[On smoking].

Tobacco use and nicotine addiction are significant health concerns in the United States. Early research regarding the relationship between self-efficacy (SE) and the addictive behaviors suggested that the higher the level of SE to quit smoking, the more likely an individual would be to successfully quit smoking (Condiotte & Lichtenstein, 1981). More recent research has shown that high, but not extremely high SE is ideal for successful smoking cessation (Staring & Breteler, 2004). Although the present study was not able to clarify the ideal SE percentage for those attempting to quit smoking, it did reveal important information about the relationship between SE and smoking cessation success. Smoking Cessation and Self-Efficacy 5 The Relationship Between Smoking Cessation and Self-Efficacy Tobacco use and nicotine dependence are significant health concerns in the United States. The percentage of cigarette smokers in the total US population has decreased steadily since 1965, going from 42% to 21% (Centers for Disease Control [CDC], 2007). The percentage of US smokers who quit smoking for at least 1 day has increased since 1965 from 14% to 21% (CDC, 2007). While these numbers seem encouraging, they may be a bit deceptive. From 2004 to 2006, the smoking population dropped <1%, suggesting that perhaps the number of smokers has leveled off and will only be fluctuating slightly from now on (CDC, 2007). The amount of smokers who quit for at least 1 day has followed somewhat of a bell curve, hitting its highest percentage of 25% in 1990 and 1993 and dropping steadily to 21% in 2006 (CDC, 2007); also, it may be inaccurate to define quitters as those who have been quit for 1 or more days during the previous 12 months, as the majority of those people fail to maintain permanent smoking cessation (CDC, 1993). Despite the many known health risks of smoking, the percentage of the population that continues to smoke is larger than might be expected. However, of the 21% of the population who smoke, 70% claim that they want to quit (CDC, 2008). From 2005 to 2006, approximately 44% of adult smokers and 54% of high-school age smokers had made a quit attempt that lasted at least 1 day; there is no report of how many of these attempts resulted in long-term smoking cessation (CDC, 2008). Research has shown, however, that most quit attempts result in relapse (Ockene, Emmons, Mermelstein, Perkins, Bonollo, Voorhees, et al., 2000). Nicotine has been found to be more addictive than alcohol, and as addictive as heroin (Hunt, Barnett, & Branch, 1971). The amount of smokers who quit smoking and remain abstinent after 1 year ranges between 13-31% (Garvey, Bliss, Hitchcock, Heinold, & Rosner, 1992; Norregaard, Tonnesen, & Petersen, 1993; McIntyre, Lichtenstein, & Smoking Cessation and Self-Efficacy 6 Mermelstein, 1983; Tonneson, Fryd, Hansen, Helsted, Gunnersen, Forchammer, et al, 1988). Clearly, successful smoking cessation is a difficult goal to achieve. Nicotine addiction & self-efficacy Albert Bandura (1977) originally defined self-efficacy (SE) as a person’s belief that he can successfully perform a behavior in order to obtain certain results. Initial research found a positive correlation between SE and the length of time a behavior change would be pursued (Bandura & Adams, 1977; Bandura, 1980). Researchers believed that the higher the level of SE, the more successful a person would be in making and maintaining behavioral changes. When a person feels like he has little or no ability to exercise control over a certain behavior, he is less likely to try to change that behavior. If he does decide to try, he is more likely to give up when results are not immediate or setbacks occur (Bandura, 1997). Evidence for this theory was first found for anxiety behaviors such as coping and fear-extinguishing (Bandura, Adams, Hardy, & Howells, 1980; Bandura, 1980). In 1981, Condiotte and Lichtenstein were the first to apply SE theory to cigarettesmoking behavior. They hypothesized that there would be a positive correlation between SE and successful maintenance of smoking cessation (Condiotte & Lichtenstein, 1981). Results strongly supported the hypothesis, adding to the body of literature theorizing that higher SE is more beneficial for behavior execution (Condiotte & Lichtenstein, 1981). However, an extension of Condiotte and Lichtenstein’s research revealed that pretreatment SE is not a good predictor of smoking cessation success, while post-treatment SE is a good predictor of short-term change only; it does not predict well smoking cessation at 1 year (McIntyre, Lichtenstein, & Mermelstein, 1983). This study suggested that SE is not a stable construct; further research has shown that it fluctuates in response to different situations and Smoking Cessation and Self-Efficacy 7 different mental and physical states (DiClemente, 1986; Ockene, et al, 2000). Because SE can be so malleable, an SE score at a given point during cessation treatment is not necessarily indicative of long-term change. Dijkstra and de Vries (2000) studied how four types of SE (Situational SE, Skill SE, Relapse SE, and Try SE) were related to cigarette smoking behavior and smokers’ quit history, as well as how well these SE types predicted future quit behavior. They defined the different facets of SE as follows: Situational SE is a person’s confidence in his ability that he will be able to perform a new behavior in different situations; Skill SE is a person’s confidence that he will be able to use specific skills to combat temptations that threaten his behavior change; Relapse SE is a person’s confidence that he will be able to return to the new behavior after a lapse or relapse into the old behavior; and Try SE is a person’s confidence in his ability to partially or temporarily change his behavior (Dijkstra & de Vries, 2000). This study found that the only type of SE that was not significantly correlated with intention to quit smoking was Relapse SE, or perceived ability to maintain behavior change after a relapse (Dijkstra, & de Vries, 2000). Of the other three types of SE, Skill SE was the most strongly correlated with intention to quit, such that smokers who perceived themselves to have greater skills to cope with triggers and potential setbacks had stronger intentions to quit smoking than did those with low Skill SE (Dijkstra & de Vries, 2000). Skill SE and Relapse SE were the only predictors of an actual quit attempt, such that high Skill SE predicted that a quit attempt of at least 24 hours would be made, while high Relapse SE decreased the chances that a quit attempt would be made (Dijkstra, & de Vries, 2000). It is interesting to note that SE seems more linked to intention to quit than to actual quit success. This study points future research in the Smoking Cessation and Self-Efficacy 8 direction of finding the connections between intention and action, and exploring how SE can strengthen these connections. In 2006, Baldwin, Rothman, Hertel, Linde, Jeffery, and Finch, et al studied the influence of SE to quit smoking and satisfaction beliefs about quitting on initiation and maintenance of smoking cessation in smokers utilizing a cessation program. They found that both participant SE and perceived satisfaction with quitting immediately prior to quitting was positively correlated with attempt to quit; however, only satisfaction with quitting was predictive of cessation maintenance at 2 months after the program ended (Baldwin, et al, 2006). Satisfaction with quitting after 2 months of being quit was positively correlated with maintenance of smoking cessation at 9 months after the program ended; however, neither SE nor satisfaction with quitting after 9 months of cessation were predictors of cessation maintenance at 15 months after the program ended (Baldwin, et al, 2006). This research suggests that SE to quit smoking is only predictive of an attempt to quit; SE to quit does not predict successful cessation maintenance. It seems that once a person quits smoking, other factors become more influential on their decision to remain quit; they are no longer as influenced by confidence in their ability to maintain. Quit history Some of the influences that cause SE to fluctuate include personal mastery (Yzer & van den Putte, 2006); depressed mood (Scholte & Breteler, 1997); and social and peer pressures (Chang, Lee, Lai, Chiang, Lee, & Chen, 2006). In the realm of smoking cessation, personal mastery is one of the greatest determinants of SE to quit. Quit history is probably a good indicator of a smoker’s feelings of personal mastery for the task of ceasing to smoke. Carey and Carey (1993) found that smokers who successfully quit for 1 year had higher SE scores before they quit than did their relapsing counterparts. Also, successful quitters’ SE scores went up Smoking Cessation and Self-Efficacy 9 significantly after they quit, while non-successful quitters’ SE scores went down significantly. These results suggest that smokers who try to quit and fail will feel less confident in their ability to quit and may be less likely to try again. Yzer and van den Putte (2006) found that duration of past quit attempts was predictive of intention to attempt quitting again, and had a small but significant effect on SE to quit successfully in the future. Smokers whose prior quit attempts were short (7 days or less) had lower SE than smokers whose prior quit attempts were long (1 to 3 months) (Yzer & van den Putte, 2006). However, there was a stronger correlation between current SE to quit and current quit intention for smokers whose prior quit attempts were short; there was a weaker (but still significant) relationship between current SE to quit and current quit intention for smokers whose prior quit attempts were long (Yzer & van den Putte, 2006). These results indicate that smokers who have quit for very short periods of time in the past base their current smoking cessation SE more heavily on their qu