0306-4603 ‘7X 0x0I-wY9502.00,0

“CONSONANT” AND “DISSONANT” SMOKERS AND THE SELF-ATTRIBUTION OF

ADDICTION

J. RICHARD EISER, STEPHEN R. SUTTON

Institute of Psychiatry, University of London

and

MALLORY WOBER

Independent Broadcasting Authority, London

Abstract-In a study concerned with the relationship between smokers’ wish to give up smoking and their perceived ability to do so, 115 smokers completed a short postal questionnaire. This asked how much they smoked, whether they would find it difficult to give up, would like to and had ever or recently tried to do so. They were also asked if they regarded themselves as addicted, obtained “real pleasure” from cigarettes, and were frightened about the risk to their health. Discriminant analyses showed that being frightened about health risks was the most important predictor of both wanting and having recently tried to stop, but was unrelated to the claimed success of any such attempt. Those who saw themselves as more addicted saw giving up as more difficult and smoking as more pleasurable. Those who had recently failed in an attempt at reduction or cessation also saw themselves as more addicted, as did “dissonant” smokers (who said that they would like to give up if they could do so easily). It is argued that the self-attribution of addiction provides smokers both with an explanation for previous failures at cessation, and a subjectively valid justification for continuing to smoke even when the risks to health are acknowledged.

In their classic study of smoking habits and attitudes in Great Britain, McKennell & Thomas (1967) introduced a distinction between so-called “consonant” and “dis- sonant” smokers. “Consonant” smokers are described as holding relatively positive atti- tudes about smoking and not expressing a wish to stop, whereas “dissonant” smokers are described as continuing to smoke inspite of a wish to stop, as smoking more heavily, and as being more “addicted” in terms of measures relating to subjective craving for cigarettes and perceived difficulty of giving up smoking. McKennell & Thomas say of “dissonant” smokers that “they agree with a wide variety of negative statements about smoking” (p. 5) and “tend to accept the arguments against smoking even though they continue to smoke” (p. 90).

Operationally, “dissonant” smokers are defined as those who respond affirmatively to the question “would you like to give up smoking if you could do so easily?“, “con- sonant” smokers being those who respond negatively. The assumption, following Fest- inger’s (1957) theory of cognitive dissonance, is that “dissonant” smokers experience inconsistency between the cognitions that they smoke and that smoking is bad for them. However, McKennell & Thomas do not suggest that dissonance theory can explain the behaviour of these “addicted” smokers:

“The terms ‘consonant’ and ‘dissonant’ were chosen merely as convenient labels for summarizing the characteristics of the two groups of smokers, and do not signify an adherence to Festinger’s formal theory. . . According to Festinger’s theory, an individual will strive to reduce inconsistencies (dis- sonance) between his attitude and his behaviour... Our finding that so many addicted smokers live with the habit while holding negative attitudes towards it and wish to give it up, is difficult to reconcile with the theory” (p. 119).

The presence of “dissonant” smokers is seen as posing not only a theoretical, but also a practical dilemma. According to McKen’nell & Thomas (p. 5), “Dissonant smokers do not seem to be a good target for anti-smoking persuasion. To a large degree they

99

100 J. RICHARD EISER. STEPHEN R. SUTTON and MALLORY WOBER

already have the required attitudes: their problem is not whether to stop but how to stop”.

Regarding such smokers as “addicted” offers an account of their inability to stop, and of their continued counter-attitudinal behaviour. Judging from the relatively small number of smokers who succeed in giving up, there are strong reasons to regard tobacco, and more specifically, nicotine as a dependence-producing drug (Russell, 1976). At the same time, addiction in the individual. is typically measured at least partly in terms of verbal self-reports of subjective craving and perceived difficulty of abstinence, and such measurements might well reflect the influence of social psychological and cognitive factors, over and above any purely pharmacological effects. Moreover, the evidence that U.S. Army enlisted men who had used opiates in Vietnam were mostly able to give up such drugs on their return home (Robins, Davis & Goodwin, 1974) testifies to the importance of the availability of a drug, and also implies that the individual’s

perceiued need for a drug in a given situation may be a prime determinant of his ability or inability to give it up.

It would thus seem important to consider the process of self-attribution of addiction, ‘in other words: how a smoker may come to see himself as dependent on cigarettes and unable to give them up. The literature on self-attribution processes (e.g. Bern, 1967) suggests that individuals may attribute traits, attitudes and motives to themselves on the basis of their observations of their own behaviour. These attributions provide both a subjectively rational account of one’s previous behaviour and a prediction about how one is likely to behave in the future. One such self-attribution might be that one finds smoking particularly pleasurable. Another, not necessarily incompatible might be that one smokes because one is “addicted”. Thus, by labelling himself as an addict, a smoker can “explain” his past failures at giving up. and can predict that he would fail if he tried again.

The self-attribution of addiction may also provide a means of dissonance resolution for the so-called “dissonant” smoker. As has been argued elsewhere (Eiser. in press), counter-attitudinal behaviour (e.g. continued smoking in spite of acknowledgement of dangers to health) is not necessarily dissonance-arousing for individuals who see their behaviour as beyond their voluntary control (e.g. who say “I can’t help myself”), or who selectively reduce their self-esteem (e.g. who say “I haven’t the will-power”). In terms of this interpretation, “dissonant” smokers are not in a state of unresolved dis- sonance, once they label themselves as addicted. It may well be, then, that many smokers are motivated to see themselves as addicts. To say that one would like to give up smoking if one could do so easily does not oblige one to try if one is convinced that it would in fact be very difficult. The “dissonant” smoker who sees himself as an addict can therefore justify his behaviour, without needing to deny the risks of smoking. On the other hand, the “consonant” smoker, who claims to smoke from choice, can less easily afford to admit that smoking may damage his health.

A previous study (Eiser. Sutton & Wober, 1977) found that smokers who re- garded themselves as addicted to cigarettes claimed to derive more real pleasure from a cigarette, and were less likely to be currently trying to stop, than those who said they did not think they were addicted, or did not know. The present study extends this approach to consider also the relationships between the self-attribution of addiction and the McKennell & Thomas distinction between “consonant” and “dissonant” smokers and smokers’ perceptions of the personal risk of smoking as well as of the pleasure which smoking provides. In addition, it investigates the usefulness of these factors in identifying smokers who are likely to have recently tried to give up smoking, and who have succeeded in the attempt.

Subjects , METHODS

During the week beginning 10th May, 1976, 1393 programme appreciation diaries were sent by the Independent Broadcasting Authority, London to a representative

Self-attribution of addiction 101

sample of the population of the North-West of England, aged 18 yr and over, as part of their regular weekly monitoring of television audience reactions. Of these, 576 were drawn at random from the electoral register, the remainder having responded to previous

survey (including that reported by Eiser. Sutton & Wober, 1977). These diaries required subjects to record their evaluations of any programmes viewed during the week begin- ning 17th May. 1976. Attached to each diary was a separate single page questionnaire which asked a number of questions concerning smoking (under the rationale of an evaluation of the effects of broadcasting on smoking). A total of 367 diaries were returned from subjects of known sex, age and social class, of which 314 were accompanied by usable questionnaires, the response rate being fairly typical for surveys of this kind. Comparisons between smokers and non-smokers are described elsewhere (Eiser, Sutton & Wober. 1978). The present report is concerned only with the responses of those subjects (N = 115) who indicated that they had smoked cigarettes regularly during 1975. The sample was classified into three age groups (18-34 yr. N = 40; 35-54 yr. N = 50; 55 yr and over. N = 25) and into three social class groups (ABCi, i.e. professional and non manual. N = 34; C,, i.e. skilled manual. N = 46; DE, i.e. semi-skilled and unskilled manual. N = 35). There were more female (62) than male (53) smokers (con- trary to what would have been expected from the proportions in the genera1 population), but the sex ratio was almost identical to that among non-smokers responding to the questionnaire.

The questionnaire

Those subjects who indicated they had smoked cigarettes regularly during 1975 answered the following questions.

(a) On average, how many cigarettes a day did you smoke during 1975? (b) How difficult would it be for you to give up cigarettes if you wanted to?

(1 = Not at all difficult; 2 = Fairly difficult; 3 = Very difficult).

(c) Would you like to stop smoking cigarettes altogether if you could do so easily‘? (1 = No; 2 = Yes).

(d) Have you ever tried to give up smoking altogether? (1 = No; 2 = Yes). (e) Do you think that you are addicted to cigarettes? (1 = No; 2 = Don’t know;

3 = Yes).

(f) Do you get real pleasure from a cigarette? (1 = Hardly ever; 2 = Sometimes; 3 = Almost always).

(g) Are you frightened that your cigarette smoking might seriously damage your own health? (1 = No; 2 = Don’t know; 3 = Yes).

(h) This year, have you tried seriously to stop or reduce your cigarette smoking? (1 = No: 2 = Yes, I have tried to cut down; 3 = Yes, I have tried to stop altogether).

(i) If you have tried, how have you got on so far? (1 = I have been unable to stop/cut down; 2 = I have succeeded so far),

RESULTS

The data were analysed to determine how well subjects’ responses to the questionnaire, and information relating to their sex, age and social class enabled one to distinguish those smokers who:

(i) Were “consonant” as opposed to “dissonant” according to the McKennell & Thomas (1967) definition;

(ii) Described themselves as addicted to cigarettes, as opposed to those who did not;

(iii) Claimed to have tried giving up or reducing their smoking this year, as opposed to those who did not; and

(iv) Claimed to have succeeded in giving up or reducing their smoking, as opposed to those who claimed to have tried but failed.

102 J. RICHARD EISER. STEPHEN R. SUTTON and MALLORY W~BER

In each case, a step-wise discriminant analysis was performed, selecting at each step the variable which maximized Rao’s V-a generalized measure of the distance between the two groups being compared, which may be thought of as a multi-variate F-ratio (Nie er al., 1975). The purpose of discriminant analysis is to find the set of predictors which. in combination with each other, discriminate best between the criterion groups, and to assess the relative contributions of such predictors to the discrimination. In addition, univariate F-tests were performed to test the significance of the mean difference on each item between the groups being compared, and the resulting F-ratios are shown in the final columns of Tables 1-4. Sex was coded numerically as 1 = female, 2 = male, age as 1 = 18-34 yr, 2 = 35-54 yr, 3 = 55 yr and over. and social class as 1 = ABCr. (professional, non-manual), 2 = C2 (skilled manual), 3 = DE (semi-skilled, unskilled manual).

“Consonant” us “Dissonant” smokers

Following the McKennell & Thomas (1967) definition, those subjects who responded “No” to item c (N = 35) were classified as “consonant” and those who responded “Yes” to item c (N = 80) were classified as “dissonant”. Table 1 summarizes the results of a discriminant analysis to discriminate “consonant” from “dissonant” smokers. The first five variables entered into the analysis all resulted in a significant improvement in discri- mination. Considering these in turn, “dissonant” smokers (those who said they would like to give up smoking if they could do so easily) were more likely to say that they were frightened-that their cigarette smoking might seriously damage their own health, that they had tried to give up smoking altogether at some time. that they were addicted to cigarettes. but that they obtained somewhat less pleasure from a cigarette although. on average, they smoked about 33% more cigarettes per day than “consonant” smokers. Significant differences between the means for the two groups were also obtained on items h and b, although these two variables did not significantly contribute to an im- provement in discrimination, on account of their high correlations with items d and e respectively, which were entered at steps 2 and 3. The analysis enabled 95 subjects (82.6% of the sample) to be correctly classified as “consonant” or “dissonant”.

“Addicted” us “Not addicted” smokers

Of the 115 smokers, 61 said that they thought they were addicted to cigarettes. A discriminant analysis was therefore performed to distinguish these from the 54 who responded “No” or “Don’t Know” to item e, and this is summarized in Table 2. The most important predictor was that of the perceived difficulty of giving up. In addition, those who saw themselves as addicted claimed to derive more pleasure from cigarettes,

Table 1. Stepwise discriminant analysis to predict which smokers were “consonant” and which “dissonant”

, Standardized

Significance discriminant Means of change in function Consonant Dissonant F

Step Variable entered Rao’s V Rao’s V coefficient N = 35 N = 80 (df. = 1. 113)

1. Frightened (g) 25.99 <O.OOl - 0.422 1.54 2.41 25.99*+ 2. Tried to give ever up (d) 39.58 <O.OOl -0.355 1.43 1.80 17.76** 3. Addicted (e) 49;97 0.00 I - 0.422 0.74 2.38 12.57** 4. Pleasure (f ) 56.67 0.010 -0.391 2.54 2.30 5.50* 5. Cigarettes day (a) per 61.58 0.027 -0.273 15.60 20.70 6.17: 6. Tried to give up this

year Or) 64.41 0.093 - 0.267 1.34 1.90 14.96** 7. Social class 66.03 0.204 -0.165 1.80 2.10 3.71 8. Difficulty (b) 66.87 0.358 -0.156 1.91 2.39 11.47** 9. Age 67.52 0.421 0.101 1.97 1.83 0.94

10. Sex 67.56 0.842 -0.025 1.49 1.45 0.12

Note: A positive standardized discriminant function coefficient implies that a higher score on the relevant variable is predictive of being “consonant”.

*P < 0.05. **p < 0.001.

Self-attribution of addiction 103

Table 2. Stepwise discriminant analysis to predict which smokers regarded themselves as addicted and which did not

Standardized Means Significance discriminant Not of change in function Addicted addicted F

Step Variable entered Rao’s V Rao’s V coefficient N = 61 N = 54 (d.f. = 1.113)

I. Difficulty (b) 76.38 <O.oOl 1.135 2.67 1.76 76.38**

2. .Pleasure (I) 84.58 0.004 0.453 2.52 2.20 11.91**

3. Sex 93.63 0.003 0.322 1.48 1.44 0.11

4. Like to stop (c) 102.74 0.003 - 0.293 1.82 .1.56 10.10’ 5. Tried to give up

ever (d) 105.44 0.101 -0.162 1.75 1.61 2.74

6. Age 107.97 0.111 0.164 1.90 1.83 0.24

7. Frightened (g) 108.80 0.362 -0.138 2.26 2.02 I .99 8. Tried to give up

this (h) year 109.75 0.329 0.120 1.80 1.65 1.22

9. Social Class 110.45 0.403 0.082 2.03 1.98 0.12

Variable not entered:

Cigarettes per day (a) 21.66 16.31 8.08*

Note: A positive standardized discriminant function coefficient implies that a higher score on the relevant variable is predictive of regarding oneself as “addicted”.

*P < 0.01. **p < 0.001.

also expressed to stop if they could do so easily. to more “dissonant” still enjoy their who did not see themselves as per day, although this variable did not contribute significantly to improvement in

of the sample) by this analy- sis. Fifty of “addicted’ smokers as compared 30 the 54 were (x 2 = 8.23,

“Triers us “Non-triers”

Next, a discriminant analysis was performed to distinguish the 63 subjects who claimed to have tried to give up or cut down on their smoking “this year” from the 52 who had not tried (item h). This is summarized in Table 3. Responses to item d (which seemed to be partly implicit in responses to item h) were not included in this analysis. The most important predictor of whether or not subjects claimed to have tried to give up or cut down was the extent to which they said they were frightened

Table 3. Stepwise discriminant analysis to predict which smokers have tried to stop/cut down this year and which have not (“Tried to give up ever” (d) not included in the analysis)

Standardized Means Significance discriminant Non- of,change in function Triers triers

Step Variable entered Rao’s V Rao’s V coefficient N = 63 N = 52 (d.f. =Fl,113)

I. Frightened (g) 28.25 <O.Ool 0.802 2.52 I .69 28.25** 2. Like to stop (c) 33.66 0.020 -0.392 1.84 1.52 15.60**

3. Social class 35.27 0.204 -0.21 I 2.00 2.02 0.02

4. Addicted (e) 36.35 0.300 0.293 2.35 1.98 4.68* 5. Cigarettes day per (a) 37.99 0.201 -0.183 19.41 18.83 0.09

6. Pleasure ) 38.87 0.347 -0.188 2.30 2.46 2.73 7. Sex 39.43 0.454 -0.125 1.43 1.50 0.58

8. Age 39.57 0.713 0.059 1.87 1.87 0.00

Variable not entered:

Difficulty (b) - 2.37 2.10 4.08*

Note: A positive standardized discriminant function coefficient implies that a higher score on the relevant variable is predictive of trying to stop/cut down.

*P < 0.05, **p -2 0.001.

104 J. RICHARD EISER. STEPHEN R. SUTTON and MALLORY WOEIER

Table 4. Stepwise discriminant analysis to predict which smokers have succeeded in stopping/cutting down this year

Standardized Significance discriminant Means of change in function Successes Failures

Step Variable entered Rao’s V Rao’s V coefficient N = 21 N = 42 (df. =’ 1.61)

I. Difficulty (b) 14.08 <O.OOl -0.797 I .95 2.57 14.0x** 2. Cigarettes day per (a) 16.72 0.105 0.23x 20.24 19.00 0.31 3. Addicted (e) 18.29 0.209 - 0.484 I .90 2.57 9.47* 4. Social class 19.66 0.243 0.327 2.19 I .90 2.60 5. Pleasure (f I 21.53 0.171 0.394 2.24 2.33 0.51 6. Like to stop (c) 22.01 0.487 -0.214 I .R6 1.83 0.06 7. Tried to give up

ever (d) 22.67 0.417 0. I72 1.76 1.88 1.47 8. Sex 22.85 0.673 O.OY2 1.52 I .38 I.15

Variables not entered:

Age Frightened (g)

_~~ 1.86 I.88 0.0 I 2.52 2.52 0.00

Note: A positive standardized discriminant function coefficient implies that a higher score on the relevant variable is predictive of success.

*P < 0.01, **P < 0.001.

about the risks to their health. Also “triers” were (understandably) more keen to stop, and regarded themselves as more addicted. There was also a significant difference on item b, which did not enter into the analysis, with “triers” seeing giving up as more difficult. The analysis enabled correct classification of 88 subjects (76.5p; of the sample).

Of the 63 “triers”, 21 claimed to have succeeded so far and 42 said that they had failed. Table 4 summarizes the results of a discriminant analysis to distinguish these “successes” from “failures”. “Successes” saw giving up as easier (item b), and also saw themselves as less addicted (item e), although the latter item did not make a significant additional contribution to discrimination. No other items showed any differences between successes and failures, and it is especially interesting that the most important predictor of trying to stop, that is, how frightened they were about the risks to their health (item g), yielded identical means for the two groups. Forty-six subjects (73.0:; of the sample) were correctly classified by this analysis. Finally, Table 5 presents the intercorrelations between the different questionnaire items.

DISCUSSION

The analysis on the differences between “consonant” and “dissonant” smokers suggests that acknowledgement of personal risks to one’s health may be an important factor in leading smokers to express a wish to stop smoking. This might lead one to question

Table 5. Correlations between questionnaire items

(a) Cigarettes per day

(b) Difficulty

CC) Like to stop

(d) Tried to give up ever

W Addicted

(f) Pleasure

(g) Frightened

0-d Tried to give up this

(9 year

Success

,.kl 0.34*** 0.23;

- 0.02 0.28*** 0.14 0.18

0.05 0.07

b C d e f g

1.00 0.30*** 0.15 0.67*** 0.25+* - 0.26**

1.00 0.37*** 1.00 0.32*** 0.13 1.00

.0.22* - 0.24* 0.29*** 1.00 0.43*** 0.25** O.l8* - 0.22* I.00

0.07 - 0.43***

0.34*** 0.41*** 0.13 -0.17 0.40***. 0.03 -0.15 -0.37** - 0.09 0.00

Note: N = 115 for all correlations except those with item i. where N = 63. ‘P < 0.05, **P < 0.01, ***p < 0.001.

Self-attribution of addiction 105

why health education campaigns which have continually stressed the risk of lung cancer and other diseases seem to have had so little effect on behaviour. The apparent failure of such campaigns, taken as a whole, might imply that better success could have been achieved by emphasizing other presumably negative consequences of smoking (e.g. cost. bad breath). This would be in accordance with the McKennell & Thomas (1967) recom- mendation that extreme or “discrepant” themes should be avoided by health educators (cf. Eiser, in press). Our data, however, do not preclude the possibility that an argument based on the serious health risks, if suitably presented. may still be a powerful source of attitude change, since those smokers who expressed no wish to give up also tended to express no fear for their own health.

Being frightened about the risks to one’s health was also the most important predictor of trying to stop or cut down, but had no effect at all on the success or failure of any such attempt. This is reminiscent of an analysis of survey data following a television documentary. which appeared to be especially successful in personalizing the risk of cancer from smoking. This showed that smokers who viewed the programme were more likely to try to stop than were non-viewers, but no more likely to succeed, if they tried (Eiser. Sutton & Wober, in press). If successful cessation is not a widespread consequence of health education, this need not, in our view. be blamed on the use of the health argument itself (though possibly on its manner of presentation), but rather on smokers’ own perceived incapacity for following through any cessation attempt to a satisfactory conclusion.

Another important variable was the extent to which smokers claimed to derive “real pleasure” from cigarettes. This was directly associated both with not wanting to give up, and with perceiving oneself as addicted and unable to give up easily. This alerts one to the likely importance of positive experience, rather than mere avoidance of nega- tive withdrawal symptoms, in the self-attribution of addiction. It may thus be miscon- ceived to regard all smokers who say that they cannot give up as particularly distressed by this. or as prospective “patients” for anti-smoking “treatment”.

The finding that those subjects who claimed to have recently attempted to give up or cut down also saw themselves as more addicted might seem to contradict our sugges- tion that the self-attribution may inhibit behaviour change. However, the comparison of those who succeeded and failed in this attempt shows that it was the “failures” (who outnumbered the “successes” by 2: 1) who were most likely to see themselves as addicted and giving up as difficult. For many smokers, therefore, the self-attribution of addiction may be a subjectively rational inference from failed attempts at cessation or reduction.

It might nonetheless be argued that the cognitive factors which we have investigated in this study, though useful for predictive purposes, are irrelevant to any causal analysis of addictive behaviour. Pharmacological factors might lead to a physiological state of dependence which in turn leads to “actual” inability to give up, after which smokers correctly perceive themselves as addicted. In regarding this analysis as incomplete we are not denying the importance of the pharmacological components of tobacco in the context of such issues as the self-regulation of nicotine intake, the development of toler- ance to its effects, the avoidance of withdrawal symptoms and, last but not least, the pleasure which smoking can give.

This argument, however, neglects a fundamental aspect of the relationship between attributions and behaviour. Expectancies for future success and failure at a specific task may both reflect previous experience and shape future achievement, particularly through their influence on the amount of effort an individual will be prepared to exert in subsequent attempts. Both within a clinical and an experimental context, there is convincing evidence of the influence of learned expectations on people’s (and animals’) capacity for achievement-related or adaptive behaviour (Seligman, 1975: Weiner, 1974). In our own study, it is also worth noting that the number of cigarettes which subjects smoke per day, (admittedly an extremely crude index of actual dependence) though very significantly correlated with perceived difficulty of giving up and self-attributed

106 J. RICHARD EISER, STEPHEN R. SUTTON and MALLORY WOBER

showed near-zero correlations with whether subjects

merely epiphenomenal,

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hence, in our view, this is not a theme that be incorporated health education

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