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Risk perception and motivation to quit smoking: A partial test of the Health Action Process Approach

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Risk perception and motivation to quit smoking: A partial test of the Health Action Process Approach
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  Short Communication Risk perception and motivation to quit smoking: A partial test of the Health ActionProcess Approach Rebecca J. Williams a , Thaddeus A. Herzog b, ⁎ , Vani N. Simmons c a Department of Public Health Sciences, John A. Burns School of Medicine, University of Hawaii at Manoa, 1960 East-West Road, Honolulu, HI 96822, United States b Cancer Research Center of Hawaii, 677 Ala Moana Boulevard, Suite 200, Honolulu, Hawaii 96813, United States c University of South Florida and H. Lee Mof   󿬁 tt Cancer Center & Research Institute, 4115 E. Fowler Avenue, Tampa, FL 33617, United States a b s t r a c ta r t i c l e i n f o Keywords: SmokingMotivationRisk perceptionHealth Action Process Approach Introduction:  The Health Action Process Approach (HAPA) posits a distinction between pre-intentionalmotivation processes and a post-intentional volition process that leads to the actual behavior change. Forsmoking cessation, theHAPApredicts thatincreasedriskperceptions would foster adecisiontoquit smoking.From a cross-sectional perspective, the HAPA predicts that those who do not intend to quit (non-intenders)should have lower risk perceptions than those who do intend to quit (intenders). Method:  Adultsmokersparticipatedinacross-sectionalsurvey.Multiplemeasuresofmotivationtoquitsmokingand riskperceptionsfor smoking were assessed. ANOVA and contrastanalysiswere employed for data analysis. Results:  The results were generally supportive of the HAPA. Non-intenders had systematically lower riskperceptions compared to intenders. Most of these  󿬁 ndings were statistically signi 󿬁 cant. Conclusion:  The results demonstrated that risk perceptions distinguish non-intenders from intenders. Theseresults suggest that smokers low in motivation to quit could bene 󿬁 t from information and reminders about theserious health problems caused by smoking.© 2011 Elsevier Ltd. All rights reserved. 1. Introduction Two important psychological variables associated with smokingcessation are motivation to quit and health risk perceptions of smoking. Although both of these variables have been studiedextensively, few theories explicitly de 󿬁 ne their relationship. TheHealth Action Process Approach (HAPA) was used as the theoreticalmodelin thecurrentstudybecauseitspeci 󿬁 es a relationshipbetweenlevel of motivation to quit and degree of risk perceptions (Schwarzer,2008).TheHAPAproposesthatthereisadistinctionbetweenthepre-intentional motivation process (including risk perceptions) that leadsto intention to make a behavior change and the post-intentionalvolition process that leads to the actual behavior change (Schwarzer,2008). Thevolitionprocesscanbe furthersub-dividedintoa planningphase, action phase, and maintenance phase. In the example of smokingcessation, theHAPApredictsthatthosewhodo notintendtoquit (non-intenders) should have lower risk perceptions than thosewho do intend to quit (intenders). 1.1. Operationalizing motivation to quit using the HAPA Given that the HAPA does not recommend any speci 󿬁 c measure of motivation to quit, the current study employed two disparatemeasuresofmotivationtoquit:theStagesofChange(SOC;Prochaska,DiClemente, & Norcross, 1992) and the Contemplation Ladder (CL;Biener & Abrams, 1991). By employing these two measures of motivation to quit, the HAPA can be tested using different underlyingassumptions regarding the measurement of motivation to quit. 1.2. Hypotheses OurhypothesesarederivedfromtheHAPA.Wepredictthatsmokerslow in motivation to quit (i.e., non-intenders) will evince lower riskperceptions than those who are medium or high in motivation to quit(i.e., intenders). Further, we hypothesize no signi 󿬁 cant differences inriskperceptionsbetweenthosemediumandthosehighinmotivationtoquit, as these two groups both are classi 󿬁 ed as  “ intenders ”  within thecontext of the HAPA. Hypotheses can be summarized as a pattern of relatively  “ low – high – high ”  risk perceptions for low (non-intender),medium,andhighmotivationtoquitsmokers,respectively.Hypotheseswill be tested formultiple measures ofbothmotivation to quit and riskperceptions. 2. Methods  2.1. Participants and procedures Participants for this cross-sectional study were recruited usingnewspaper advertisements and  󿬂 yers distributed atcommunity events Addictive Behaviors 36 (2011) 789 – 791 ⁎  Corresponding author. Tel.: +1 808 441 7709. E-mail address:  therzog@cc.hawaii.edu (T.A. Herzog).0306-4603/$  –  see front matter © 2011 Elsevier Ltd. All rights reserved.doi:10.1016/j.addbeh.2011.03.003 Contents lists available at ScienceDirect Addictive Behaviors  in Tampa, Florida. Eligible participants (a) were 18years old or over,(b) could read English, (c) had a mailing address, (d) and were self-identi 󿬁 edassmokers.Potentialparticipantswerescreenedforeligibilityrequirements on the telephone. Participants were mailed question-naires along with a stamped and addressed return envelope. Uponreceipt of completed questionnaire, participants were mailed a $25check.  2.2. Measures 2.2.1. Stages of Change (SOC) algorithm The SOC construct partitions smokers into three categories (e.g.,DiClemente et al., 1991). Smokers in the pre-contemplation stageindicatedthattheydonotintendtoquitsmokinginthenext6 months.Contemplators are smokers who intend to quit in the next 6 monthsand (a) are not seriously intending to quit within the next 30 days or(b)havenotmadeatleastone24-hourquitattemptinthepastyear,orboth (a) and (b). Smokers in the preparation stage are seriouslyintendingtoquitwithinthenext30 daysandhadatleastone24-hourquitattemptduringthepastyear.Inthecurrentstudy,precontempla-tion stage smokers are considered low in motivation to quit and areclassi 󿬁 ed as non-intenders within the context of the HAPA. Contem-plation and preparation smokers are considered medium and high inmotivation to quit, respectively, and smokers in both of these stagesare considered intenders for purposes of the HAPA.  2.2.2. The Contemplation Ladder (CL) This instrument employs an 11-point Likert scale depicted as aladder(Biener&Abrams,1991).Forthecurrentstudy,lowmotivationtoquit(i.e.,non-intenders)wasde 󿬁 nedbyresponse0( “ Nothoughtof quitting ” )toresponse2( “ ThinkIneedtoconsiderquittingsomeday ” ).Intermediate motivation to quit was de 󿬁 ned as responses 3 to 7,centering on response 5 ( “ Think I should quit, but not quite ready ” ).High motivation to quit ranged from response 8 ( “ Starting to thinkabout how to change my smoking patterns ” ) to response 10 ( “ Takingaction to quit, such as cutting down on smoking, enrolling in aprogram ” ). This method of partitioning the CL has been used in pastresearch and has been validated for measuring the readiness of smokers to make a behavior change (Biener & Abrams, 1991; Herzog,Abrams, Emmons, & Linnan, 2000). The rationale for partitioning theCL in this manner is to create a variable that contains three levels of motivation to quit. The transformed three-level CL facilitates compar-isons with the three-level SOC.  2.2.3. Risk perception items Two categories of risk perception were assessed. The  󿬁 rst categorymeasured “ absoluterisk ” ofsmoking(i.e., “ Howlikelydoyouthinkyouaretodevelopthefollowinghealthconditionsasaresultofsmoking? ” ).The second category of risk perception was  “ relative risk ”  perception(i.e.,  “ compared to other smokers your same age and sex, how wouldyou rate your risk of getting one of the following conditions? ” ).Responses ranged from  “ Very unlikely ”  to  “ Very likely ”  on a  󿬁 ve pointscaleforbothabsoluteandrelativeriskquestions.Forbothcategoriesof risk perception, risk associated with the following smoking-relateddiseases was assessed: lung cancer, heart disease, emphysema,circulatory problems, stroke, and  “ other types of cancers. ” 3. Results  3.1. Participant characteristics A total of 273 individuals quali 󿬁 ed for the study and were sentsurveys.Ofthese,242(89%)surveyswerecompletedandreturned.Themean age of participants was 47.00years old ( SD =13.19), with morethan two thirds (68%) female. The sample was primarily Caucasian(71%), followed by African Americans (23%) and Hispanics (10%).Thirty-threepercentofparticipantshadahighschoollevelofeducationor less. Forty-seven percent of participants were employed, with theremaining participants being either unemployed (20%), retired (13%),or disabled (20%). The median income was between $20,000 and$30,000. Participants smoked ata meanrateof 19.10cigarettesperday( SD =10.90) and had smoked for a mean of 26.08years ( SD =13.18).  3.2. Data reduction Thefactor structureoftherisk perception scales wasassessed usingprincipal components analysis (PCA). Separate PCA's were conductedforabsoluteandrelativeriskquestions,respectively.EachPCArevealedaone-factorstructure,leadingustocomputecompositeriskscores.Theinitial eigen values yielded a one factor solution explaining 77% of thevariance for absolute risk variables (eigen value=4.64). A one-factorsolution was also found for the relative risk variables (eigenvalue=4.36) and accounted for 72% of the variance. Other factors hadeigen values below 1.00. The alpha level for all risk variables was set at  p =0.05. Scree plots further indicated in graphical representation onefactorsolutions.Cronbach'salphasforthesixrelativeriskcategoriesandsix absolute risk categories were 0.94 and 0.92, respectively.  3.3. Cross-tabulations of the SOC and CL A Wilcoxon Signed Ranks Test revealed that the SOC classi 󿬁 edsmokers as signi 󿬁 cantly less motivated to quit compared to the CL (  Z  =7.04,  p b .001; see Table 1). This pattern of results is consistentwith previous research (e.g., Herzog & Blagg, 2007).  3.4. Main results We employed ANOVA to test our hypotheses. Contrast analyseswithin the context of ANOVA (Rosenthal & Rosnow, 1985) wereemployed to test the speci 󿬁 c hypothesis that the means for risk per-ceptionwouldreveala “ low – high – high ” patternforlow,medium,andhighmotivationtoquit,respectively.Contrastweightsassociatedwiththe  “ low – high – high ”  predictions were − 2, 1, and 1, for low, medium,andhighmotivationtoquit,respectively.Theseweightswereusedforboth the SOC and CL.  3.4.1. Stage of Change (SOC) Two separate one-way ANOVAs were calculated for SOC: one forabsolute risk, and one for relative risk. For absolute risk, there was asigni 󿬁 cant main effect for SOC,  F  (2, 234)=4.32,  p =0.014,  eta =0.19 . In other words, risk perceptions differed by stage. Contrast analysesrevealed that the predicted  “ low – high – high ”  pattern of means alsowas supported for absolute risk,  t  (234)=2.83,  p =.005,  r  =0.18. Forrelative risk, neither the main effect of SOC nor the  “ low – high – high ” contrast were statistically signi 󿬁 cant (each  p N .05; see Table 2).  3.4.2. Contemplation Ladder (CL) Separate one-way ANOVAs (one for absolute risk and one forrelative risk) also were calculated for the CL. Main effects for the CL groupwereobtainedforbothabsoluterisk, F  (2,226)=3.17,  p =0.044,  Table 1 Cross-tabulation of Stages of Change (SOC) and Contemplation Ladder (CL).Contemplation LadderLowMTQ (%)MediumMTQ (%)HighMTQ (%)Sum (%)Stages of ChangeLow MTQ (%) 24 39 6 69 (31%)Medium MTQ (%) 5 54 47 106 (47%)High MTQ (%) 2 8 38 48 (22%)Sum (%) 31 (14%) 101 (45%) 91 (41%) 223 (100%)Note. MTQ=motivation to quit.790  R.J. Williams et al. / Addictive Behaviors 36 (2011) 789 – 791  eta =0.16, and relative risk,  F  (2, 224)=5.34,  p =0.005,  eta =0.21.Further, the predicted  “ low – high – high ”  contrast was supported forboth absolute risk,  t  (226)=2.41,  p =.017,  r  =0.16, and relative risk, t  (224)=3.24,  p =.001,  r  =0.21; please see Table 2. 4. Discussion This study assessed risk perceptions of smokers at different levelsof motivation to quit. Using two measures of risk perception and twomeasures of motivation to quit, the predictions derived from theHAPA were mostly supported. Speci 󿬁 cally, low-motivation to quit(i.e., non-intenders) demonstrated low risk perceptions relative tosmokers who were medium or high in motivation to quit (intenders).The general pattern of results were similar for the SOC and CL,however one difference did emerge. For the SOC, the low – high – highcontrast (and main effect of SOC) was con 󿬁 rmed for absolute risk, butnot for relative risk. For the CL, main effects and the contrasts weresigni 󿬁 cant for both absolute and relative risk.MeanspresentedinTable2revealthatnon-intendersasclassi 󿬁 edbythe CL had lower mean risk perceptions than non-intenders asmeasuredbytheSOC.Thispatternofresultsrevealsthatthedistinctionspostulated by the HAPA are more clearly evident when the CL isemployed, as compared to the SOC. However, the overall direction andtrends in the results were similar for the SOC and CL.The current study is subject to limitations. The sample used in theanalysis was not a random sample from the population of smokers.Instead,participantsreceivedmonetaryincentivestoparticipateinthestudy, leading to a possible selection bias. However, a fully represen-tative sample was not needed to meet the study objectives.The overall results demonstrate that risk perception does distin-guish non-intenders from intenders. However, these cross-sectionalresults do not demonstrate the causal direction of this relationship.Further, although the results reveal differences in risk perceptionacross levels of motivation to quit, risk perceptions still weresubstantial even among the non-intenders. Nonetheless, the resultsdo provide support for the notion that smokers low in motivation toquit can bene 󿬁 t from information and reminders about the serioushealth problems caused by smoking. Future research should focus onhow messages regarding health risks can be incorporated intointerventions targeted at smokers who do not intend to quit. Role of Funding Sources This study was funded by National Institute on Drug Abuse (NIDA) grant R03DA16667. NIDA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Contributors Williams was involved in all aspects of manuscript preparation, and alsocontributed to data analysis. Herzog designed the study, wrote the protocol, and wasinvolved in all aspects of manuscript preparation and data analysis. Simmons designedthe measures of health risk perception and contributed to the  󿬁 nal version of themanuscript. All authors contributed to and have approved the  󿬁 nal manuscript. Con 󿬂 ict of Interest All authors declare that they have no con 󿬂 icts of interest.  Acknowledgements The authors wish to thank Christopher Blagg for his valuable contributions to thestudy. References Biener,L.,&Abrams,D.B.(1991).TheContemplationLadder:Validationofameasureof readiness to consider smoking cessation.  Health Psychology ,  10 , 360 − 365.DiClemente,C.C.,Prochaska,J.O.,Fairhurst,S.,Velicer,W.F.,Velasquez,M.M.,&Rossi,J.S.(1991). The process of smoking cessation: An analysis of precontemplation,contemplation, and preparation stages of change.  Journal of Consulting and ClinicalPsychology ,  59 , 295 − 304.Herzog, T. A., Abrams, D. B., Emmons, K. A., & Linnan, L. (2000). Predicting increases inreadiness to quit smoking: A prospective analysis using the contemplation ladder. Psychology and Health ,  15 , 369 − 381.Herzog, T. A., & Blagg, C. O. (2007). Are most precontemplators contemplating smokingcessation? Assessing the validity of the stages of change.  Health Psychology ,  26  ,222 − 231.Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how peoplechange.Applicationstoaddictivebehaviors.  AmericanPsychologist  , 47  ,1102 − 1114.Rosenthal, R., & Rosnow, R. L. (1985).  Contrast analysis: Focused comparisons in theanalysis of variance.  New York: Cambridge University Press.Schwarzer,R.(2008).Modelinghealthbehaviorchange:Howtopredictandmodifytheadoption and maintenance of health behaviors.  Applied Psychology ,  57  , 1 − 29.  Table 2 MeanriskperceptionbylevelofmotivationfortheStagesofChangeandContemplationLadder.Level of motivationto quitAbsolute risk perceptionmean (SD)Relative risk perceptionmean (SD) Stage of Change Low MTQ 3.6 (1.00) 3.3 (0.94)Mid MTQ 3.9 (0.80) 3.5 (0.85)High MTQ 3.9 (0.91) 3.5 (0.98) Contemplation Ladder  Low MTQ 3.4 (0.95) 3.0 (0.86)Mid MTQ 3.8 (0.90) 3.4 (0.88)High MTQ 3.9 (0.87) 3.5 (0.87)Note. MTQ=motivation to quit.791 R.J. Williams et al. / Addictive Behaviors 36 (2011) 789 – 791
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