Journal of Consulting ami Clinical Psychology 1977, Vol. 4.5, No. 3, 358-360
Self-reinforcement by Recorded Telephone Messages to Maintain Nonsmoking Behavior Ron Dubren American Health Foundation, New York, New York Sixty-one recent ex-smokers who had stopped smoking as part of a televised "clinic" were assigned to cither a tape-reinforcement or nonreinforcement condition and were followed up a month later. The group that had been sent a special phone number that they could call to receive different prerecorded reward messages on a daily basis (tape reinforcement) had significantly fewer recidivists (10/29) upon follow-up than the group (nonreinforcement) that had not been sent the number (21/32). The results indicate that such a self-regulated reward system can be an extremely cost-effective tool in preventing short-term recidivism among neophyte ex-smokers. Behavioral research on the modification of smoking has shown that a wide variety of techniques (e.g., hypnosis, clinics, group therapy, aversive conditioning, self-control) can be successful in helping people stop smoking. However, regardless of the treatment method, it has also been observed that only about one in five are off cigarettes a year after the initial treatment (Schwartz, 1969). These relapse rates for smoking are strikingly similar to those observed in alcohol and heroin treatment programs (Hunt, Barnett, & Branch, 1971). Such recidivism is partly due to the fact that these treatments are aimed at initial behavioral changes with little provision made for effective maintenance and support once the client leaves the treatment structure or setting. Bernstein (1969), in his review of smoking cessation research, argued that "attention must be directed to the development of procedures designed to maintain nonsmoking on a long-term basis" (p. 436). Since the greatest relapse occurs in the first weeks following the end of treatment, Hunt and Matarazzo (1973) have suggested that the length of a treatment program for smoking be extended beyond the presumed goal of total abstinence. They also suggest
This research has been aided in part by Grant CCG-187 from the American Cancer Society. Requests for reprints should be sent to Ron Dubren, American Health Foundation, 1370 Avenue of the Americas, New York, New York 10019.
the use of booster sessions for successful abstainers as another possible solution. The trouble with such sessions is that the neophyte ex-smokers may not feel that these sessions are needed until a relapse actually occurs. Furthermore, lengthening treatment builds in a continuing need for the physical presence of the client in the treatment setting. This is often neither convenient nor inexpensive, and it is rejected by most neophyte nonsmokers as a viable solution, especially when they perceive that they have achieved their goal. When behavior modification first became prominent, many critics argued that its major shortcoming was that the kinds of changes mediated by the extremely well-controlled contingencies of the treatment setting could never be maintained in the chaos of the real world. However, recent advances in theoretical sophistication have led to new perspectives on the problem of maintaining behavior outside the treatment setting (Kanfer & Karoly, 1972; Mahoney, 1972). The emphasis is on training clients in techniques of self-control, variously referred to as selfmanagement, self-regulation, or self-reinforcement strategies. Common to these ideas is the notion that you can teach people how to bring environmental reinforcing contingencies under their own control and thereby increase the likelihood of maintaining specified behavior changes. For example, self-presented rewards have been used in weight control as
SELF-REINFORCEMENT OF NONSMOKING
an effective incentive system (Mahoney, (1974). The following study was based on the idea that a self-reinforcement program might be effective in decreasing recidivism among recent ex-smokers. A self-regulated system was designed in which a neophyte nonsmoker could choose to obtain a series of freely available rewards for continued nonsmoking. These rewards were in the form of 20 different 3-minute pretaped messages that were available by telephone. The content of these messages was aimed at providing reinforcement during the first 4 weeks following termination of smoking. It was hypothesized that neophyte nonsmokers who were given access to this self-regulated reward system would be more likely to be off cigarettes a month later than nonsmokers who were not. Method Subjects Subjects were drawn from a population of smokers who were participating in a 3-week stopsmoking TV clinic conducted by a local nightly news program (WNEW-TV, New York) with support from the American Health Foundation. During the last week of the TV clinic, smokers who had successfully been off cigarettes for at least 24 hours were asked to send a postcard to the American Health Foundation with their names, addresses, and phone numbers. Approximately 200 cards were received, from which 67 were selected based on their living in New York. Sex was determined by inference, and ambiguous cases were excluded, leaving 28 males and 36 females to be randomly assigned to the experimental and control conditions. Three of the experimental subjects (two females and one male) were not reachable at follow-up 1 month later and were excluded from the study, leaving a total of 29 subjects in the experimental group and 32 in the control group.
Apparatus A Sanyo telephone answering system (Model 139D4) was connected to a specific telephone number, which was used exclusively for the study. Twenty 180-scc loop-type casette tapes were used to record the reinforcement messages, resulting in 20 different prerecorded messages.
Procedure Following cating that at least 24 Foundation
the announcement on TV, cards indithe smoker had been off cigarettes for hours arrived at the American Health on Thursday and Friday of the last
week of the TV clinic. Those selected for inclusion in the study were randomly divided into groups on Friday afternoon and were stratified so that an equal number of males and females would be included in the experimental (tape-reinforcement) and control (no-reinforcement) conditions. Those in the tape-reinforcement group (14 males and 18 females) were sent a letter describing the self-reinforcement system and its purpose that same Friday afternoon. The letter informed them that the recorded messages would be 3 minutes in length, that messages would change daily (except on weekends) for 4 weeks, and that they would be available at any time, day or night, for 24 hours. Access to the messages would be by a self-initiated telephone call to a specific number, typed on a wallet-sized card included in the letter. In was recommended that the subjects call this number daily as an aid in staying off cigarettes in the potentially difficult first few weeks following cessation. Those subjects in the nonreinforcement group were not contacted. The reinforcement messages l were written by me, based on my experience in working with smokers and by my exposure to others who arc experienced in this area. The messages were available for 4 weeks, and the final Friday message played through the fourth weekend. On the ensuing Monday and Tuesday, follow-up calls were made to all participants who could be reached (29 of 32 in the tape-reinforcement group; 32 out of 32 in the nonreinforcement group). Information was gathered as to current smoking status (i.e., number of cigarettes smoked in the past 24 hours), and, if the subjects were currently smoking, they were asked how long they had been off cigarettes before they began smoking again. For those in the tape-reinforcement group, additional self-report data were gathered as to whether they called the special phone number, and, if they did, they were asked to estimate how many calls they made during the 4 weeks.
Results and Discussion In the telephone self-reinforcement group, 19 of 29 subjects reported that they were not smoking at the time of the follow-up, compared to 11 out of 32 of the nonreinforcement group. A chi-square analysis indicated a significant effect due to having access to the taped messages, x 2 ( l ) = 4.72, p < .05. Of those who had gone back to smoking at the time of the follow-up, comparisons were made as to how long they had been off cigarettes before returning to smoking. Those in the tape-reinforcement group (n = 10, 1 Written versions of these messages are available from the author on request.
M = 7 days) reported that they were off cigarettes for a significantly longer period than those in the nonreinforcement group (n = 21, M = 3 days), *(29) = 1.79, p < .05. Of those still smoking, no significant differences were found between the tape-reinforcement and nonreinforcement groups in the number of cigarettes smoked at the time of follow-up. Of the 29 who were in the tape-reinforcement condition, 23 reported calling the special number at least once. Of those who called, 7 reported calling the special number all 20 times. For all 29 subjects, the mean number of calls was 8.4. Excluding those who never called, the mean number of calls was 10.6. These results demonstrate that a telephone message system can significantly decrease the amount of recidivism in the first month following the termination of smoking. Not only did access to the recorded messages decrease the amount of total relapse, it also delayed the onset of relapse among those who did return to smoking. Certain flaws in the design of the study must make these results tentative. It is possible that the observed effect was due to an attention placebo effect of receiving something as opposed to receiving nothing. This might also have introduced a self-report bias in the direction of a decreased willingness to report a relapse, especially after having been offered help. However, the number of calls made daily into the telephone answering system was monitored, making it possible to compare the total number of calls actually made with the total number of calls that were reported, as an index of overall self-report accuracy. In this regard, more calls were monitored (256) than the total amount reported made (245). This can probably be explained by both inaccuracies in recall and by the fact that some individuals reported occasionally calling more than once a day and sometimes for extra reinforcement on weekends. There is evidence that the system is indeed being used by a random population of recent ex-smokers. Twenty-one (73%) of the subjects who were sent the phone number reported calling at least twice, making an average of 11.7 calls each.
The study is not able to assess if the specific content of the messages was reinforcing. In fact, it is not possible to specify what particular aspects of the structured calling-in system decreased the relapse rate. Rather than speculate, replications of this study are now being planned that will attempt to clarify these issues. It may be possible that the function of such a system is merely to delay an inevitable relapse. Future research may also show that the system could have further benefit if it were available for a longer period of time. Also, it may be possible to identify who is best suited to such a selfreinforcement system and why. Another direction of future research should be to compare the effect of written versus recorded reinforcement messages. This will also enable us to look at differences involved in self-initiated versus other-initiated reinforcement, for example, by using a mailed message. Apart from why the system reinforces nonsmoking behavior is the very concrete fact that it does. The practical implications for such self-reinforcement maintenance systems are seen both in their extreme cost effectiveness and in their potential applicability in many settings for many different kinds of behavior change problems. References Bernstein, D. A. The modification of smoking behavior: A review. Psychological Bulletin, 1969, 71, 418-440. Hunt, W. A., Barnett, L. W., & Branch, L. G. Relapse rates in addiction programs. Journal of Clinical Psychology, 1971, 27, 455-456. Hunt, W. A., & Matarazzo, J. D. Three years later: Recent developments in the experimental modification of smoking behavior. Journal of Abnormal Psychology, 1973, 81, 107-114. Kanfer, F. H., & Karoly, P. Self-control: A behavioristic excursion into the lion's den. Behavior Therapy, 1972, 3, 398-416. Mahoney, M. J. Research issues in self-management. Behavior Therapy, 1972, J, 45-63. Mahoney, M. J. Self-reward and self-monitoring techniques for weight control. Behavior Therapy, 1974, 5, 48-57. Schwartz, J. L. A critical review and evaluation of smoking control methods. Public Health Reports, 1969, 84, 483-506. Received February 13, 1976 •