high risk
smoking situations by stress management tech-
niques, or by changing their habitual response
in the situation, or by replanning and restructuring
the task, or by physically, or mentally substituting
the cigarette by another pleasurable activity. The
strategies chosen depended on the nature of the
situation and the needs and convenience for
the smoker. The coping strategies were rehearsed
in the group, and as homework, before being
implemented in a systematic fashion over the
weeks of gradual cessation. The uniform strategy
group (R) practised relaxation in all situations. The
basic relaxation procedure was a Jacobsen type
procedure including tensing and relaxing arm, leg,
trunk and face muscles coupled with breathing and
imagery instruction. After mastery of the procedure,
subjects learnt to apply relaxation strategies in vivo.
Each week the participants rehearsed, and imple-
mented, relaxation strategies in place of smoking, in
the targeted smoking situation. The control group (C)
did not rehearse any coping strategies. Some
general strategies were however detailed including,
creating a delay, breathing, changing situations,
avoiding cues, drinking water. These strategies
were given since it was suspected that smokers
would already be familiar with some of these aids.
Some smokers in the control group did in fact
employ substitution strategies, but in a haphazard
# 1998 John Wiley & Sons, Ltd.
147
manner. At the end of treatment, subjects com-
pleted questionnaires detailing the types of strat-
egies offered in the programme, with ratings of how
useful they had found them. The active coping
group clearly used more active coping strategies
than the other two groups, which confirmed the
differential effects of therapy. All 10 of the active
coping group reported use of at least one beha-
vioural coping strategy, of whom nine found it
useful, compared to six (67%) of the relaxation
group, of whom four found it useful, and two (25%)
of the control group, of whom one found it useful.
All nine of the relaxation group had specifically
used what they considered to be relaxation, of
whom eight found it useful compared to nine (90%)
of the active coping, of whom seven found it useful,
and five (62%) of the control group, of whom three
found it useful. Only the relaxation group reported
significant changes in stress and arousal over
treatment (see Results). Satisfaction with the group
was also rated (0±5) at the end of treatment, by
means of a questionnaire addressing expectations,
therapist style and the method used. Overall mean
ratings were comparable for the three groups
(A ˆ 4.4; R ˆ 4.3; C ˆ 4.5).
Analysis
At the final analysis, the complete data of
27 smokers was available. This comprised 10 in
the active coping group (A), nine in the relaxation
group (R), and eight in the control group (C). Data
on number of cigarettes smoked was available for
both baseline sessions (baseline 1 and baseline 2) for
all 10 attendance sessions, and for 2-month, and
6-month follow-up. Data on arousal, craving, and
confidence were collected at baseline 2, and from
second to ninth sessions inclusive, and at 2-month
follow-up. The pre±post questionnaire measures
were collected at baseline 2, and at 2-month follow-
up. Repeated measures ANOVA, and regression
analyses, are reported as F ratios. Where F-values
refer to individual treatment groups they are
abbreviated for clarity of reference in the text to
F(A), F(R), F(C) respectively.
Results
There were no differences at baseline, between
groups, in any of the following self-reported
smoking characteristics: amount smoked; age of
starting; length of habit; personality.
Number of cigarettes was self-monitored at two
baseline levels (on first interview, and 1 week prior
Clin. Psychol. Psychother. 5, 145±154 (1998)
148 K. O'Connor and R. Langlois

to treatment) and at each successive week of
10 treatments, plus a 2-month (F2), and a 6-month
follow-up. There was a non-significant decrease in
number of cigarettes recorded, from baseline 1 to
baseline 2. Baseline 2 (B2) was considered as the
pre-treatment measure. All groups reported a linear
reduction over sessions. (Active coping (F(1,9
A) ˆ 18.65; p 5 0.01; relaxation F(1,8 R) ˆ 14.72;
p 5 0.01; control group F(1,7 C) ˆ 7.07; p 5 0.05).
There were no differences between groups. Mean
number of cigarettes reported smoked per group
was as follows: group A, B2 xÅ ˆ 24.22 (SDn719.70),
F2 xÅ ˆ 7.72 (SDn715.99); group R, B2 xÅ ˆ 18.91
(SDn715.19), F2 xÅ ˆ 5.13 (SDn716.05); group C, B2
xÅ ˆ 19.17 (SDn715.77), F2 xÅ ˆ 6.67 (SDn717.67). At
6-month follow-up four of the active coping
group (40%), two of the relaxation group (22%)
and one of the control group (12.5%) reported they
had stopped smoking.
Regression analysis measured the trends in
situational craving from B2 through sessions 2±9 to
F2 for the 12 items on the craving questionnaire. All
groups showed a pronounced craving profile across
smoking situations at baseline which was not
present at follow-up. Mean craving and confidence
over all 12 situations for each group at B2 and at F2
is given in Table 1. The relaxation group showed a
linear trend across sessions for reduced craving
(F)R) ˆ 5.21, p 5 0.01). Reduction in craving was
significant for this group at final session
(F(R) ˆ 13.12; p 5 0.01) and at F2 (F(R) ˆ 24.84;
p 5 0.01) as compared to B2. The coping group
also showed a significant reduction at
F2(F(A) ˆ 9.70 p 5 0.05) with a linear trend over
sessions (F(A) ˆ 14.81; p 5 0.001). The control
group showed a reduction in craving at F2, but
also a series of quadratic and cubic trends over
sessions, which hence makes the results difficult to
interpret (see Table 1).
The coping group showed an overall linear
increase in confidence in not smoking for six of
the 12 situations (F(A) ˆ 7.95; p 5 0.01) (after a
meal (F(A) ˆ 5.82; p 5 0.02), concentration (F(A) ˆ
8.83; p 5 0.01), during conversation (F(A) ˆ 4.78;
p 5 0.04), doing complicated work (F(A) ˆ 6.94;
p 5 0.01), waiting for something (F(A) ˆ 5.92;
p 5 0.02) and under emotional stress (F(A) ˆ 13.94;
p 5 0.01). The control group showed a linear
increase in confidence for three situations only
(F(C) ˆ 11.35; p 5 0.01) (after a meal (F(C) ˆ 16.26;
p 5 0.01), waiting for something (F(C) ˆ 6.56;
p 5 0.03) and stress (F(C) ˆ 14.96; p 5 0.01)). The
relaxation group showed a non-significant increase
in confidence.
The stress-arousal adjective checklist was divided
into four subscales of high stress, low stress, high
arousal, and low arousal after Mackay (1980). High
stress included such items as, bothered, jittery,
nervous, fearful, which might be considered as
high stress. Only the relaxation group showed a
linear reduction in high stress over treatment
(F(R) ˆ 3.98; p 5 0.05). Low stress included the
opposite end of the stress dimension such as,
peaceful, relaxed, contended. There was no consist-
ent change across treatment sessions for any group.
High arousal included items such as, energetic,
vigorous, alert, stimulated. The relaxation group,
only, showed a significant linear increase
across sessions (F(R) ˆ 10.97; p 5 0.02). Low arousal
included items such as, drowsy, tired, idle, sluggish,
and showed no group differences, or trends over
treatment.

Table 1. Mean change over 12 smoking situations and standard deviation (n 7 1) in % craving to smoke and %
confidence in not smoking for each treatment group over weekly treatment sessions and 2-month follow-up for Study 1

Active coping group Relaxation group Control group

(N ˆ 10) (N ˆ 9) (N ˆ 8)

Craving Confidence Craving Confidence Craving Confidence

(0±100) (0±100) (0±100) (0±100) (0±100) (0±100)
Pre-treatment 74.62 (5.43) 59.67 (19.27) 74.60 (15.67) 53.15 (16.58) 72.50 (9.61) 51.04 (17.58)
Session 2 73.17 (5.85) 55.54 (15.35) 72.92 (15.98) 56.76 (17.15) 58.02 (17.44) 63.44 (18.17)
Session 3 67.31 (9.73) 55.46 (11.83) 65.00 (16.29) 60.46 (13.16) 50.00 (18.36) 65.52 (16.12)
Session 4 61.66 (10.25) 60.74 (10.32) 57.13 (16.05) 63.39 (16.15) 56.17 (8.71) 57.67 (13.36)
Session 5 60.52 (7.94) 59.63 (9.97) 52.41 (15.00) 74.72 (4.23) 43.12 (19.10) 64.45 (18.75)
Session 6 50.77 (15.30) 62.86 (14.47) 51.96 (19.01) 66.79 (15.21) 46.76 (19.19) 62.20 (13.49)
Session 7 48.33 (22.56) 66.30 (18.05) 41.69 (22.33) 75.07 (12.83) 36.11 (20.17) 76.94 (14.47)
Session 8 48.28 (17.89) 67.45 (10.34) 38.17 (25.06) 77.83 (16.76) 47.74 (23.61) 69.64 (16.87)
Session 9 47.27 (22.61) 74.17 (17.95) 35.76 (20.34) 77.36 (14.29) 27.38 (24.36) 72.98 (31.35)
Follow-up 35.17 (28.48) 88.17 (35.64) 21.01 (22.80) 64.58 (39.79) 18.18 (22.18) 85.68 (15.01)

# 1998 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 5, 145±154 (1998)
Confidence During Smoking Reduction
Discussion
The principal hypothesis that smokers receiving
coping strategies would show a more uniform
increase in confidence, and decrease in self-reported
craving, during a graded reduction programme,
than would a comparative group receiving either
uniform strategies, or no specific strategies, did
receive some support. The coping group reported a
linear increase in confidence in more situations,
over the 10 sessions, than did the other groups.
However, all groups reported a linear reduction in
the amount smoked over sessions, and an overall
decrease in craving to smoke. Craving and reported
use did not increase in any group, in other
situations, when one situation was eliminated.
The focus of this study was on the self-reported
cognitive changes within each group during the
process of reduction. The number of subjects was
too small and the self-report measures of smoking
insufficient to permit any conclusion of the com-
parative efficacy of the treatment modalities.
STUDY 2
Another intervention that might selectively increase
confidence in not smoking, during smoking
reduction, is self-efficacy training. The second
study was designed to test this possibility, by
comparing a group of smokers receiving a purely
behavioural coping skill package (BST), with a
group receiving cognitive therapy aimed at increas-
ing self-efficacy, (SET) and, with another control
group offered the standard package in the first
study without being exclusively focused either on
behavioural skill or efficacy (COT). The aim of
Study 2 was to examine the contribution of self-
efficacy training to improve confidence in coping
during smoking reduction. The hypothesis was that
increased self-efficacy training would result in
reports of higher self-confidence in coping with
not smoking during reduction, as compared with a
behavioural skill group which learnt coping skills,
but without specific cognitive training aimed at
enhancing efficacy.
Method
Recruitment
Sixty-six smokers were recruited from the general
population. Sixty (20 per group) participated and
the groups were matched for sex, age, smoker
characteristics, and personality. All groups were
comparable in terms of type of situational smoking
# 1998 John Wiley & Sons, Ltd.
149
preference, age, sex, and motivation to quit. Age:
SET, xÅ 37.7 (SDn716.3), BST, xÅ 37.7 (SDn717.8), COT,
xÅ 40.6 (SDn716.2); cigarettes per day: SET, xÅ 20.11
SDn716.7), BST, xÅ 24.6 (SDn716.9), COT, xÅ 19.3
(SDn714.6). Sixty smokers began the treatment
programme (20 per group). Post-treatment data
was collected on 49 of these (SET ˆ 19, BST ˆ 15,
COT ˆ 15) and 3-month follow-up data on 44
(SET ˆ 16, BST ˆ 14, COT ˆ 14) and 9-month
follow-up on 42 (SET ˆ 15, BST ˆ 13, COT ˆ 14).
Drop-out characteristics are discussed later.
Treatment
Two subgroups of (initially) 10 subjects were run,
by the same therapist, for all conditions. The
programme lasted 10 weeks, and followed essen-
tially the same structure and time schedule as the
first study, but naturally there were differences in
the way this programme was implemented in the
cognitive (SET) groups and behavioural (BST)
groups. The behavioural skills group concentrated on
implementing behavioural dissociations and substi-
tutions in smoking situations, according to the
active coping rationale of the first study. In the
SET group, coping with situations was approached,
exclusively, from the point of view of raising belief
in ability to quit. The cognitive training concentrated
on developing belief in personal competence to cope
with abstinence. Traditional cognitive methods,
such as challenging irrational expectations, de-
dramatizing outcome, and reality testing to dispel
automatic assumptions, were employed to focus on
situations where difficulties were anticipated. So a
typical self-efficacy training began by eliciting auto-
matic doubts about the ability to control craving,
and then analysed, in more detail, beliefs and
expectancies such doubts entailed, e.g. What exactly
did the person believe would happen if they did not
smoke? What were alternative possibilities to
negative expectations? The person was encouraged
to reality test beliefs in the situation and to separate
fact from fiction. The experiences of abstinence were
related to past experiences of successful problem
solving. In particular, attempts were made to shift
attributions from characteriological interpretations
of difficulties (e.g. I always fail) to behavioural
interpretation (e.g. I sometimes fail when faced with
situations I didn't foresee) and to emphasize that
causes of difficulties were personally changeable.
The smoking reduction hierarchy of situations was
derived, exclusively, from ratings of confidence
about not smoking in different situations. The
smokers received no training in behavioural coping
skills.
Clin. Psychol. Psychother. 5, 145±154 (1998)
150
Measures
The situational craving, confidence, and stress-
arousal instruments, and the self-monitoring
smoking cards, were identical to the first study.
Saliva nicotine samples were tested by measure-
ment of cotinine levels and were collected from all
smokers at all attendance sessions, but not all these
samples were analysed, and a complete analysis
was limited to verifying smoking status post-
treatment. A cognitive scale measuring degree of
belief in statements about smoking was adminis-
tered at baseline and post-treatment. All groups
also completed, post-treatment, a questionnaire on
strategies used, and subjects rated degree of
satisfaction with the programme.
Cotinine Analysis
Salivary levels of cotinine were measured by
high-performance liquid chromatography (HPLC)
with UV detection. Cotinine was extracted from
alkalinized saliva samples using ethyl acetate as the
extraction solvent. After centrifugation, the aqueous
phase was discarded and the organic layer was
evaporated to dryness under a gentle stream of
nitrogen. The dried residue was resuspended in
200 ml of mobile phase of which approximately
50 ml were used for the analysis.
The analysis was performed with a Hewlett-
Packard 1050 HPLC model. The delivery system
was connected to a chromatographic column
(12.5  0.46 cm i.d.) which was packed with 5 mm
ODS material (Hichrom). Cotinine and the internal
standard were detected at 261 nm.
The mobile phase was a mixture of acetonitrile:
0.005 M NaH2PO4 pH 3.0 buffer (60:40) and the
flow rate was set at 1.0 ml/min. Under these
chromatographic conditions, cotinine and the
internal standard eluted at the following retention
times: 3.68 and 6.19 min, respectively. Nicotine did
not interfere with the analysis, its retention time
being 10.58 min.
Cotinine, which is a major metabolite of nicotine,
offers several advantages over other biochemical
markers, since it is stable in body fluids, has a
long half-life and its concentration is not influenced
by diet, physical activity or environment. Further-
more, cotinine concentration in its serum forms in
cigarette smokers seems directly related to nicotine
intake (Rosa et al., 1992). Pomerleau et al. (1990)
reported a strong relationship between nicotine
tolerance as measured by self-report questionnaire
and plasma cotinine. Cummings and Richard (1988)
provide the optimum cut-off points for biochemical
# 1998 John Wiley & Sons, Ltd.
K. O'Connor and R. Langlois
validation of smoking status for both plasma and
saliva nicotine.
Results
All groups showed a linear decrease in number of
cigarettes recorded, for all smoking situations, over
therapy sessions. There were no differences among
groups in this decrease up to post-treatment (SP).
However, at 3-month follow-up (F3) the control
group smoked more than the other groups, and
significantly more than the BST group (t30 ˆ 1.71;
p 5 0.05). The mean number (xÅ ) of cigarettes
reported smoked was as follows: SET, SP xÅ ˆ 4.2
(SDn715.4), F3, xÅ ˆ 9.0 (SDn717.5); BST SP, xÅ ˆ 7.6
(SDn718.1). F3, xÅ ˆ 11.5 (SDn7110.1); COT SP,
xÅ ˆ 4.5 (SDn715.8), F3, xÅ ˆ 7.7 (SDn715.9). At F3,
five of the SET, and five of the BST groups, and
three of the COT group had quit smoking. At
9-month follow-up (F9), three of the SET group, two
of the BST group and two of the COT group, were
abstinent as determined by the cotinine analysis.
No further subjects had quit.
There were no significant differences at baseline,
in craving between groups, and each group
contained smokers with preferences to smoke in a
range of situations. All groups showed a significant
decrease in craving over all situations during
treatment. The control group reported higher
craving in all situations than did the other two
groups, but there were no post-treatment differ-
ences in craving between SET and BST groups.
Also, all groups showed a slight non-significant
increase in craving from post-treatment to F3 (see
Table 2). But at F9, the reduction was maintained,
and mean craving over situations was: SET ˆ 40.74
(SDn717.28); BST ˆ 45.93 (SDn7112.82); COT ˆ 50.51
(SDn7112.74).
Confidence about not smoking increased in all
three groups during reduction. Significant differ-
ences in confidence ratings between individual
situations had disappeared at SP and at F3. The
SET group showed a significant increase over all
12 situations, the BST group over 10, and the control
group over seven situations. The SET group had
less variation than the other two groups at SP, indi-
cating greater between subjects uniformity in confid-
ence levels. At F9, mean confidence level and over
situations was: SET ˆ 71.26 (SDn717.05); BST ˆ 62.59
(SDn7111.62); COT ˆ 64.55 (SDn7111.17).
The overall product±moment correlation between
mean confidence level over all situations and
cotinine level across subjects was negative overall
(r(35) ˆ ÿ0.55; p 5 0.001) and for each group
Clin. Psychol. Psychother. 5, 145±154 (1998)
Confidence During Smoking Reduction 151

Table 2. Craving (0±100) and confidence (0±100) in not smoking over each of 12 smoking situations and for treatment
group (SET, COT, BST) at baseline, post-treatment, and 3-month follow-up in Study 2 (SDn71 in parentheses)

Baseline (SO) Post-treatment (SP) 3-month follow-up

Craving Confidence Craving* Confidence Craving Confidence

After a meal SET 97.9 (5.4) 38.0 (31.4) 29.5 (42.7) 87.4 (20.0){ 56.9 (41.7) 74.4 (25.5)
COT 100.0 (0.0) 32.5 (31.4) 48.6 (42.6) 66.7 (34.5){ 63.3 (39.4) 56.0 (34.8)
BST 96.0 (15.5) 38.8 (31.7) 22.2 (38.4) 77.3 (36.3{ 51.5 (40.9) 68.5 (34.1)
With alcohol SET 82.9 (24.8) 44.5 (37.7) 23.9 (34.7) 88.4 (19.8){ 41.7 (39.5) 74.6 (26.5)
COT 92.7 (25.7) 32.4 (27.3) 50.7 (33.8) 61.3 (29.2){ 55.3 (40.0) 62.0 (34.9)
BST 83.7 (34.9) 31.0 (34.4) 27.3 (40.6) 76.0 (36.6){ 43.8 (40.9) 64.6 (36.0)
Taking a break SET 81.1 (18.8) 52.0 (29.5) 19.5 (29.1) 91.6 (16.7){ 36.9 (36.5) 80.0 (20.7)
COT 94.0 (11.8) 45.0 (27.7) 39.3 (35.8) 70.7 (34.7){ 45.3 (37.2) 70.7 (33.5)
BST 87.0 (21.7) 51.2 (32.3) 20.0 (27.2) 86.0 (26.9){ 43.1 (36.4) 68.5 (29.7)
Concentrating SET 61.6 (30.6) 65.3 (29.8) 17.4 (29.2) 92.7 (12.8){ 35.0 (36.0) 84.4 (20.3)
COT 77.7 (25.1) 59.2 (25.3) 36.4 (36.6) 77.3 (10.6){ 40.0 (32.5) 73.3 (28.2)
BST 56.0 (31.1) 79.2 (25.0) 19.3 (33.9) 80.0 (36.1) 31.9 (36.1) 83.9 (29.6)
In conversation SET 60.0 (27.9) 63.8 (27.7) 16.8 (23.6) 92.1 (15.1){ 28.7 (34.4) 82.2 (19.7)
COT 67.3 (14.4) 66.9 (14.9) 36.4 (30.5) 71.3 (34.0) 32.7 (26.6) 76.7 (32.9)
BST 70.7 (25.8) 70.4 (26.1) 13.3 (24.4) 87.7 (26.7){ 23.8 (28.1) 78.5 (26.4)
Relaxing SET 65.3 (26.7) 52.3 (29.1) 12.1 (23.2) 92.1 (16.5){ 30.3 (33.1) 84.4 (21.0)
COT 73.3 (20.6) 70.8 (22.9) 30.0 (33.5) 72.7 (35.1) 41.3 (32.9) 66.0 (32.9)
BST 77.0 (23.1) 59.2 (22.9) 20.7 (29.9) 91.7 (13.6){ 21.5 (33.0) 83.8 (23.3)
Bored SET 73.7 (31.5) 41.2 (37.6) 14.7 (24.1) 91.8 (16.4){ 36.2 (33.4) 73.7 (30.3)
COT 72.0 (17.8) 48.5 (25.8) 31.4 (34.6) 71.3 (34.6){ 44.0 (35.2) 67.3 (32.4)
BST 56.7 (27.4) 73.8 (25.7) 12.0 (24.0) 86.7 (25.2){ 16.9 (24.3) 85.4 (21.8)
Watching TV SET 72.6 (21.6) 55.9 (29.6) 11.6 (23.4) 94.2 (13.5){ 26.2 (34.8) 86.2 (21.2)
COT 73.7 (15.4) 63.1 (18.9) 26.4 (33.0) 73.3 (34.8) 42.7 (36.7) 66.7 (33.7)
BST 66.7 (17.6) 63.5 (17.7) 10.0 (17.3) 92.0 (15.7){ 20.7 (25.3) 82.3 (23.5)
Pleasurable activity SET 52.1 (28.8) 79.4 (17.5) 12.6 (20.8) 93.2 (15.6){ 28.1 (31.4) 84.7 (17.6)
COT 61.7 (22.6) 69.2 (20.2) 28.6 (34.4) 71.3 (34.4) 36.7 (31.1) 76.0 (32.5)
BST 60.7 (23.4) 74.6 (26.6) 6.0 (11.8) 94.0 (11.2){ 23.8 (31.2) 83.1 (24.3)
Doing complicated work SET 64.7 (31.9) 63.5 (29.6) 16.3 (27.9) 90.5 (16.1){ 30.6 (33.0) 85.6 (17.5)
COT 80.7 (22.3) 46.1 (31.5) 32.1 (33.3) 76.0 (30.7){ 40.7 (26.3) 69.3 (29.1)
BST 51.3 (32.9) 80.8 (23.3) 16.0 (32.7) 82.0 (32.3) 25.4 (30.2) 78.5 (28.2)
Waiting for something SET 76.6 (24.0) 57.1 (26.6) 17.9 (28.6) 89.5 (18.4){ 31.2 (34.0) 82.8 (20.6)
COT 81.7 (11.6) 52.3 (28.6) 23.6 (28.1) 74.7 (35.0){ 39.3 (35.1) 62.0 (34.1)
BST 73.3 (28.8) 58.5 (28.2) 11.3 (22.0) 88.7 (21.7){ 25.4 (29.6) 82.3 (22.4)
Emotionally stressed SET 85.8 (17.1) 32.6 (24.7) 25.8 (39.5) 81.4 (26.0){ 49.4 (41.7) 69.7 (36.1)
COT 94.3 (10.5) 42.3 (32.9) 45.7 (36.7) 64.7 (30.4){ 57.3 (38.4) 59.3 (30.6)
BST 79.0 (28.7) 39.2 (30.7) 29.3 (40.4) 80.7 (32.8){ 51.1 (39.7) 65.0 (31.1)
* All SO±SP differences in craving significant at p 5 0.01. {SO±SP differences significant at p 5 0.05; {SO±SP differences significant at
p 5 0.01.

(BST, r(11) ˆ ÿ0.40; SET, r(13) ˆ ÿ0.57; COT,
r(11) ˆ ÿ0.86). The correlation between mean
craving over all situations and cotinine levels was
positive overall (r(35) ˆ 0.62; p 5 0.001) and for each
group (BST, r(11) ˆ 0.41; SET, r(13) ˆ 0.69; COT,
r(11) ˆ 0.78), so there was a consistent relationship
between the objective measure of smokers' status
and subjective ratings of confidence and craving.
Analysis of the stress-arousal questionnaire
revealed a group effect for high stress
(F(2,39) ˆ 3.37; p 5 0.04). The SET group reported
higher levels at SP than the other groups. There were
no significant trends in high or low arousal over
sessions. Reports of arousal were variable from week
to week, and within group variation was large.
Subjects completed, at SO and SP, a self-report
scale measuring their degree of belief (0±5) in 13
statements about their habit. The scale was adapted
from the attributional style measure of Anderson
(1983), which assesses whether events are attributed
to, internal/external, stable/unstable, charactero-
logical/behavioural, global/specific sources. The

# 1998 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 5, 145±154 (1998)
152
statements effectively measured if, and how, the
person believed their smoking and other habits
could be controlled; the extent to which they felt
able to control the habit by themselves, or whether
they considered the habit was out of their control;
and whether they believed the habit was dependent
on physical factors, on situational variation, or on
other people. All three groups rated the belief that
smoking was a physical dependence, less at SP than
at SO (SET ˆ t18 ˆ 6.11, p 5 0.01; BST ˆ t14 ˆ 3.90,
p 5 0.01; COT ˆ t14 ˆ 4.74, p 5 0.01). Both BST and
COT, but not the SET group, rated the belief, that
smoking could be actively controlled by specific
strategies, higher at SP (COT ˆ t14 ˆ 2.66, p 5 0.05;
BST ˆ t14 ˆ 2.21; p 5 0.05). The BST group increased
their belief, that strategies to stop smoking required
effort (t14 ˆ 2.09, p 5 0.05) and this group felt more
in control of their habits at SP (t14 ˆ 4.43, p 5 0.01).
The control group felt less ready at SP to invest
effort in stopping smoking (t14 ˆ 2.10, p 5 0.05).
At the end of the programme, strategies used by
each group were divided into, cognitive coping
skills, behavioural coping skills, strategies aimed at
general changes in lifestyle, and cognitive strategies
aimed at relapse prevention (e.g. not catastro-
phizing slips, restructuring stress, using self-
statements to maintain confidence). The SET group
used significantly less behavioural strategies than
the BST or COT group (t32 ˆ 2.20; p 5 0.02). But,
interestingly, there was no difference between
groups in cognitive coping skills used, suggesting
that even if cognitive strategies were not provided,
smokers invented them nonetheless. The SET group
used marginally more cognitive relapse prevention
strategies (t32 ˆ 1.54; p 5 0.08).
In order to examine the effect of preliminary
values on the process of reduction and outcome,
multiple stepwise regression was conducted on confi-
dence ratings, and on the self-reported number of
cigarettes smoked. Post-treatment (SP) and follow-
up scores (F3, F9) were considered dependent
variables in separate analyses, whilst scores on all
other weeks during the programme, and at base-
line (SO), were considered independent variables.
Number of cigarettes smoked at baseline was not a
predictor of amount smoked either at post-test, or at
follow-up. Both confidence at SO and at SP were
significant predictors of the number of cigarettes
reported smoked at follow-ups in situations invol-
ving: alcohol (b ˆ 0.32; T(SO) ˆ 2.8; p 5 0.01); relax-
ation (b ˆ 0.37; T(SO) ˆ 3.0; p 5 0.01); boredom
(b ˆ 0.33; T(SO) ˆ 2.1; p 5 0.04); when waiting for
something (b ˆ 0.32; T(SO) ˆ 2.29; p 5 0.03). Owing
to the low subjects to variable ratio, the results of
# 1998 John Wiley & Sons, Ltd.
K. O'Connor and R. Langlois
this last analysis can only be considered tentative. It
is, however, interesting that the smoking situations
where number of cigarettes smoked, was predicted
by level of confidence, all involved low levels of
activity and non-directed states.
Drop-Outs
We examined baseline values, for all measures,
in those who dropped out of the study, and found
that this group showed marginally more high stress
(t59 ˆ 1.61, p 5 0.07) and more low arousal
(t59 ˆ 2.23, p 5 0.01) than the survivors. They were
higher on neuroticism (t59 ˆ 2.49, p 5 0.01), and
scored lower on beliefs about ability to control life
habits in general (t59 ˆ 1.61, p 5 0.06) and on beliefs
about the importance of situational variation in
smoking (t59 ˆ 2.59, p 5 0.01). The drop-outs also
had significantly higher craving at outset when
stressed (t59 ˆ 2.19, p 5 0.01). There were no differ-
ences, between drop-outs and survivors, on number
of cigarettes smoked, initial confidence levels, or
expectations about quitting.
Discussion
The important finding, in both studies, is that
gradual reduction can be achieved systematically;
can be accompanied by improved confidence; and
can be achieved; by some smokers, regardless of
whether they adopt behavioural or cognitive coping
strategies, or no strategies at all.
In the first study, the use of specific coping
strategies allowed a more consistent increase in
confidence during reduction, whilst the second
study indicated a slight advantage for the self-
efficacy training group, since their increase in confi-
dence was more consistent across all 12 situations
and was less variable within situations than the
other groups. Also, higher confidence at baseline
and post-treatment predicted a lower consumption
of cigarettes at follow-up, particularly in low activity
situations, such as boredom, where other active
coping strategies might be more difficult to imple-
ment (O'Connor and Stravynski, 1982). Limitations
of the first study were the small number of subjects
and the use of self-report measures of smoking only.
A limitation of both studies was that the same
therapist was used for all groups. The advantage
here is that the same level of expertise and type of
animation was applied in all groups. But obviously,
even though the therapist was genuinely impartial,
bias cannot be excluded. However, satisfaction
ratings of all the groups were similar, and the fact
that there was no significant difference between
Clin. Psychol. Psychother. 5, 145±154 (1998)
Confidence During Smoking Reduction
groups in outcome, post-treatment, supports the
assumption that groups benefited equally from
therapist input. Also, such criticisms, though
relevant to conclusions concerning treatment out-
come, do not really bear on the major findings about
the progressive changes in confidence found during
the process of reduction. An important limitation to
our studies is that we did not measure puff volume,
and hence cannot comment on whether reduction in
number of cigarettes led to increased puff volume,
and nicotine compensation in those cigarettes
remaining. But, had this been the case, we would
not have expected to find the overall significant
decrease in craving. Also, the cotinine concentra-
tions mirrored the reported smoking status which
would tend to exclude compensation. Rosa et al.
(1992) noted that subjects smoking lower nicotine
cigarettes did not increase puff volume. The claim
for compensation is controversial, and both Epstein
et al. (1981), and Hatsukami et al. (1990) found that
the frequency with which cigarettes were smoked, in
a naturalistic situation, did not alter puff intensity.
Alternative methods for reducing cigarette smok-
ing gradually include nicotine fading, where
nicotine content of the cigarette is slowly decreased
(e.g. Brown et al., 1984), scheduled smoking at longer
and longer intervals throughout the day (Cinciripini
et al., 1994), and paced puffing where nicotine
delivery is modified by puff parameters (Pomerleau
et al., 1989). The advantage of the situational
approach to reduction is that it permits a functional
analysis of the smokers' behaviour (Axelrod, 1991).
The role of situational factors and cues in eliciting
behaviour has been recognized not only for smoking
cigarettes (Niaura et al., 1992) but also for nicotine
chewing gum (Parrott and Craig, 1995) and for
smokeless tobacco use (Hatsukami et al., 1991).
Identification of smoking cues is the first step in
tailoring cue exposure and coping skills to aid in
reduction (O'Connor and Langlois, 1993) and
relapse prevention (Bliss et al., 1989; Marlatt, 1990).
The finding that gradual reduction can, in some
subjects, result in increased overall confidence in
coping with not smoking, adds weight to the
viability of using reduction in those smokers who
may be contemplating, but are not yet committed to
quitting, since higher confidence suggests the
person may be more, not less, prepared to quit
after reducing. Previous studies have also pointed
to the role of efficacy in motivating the decision to
change, and in preventing relapse. Sperry and Nicki
(1991) found a high correlation between self-efficacy
and smoking outcome during a nicotine fading
programme, but no extra benefit for a group in
# 1998 John Wiley & Sons, Ltd.
153
whom self-efficacy was stressed as part of treat-
ment. Hawkins (1992) concluded that, generally,
self-efficacy was a predictor, but not a cause of
behaviour. There is controversy over the causal role
of self-efficacy in enabling quitting, and Sperry and
Nicki (1991) for example suggest that self-efficacy
reflects, but does not mediate smoking behaviour
change. However, Stuart et al. (1994) found that
although its impact may vary over the various
stages in the process of quitting, self-efficacy was
positively related to successful attempts to quit. On
the other hand, the results in the present two
studies are based on smokers who successfully
reduced, and we cannot comment on the confidence
and craving levels of those who attempt reduction
unsuccessfully. Those smokers who dropped out of
the study did report higher initial levels of craving,
but were not less confident, than those who
successfully reduced. The present research can, of
course, draw no conclusions about the relative
merits of graded reduction versus abrupt cessation,
since the studies here focused specifically on factors
affecting graded reduction. On the negative side, it
must be noted that although the higher self-rated
confidence levels were maintained at 9-month
follow-up, this confidence did not apparently
translate into any further successes at quitting. In
future studies, it would be informative to look at
long-term outcome in smokers who cut down.
ACKNOWLEDGEMENTS
The authors would like to acknowledge the help of
Dr Manon VeÂzina in the cotinine analysis. The
study was in part supported by grant no. RS-1421-
1653 from the Conseil QueÂbeÂcois de la Recherche
Sociale. The first author was supported by a bourse
from the Fonds de la Recherche en Sante du QueÂbec.
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