Citation
Effect of prevention education on smoking relapse for navy recruits

Material Information

Title:
Effect of prevention education on smoking relapse for navy recruits
Creator:
Pokorski, Thomas Lee, 1953-
Publication Date:
Language:
English
Physical Description:
ix, 163 leaves : ill. ; 29 cm.

Subjects

Subjects / Keywords:
Cigarette smoking ( jstor )
Cigarettes ( jstor )
Education ( jstor )
Employee resignation ( jstor )
Graduations ( jstor )
Military training ( jstor )
Navies ( jstor )
Relapse ( jstor )
Tobacco smoking ( jstor )
Tobacco use ( jstor )
Naval art and science -- Tobacco use ( lcsh )
Navies -- Tobacco use ( lcsh )
Sea-power -- Tobacco use ( lcsh )
Smoking cessation ( lcsh )
Tobacco habit -- Prevention ( lcsh )
Tobacco habit -- Treatment ( lcsh )
City of Gainesville ( local )
Genre:
bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1992.
Bibliography:
Includes bibliographical references (leaves 151-161).
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Thomas Lee Pokorski.

Record Information

Source Institution:
University of Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
27804077 ( OCLC )
ocm27804077
0028732204 ( ALEPH )

Downloads

This item has the following downloads:

AA00012890_00001.pdf

effectofpreventi00poko_0100.txt

AA00012890_00001_0050.txt

AA00012890_00001_0015.txt

effectofpreventi00poko_0173.txt

AA00012890_00001_0129.txt

effectofpreventi00poko_0006.txt

effectofpreventi00poko_0174.txt

effectofpreventi00poko_0151.txt

effectofpreventi00poko_0125.txt

effectofpreventi00poko_0103.txt

effectofpreventi00poko_0057.txt

AA00012890_00001_0016.txt

AA00012890_00001_0139.txt

AA00012890_00001_0123.txt

AA00012890_00001_0137.txt

AA00012890_00001_0152.txt

effectofpreventi00poko_0099.txt

effectofpreventi00poko_0073.txt

effectofpreventi00poko_0129.txt

AA00012890_00001_0165.txt

AA00012890_00001_0158.txt

AA00012890_00001_0167.txt

effectofpreventi00poko_0124.txt

AA00012890_00001_0145.txt

AA00012890_00001_0002.txt

effectofpreventi00poko_0160.txt

AA00012890_00001_0028.txt

effectofpreventi00poko_0002.txt

effectofpreventi00poko_0060.txt

effectofpreventi00poko_0010.txt

effectofpreventi00poko_0104.txt

effectofpreventi00poko_0112.txt

AA00012890_00001_0052.txt

effectofpreventi00poko_0120.txt

AA00012890_00001_0164.txt

effectofpreventi00poko_0012.txt

AA00012890_00001_0146.txt

effectofpreventi00poko_0064.txt

effectofpreventi00poko_0048.txt

effectofpreventi00poko_0082.txt

effectofpreventi00poko_0172.txt

effectofpreventi00poko_0007.txt

effectofpreventi00poko_0159.txt

AA00012890_00001_0072.txt

AA00012890_00001_0087.txt

effectofpreventi00poko_0089.txt

effectofpreventi00poko_0087.txt

AA00012890_00001_0062.txt

effectofpreventi00poko_0004.txt

effectofpreventi00poko_0018.txt

AA00012890_00001_0135.txt

AA00012890_00001_0066.txt

AA00012890_00001_0069.txt

AA00012890_00001_0130.txt

effectofpreventi00poko_0029.txt

effectofpreventi00poko_0061.txt

AA00012890_00001_0045.txt

effectofpreventi00poko_0135.txt

effectofpreventi00poko_0161.txt

effectofpreventi00poko_0015.txt

AA00012890_00001_0104.txt

AA00012890_00001_0037.txt

AA00012890_00001_0117.txt

effectofpreventi00poko_0008.txt

AA00012890_00001_0032.txt

effectofpreventi00poko_0141.txt

AA00012890_00001_0011.txt

effectofpreventi00poko_0005.txt

AA00012890_00001_0074.txt

AA00012890_00001_0073.txt

AA00012890_00001_0131.txt

AA00012890_00001_0156.txt

AA00012890_00001_0048.txt

AA00012890_00001_0001.txt

AA00012890_00001_0020.txt

AA00012890_00001_0059.txt

AA00012890_00001_0083.txt

effectofpreventi00poko_0019.txt

effectofpreventi00poko_0165.txt

AA00012890_00001_0024.txt

AA00012890_00001_0111.txt

AA00012890_00001_0085.txt

effectofpreventi00poko_0133.txt

effectofpreventi00poko_0138.txt

effectofpreventi00poko_0098.txt

effectofpreventi00poko_0065.txt

AA00012890_00001_0107.txt

effectofpreventi00poko_0071.txt

effectofpreventi00poko_0132.txt

effectofpreventi00poko_0153.txt

AA00012890_00001_0151.txt

AA00012890_00001_0098.txt

AA00012890_00001_0003.txt

AA00012890_00001_0119.txt

AA00012890_00001_0132.txt

AA00012890_00001_0055.txt

AA00012890_00001_0154.txt

AA00012890_00001_0090.txt

effectofpreventi00poko_0027.txt

AA00012890_00001_0057.txt

effectofpreventi00poko_0045.txt

AA00012890_00001_pdf.txt

AA00012890_00001_0174.txt

AA00012890_00001_0077.txt

effectofpreventi00poko_0097.txt

effectofpreventi00poko_0054.txt

effectofpreventi00poko_0152.txt

effectofpreventi00poko_0150.txt

effectofpreventi00poko_0102.txt

effectofpreventi00poko_0137.txt

effectofpreventi00poko_0078.txt

AA00012890_00001_0096.txt

effectofpreventi00poko_0093.txt

AA00012890_00001_0106.txt

AA00012890_00001_0175.txt

effectofpreventi00poko_0053.txt

AA00012890_00001_0147.txt

effectofpreventi00poko_0077.txt

AA00012890_00001_0004.txt

effectofpreventi00poko_0108.txt

AA00012890_00001_0160.txt

effectofpreventi00poko_0047.txt

AA00012890_00001_0005.txt

effectofpreventi00poko_0003.txt

AA00012890_00001_0172.txt

AA00012890_00001_0046.txt

AA00012890_00001_0071.txt

effectofpreventi00poko_0041.txt

effectofpreventi00poko_0114.txt

effectofpreventi00poko_0016.txt

AA00012890_00001_0022.txt

effectofpreventi00poko_0121.txt

AA00012890_00001_0030.txt

AA00012890_00001_0120.txt

AA00012890_00001_0036.txt

AA00012890_00001_0070.txt

AA00012890_00001_0126.txt

effectofpreventi00poko_0081.txt

AA00012890_00001_0153.txt

AA00012890_00001_0019.txt

effectofpreventi00poko_0039.txt

effectofpreventi00poko_0050.txt

AA00012890_00001_0099.txt

effectofpreventi00poko_0171.txt

AA00012890_00001_0078.txt

AA00012890_00001_0159.txt

effectofpreventi00poko_0063.txt

AA00012890_00001_0029.txt

effectofpreventi00poko_0090.txt

effectofpreventi00poko_0088.txt

effectofpreventi00poko_0142.txt

AA00012890_00001_0013.txt

effectofpreventi00poko_0049.txt

AA00012890_00001_0163.txt

AA00012890_00001_0103.txt

AA00012890_00001_0006.txt

AA00012890_00001_0064.txt

AA00012890_00001_0040.txt

AA00012890_00001_0031.txt

AA00012890_00001_0088.txt

effectofpreventi00poko_0149.txt

effectofpreventi00poko_0091.txt

effectofpreventi00poko_0055.txt

AA00012890_00001_0166.txt

effectofpreventi00poko_0096.txt

AA00012890_00001_0010.txt

effectofpreventi00poko_0068.txt

AA00012890_00001_0054.txt

effectofpreventi00poko_0030.txt

effectofpreventi00poko_0128.txt

effectofpreventi00poko_0052.txt

AA00012890_00001_0018.txt

AA00012890_00001_0102.txt

AA00012890_00001_0027.txt

AA00012890_00001_0049.txt

AA00012890_00001_0038.txt

effectofpreventi00poko_0163.txt

AA00012890_00001_0056.txt

AA00012890_00001_0042.txt

effectofpreventi00poko_0017.txt

effectofpreventi00poko_0164.txt

effectofpreventi00poko_0130.txt

effectofpreventi00poko_0167.txt

effectofpreventi00poko_0119.txt

effectofpreventi00poko_0155.txt

effectofpreventi00poko_0127.txt

AA00012890_00001_0109.txt

effectofpreventi00poko_0170.txt

effectofpreventi00poko_0085.txt

effectofpreventi00poko_0056.txt

effectofpreventi00poko_0031.txt

effectofpreventi00poko_0154.txt

effectofpreventi00poko_0113.txt

effectofpreventi00poko_0062.txt

AA00012890_00001_0063.txt

effectofpreventi00poko_0111.txt

AA00012890_00001_0086.txt

effectofpreventi00poko_0140.txt

AA00012890_00001_0136.txt

effectofpreventi00poko_0123.txt

AA00012890_00001_0173.txt

effectofpreventi00poko_0042.txt

effectofpreventi00poko_0109.txt

effectofpreventi00poko_0126.txt

effectofpreventi00poko_0110.txt

effectofpreventi00poko_0092.txt

effectofpreventi00poko_0001.txt

effectofpreventi00poko_0156.txt

AA00012890_00001_0023.txt

AA00012890_00001_0007.txt

effectofpreventi00poko_0168.txt

effectofpreventi00poko_0107.txt

AA00012890_00001_0047.txt

effectofpreventi00poko_0023.txt

effectofpreventi00poko_0009.txt

effectofpreventi00poko_0079.txt

AA00012890_00001_0143.txt

effectofpreventi00poko_0058.txt

AA00012890_00001_0026.txt

AA00012890_00001_0075.txt

effectofpreventi00poko_0143.txt

AA00012890_00001_0150.txt

effectofpreventi00poko_0116.txt

effectofpreventi00poko_0035.txt

effectofpreventi00poko_0105.txt

AA00012890_00001_0115.txt

effectofpreventi00poko_0020.txt

effectofpreventi00poko_0037.txt

effectofpreventi00poko_0101.txt

effectofpreventi00poko_0106.txt

effectofpreventi00poko_0136.txt

AA00012890_00001_0035.txt

effectofpreventi00poko_0013.txt

effectofpreventi00poko_0000.txt

effectofpreventi00poko_0067.txt

AA00012890_00001_0148.txt

AA00012890_00001_0041.txt

effectofpreventi00poko_0038.txt

effectofpreventi00poko_0051.txt

AA00012890_00001_0108.txt

effectofpreventi00poko_0094.txt

AA00012890_00001_0122.txt

AA00012890_00001_0157.txt

AA00012890_00001_0168.txt

AA00012890_00001_0124.txt

AA00012890_00001_0033.txt

AA00012890_00001_0133.txt

AA00012890_00001_0014.txt

AA00012890_00001_0091.txt

effectofpreventi00poko_0083.txt

effectofpreventi00poko_0095.txt

AA00012890_00001_0116.txt

AA00012890_00001_0170.txt

AA00012890_00001_0051.txt

AA00012890_00001_0076.txt

effectofpreventi00poko_0040.txt

AA00012890_00001_0065.txt

AA00012890_00001_0084.txt

effectofpreventi00poko_0022.txt

effectofpreventi00poko_0046.txt

AA00012890_00001_0034.txt

AA00012890_00001_0095.txt

AA00012890_00001_0142.txt

AA00012890_00001_0043.txt

AA00012890_00001_0162.txt

AA00012890_00001_0061.txt

AA00012890_00001_0092.txt

AA00012890_00001_0118.txt

effectofpreventi00poko_0024.txt

effectofpreventi00poko_0084.txt

AA00012890_00001_0114.txt

effectofpreventi00poko_0032.txt

effectofpreventi00poko_0014.txt

effectofpreventi00poko_0117.txt

effectofpreventi00poko_0076.txt

AA00012890_00001_0058.txt

AA00012890_00001_0009.txt

effectofpreventi00poko_0075.txt

effectofpreventi00poko_0011.txt

effectofpreventi00poko_0166.txt

effectofpreventi00poko_0044.txt

effectofpreventi00poko_0144.txt

AA00012890_00001_0039.txt

AA00012890_00001_0105.txt

effectofpreventi00poko_0070.txt

effectofpreventi00poko_0139.txt

AA00012890_00001_0144.txt

AA00012890_00001_0169.txt

AA00012890_00001_0171.txt

effectofpreventi00poko_0115.txt

AA00012890_00001_0008.txt

AA00012890_00001_0161.txt

AA00012890_00001_0021.txt

AA00012890_00001_0081.txt

AA00012890_00001_0093.txt

effectofpreventi00poko_0158.txt

AA00012890_00001_0149.txt

AA00012890_00001_0110.txt

AA00012890_00001_0155.txt

AA00012890_00001_0128.txt

AA00012890_00001_0141.txt

effectofpreventi00poko_0146.txt

AA00012890_00001_0097.txt

effectofpreventi00poko_0086.txt

AA00012890_00001_0044.txt

effectofpreventi00poko_0157.txt

AA00012890_00001_0080.txt

effectofpreventi00poko_0131.txt

effectofpreventi00poko_0072.txt

AA00012890_00001_0068.txt

effectofpreventi00poko_0122.txt

effectofpreventi00poko_0025.txt

AA00012890_00001_0012.txt

AA00012890_00001_0094.txt

effectofpreventi00poko_0145.txt

effectofpreventi00poko_0021.txt

effectofpreventi00poko_0059.txt

AA00012890_00001_0113.txt

AA00012890_00001_0079.txt

AA00012890_00001_0060.txt

AA00012890_00001_0125.txt

AA00012890_00001_0082.txt

effectofpreventi00poko_0033.txt

effectofpreventi00poko_0169.txt

AA00012890_00001_0134.txt

effectofpreventi00poko_0074.txt

AA00012890_00001_0100.txt

AA00012890_00001_0025.txt

effectofpreventi00poko_0148.txt

effectofpreventi00poko_0036.txt

AA00012890_00001_0053.txt

AA00012890_00001_0112.txt

effectofpreventi00poko_0066.txt

effectofpreventi00poko_0134.txt

effectofpreventi00poko_0080.txt

effectofpreventi00poko_0162.txt

AA00012890_00001_0127.txt

effectofpreventi00poko_0118.txt

AA00012890_00001_0121.txt

effectofpreventi00poko_0028.txt

effectofpreventi00poko_0147.txt

effectofpreventi00poko_0026.txt

AA00012890_00001_0089.txt

effectofpreventi00poko_0069.txt

AA00012890_00001_0017.txt

AA00012890_00001_0067.txt

AA00012890_00001_0138.txt

AA00012890_00001_0140.txt

AA00012890_00001_0101.txt

effectofpreventi00poko_0043.txt

effectofpreventi00poko_0034.txt


Full Text












EFFECT OF PREVENTION EDUCATION ON SMOKING RELAPSE FOR NAVY
RECRUITS















BY


THOMAS LEE POKORSKI


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY



UNIVERSITY OF FLORIDA


1992














ACKNOWLEDGEMENTS


I wish to express my sincere gratitude to Dr. W. William

Chen, chairman of my dissertation committee. His guidance

during the past three years, especially during the

dissertation process, has been invaluable. I would also like

to extend my appreciation to Dr. R. Morgan Pigg, Dr. Claudia

Probart, Dr. Steve Dorman, and Dr. Marc Branch for serving as

members of my doctoral committee. Without the guidance and

assistance of my committee I would never have been able to

complete this work, nor retain my sanity. I also appreciate

the statistical assistance provided by Dr. David Miller, and

the help of Dr. Roger Bertholf in cotinine analysis.

I wish to thank my parents, Pat and Joe Pokorski, for

lifelong support of all my endeavors. I'd like to

acknowledge the patience my children, Mike and Nicole, have

shown over the past few years while having to deal with a

"part-time" dad. I would especially like to thank my wife

Liz for her understanding, patience, editorial assistance,

and completion of over 600 scantron forms.

I'd like to recognize the assistance provided by the

Navy's Office of Health and Physical Readiness. Without the

financial assistance provided by this office the study could

not have been as comprehensive. I'd like also to thank the










American Cancer Society, especially Roberta Moss and Marsha

Nenno, for providing the shirts, pamphlets, and posters used

in the study.

I would like to thank Captain Kathleen M. Bruyere, U.S.

Navy, and her fine staff at Recruit Training Center, Orlando,

Florida. The assistance I received while conducting this

study was tremendous. I am especially grateful for all the

efforts of PHCM Breece, without which this study could not

have been done.

Finally, I would like to thank all the fine Navy

recruits who participated in this project and made the study

the success it was.















TABLE OF CONTENTS
page

ACKNOWLEDGEMENTS ........................................... ii

LIST OF TABLES ............................................vi

ABSTRACT ................................................... vii

INTRODUCTION ..................... ........... .. ...... ....... 1

Statement of the Research Problem .............................6
Purpose of the Study.................................... 7
Hypotheses ................ .................. ............. 8
Significance of the Study................................ 8
Delimitations ... ....................................... 11
Limitations..............................................12
Assumptions ......... .................................. 13
Definition of Terms .................................. ..... 13

REVIEW OF LITERATURE ....................................... 16


Problems Related to Tobacco Use........................17
Tobacco Use in the U.S ...................... ........ 18
Military Tobacco Use and Related Problems...............19
Navy Tobacco Use ......................... ....... .24
Smoking Relapse ............................... .....26
Smoking Policy and Effect on Smoking Cessation...........36
Other Relapse Research .. ............................. 39
Smoking Prevention.... ................ ... ................ 39
Educational Intervention .............................45
Validation of Smoking Status Self-Report................47
Bogus Pipeline ....................................... 48
Biochemical Tests ........................ ..............49
Concluding Statement....................... ............ 52

METHODS AND MATERIALS .................................... 55

Introduction.................... .......... .........55
Subjects .... .............. ..... ...................55
Instruments ........................................... 59
Self-Report Validation Techniques s................... 62
Procedures ............................................64
Data Preparation.............................................75
Analysis Plan.... ........................ ..................76










RESULTS AND DISCUSSION .................................... 79

Introduction. .........................................79
Population Description................................. 79
Results...................... ......... .... ................. 82
Discussion .............................................. 95

SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS ............... 107

Summary........................ .......................... 107
Conclusions........ ...................... ..... ............ 110
Recommendations .....................................113


APPENDIX A

APPENDIX B

APPENDIX C

APPENDIX D

APPENDIX E

APPENDIX F

APPENDIX G

APPENDIX H

APPENDIX I


INTAKE SURVEY ...............................116

GRADUATION SURVEY ........................ 123

THREE MONTH FOLLOW-UP SURVEY ................. 126

HUMAN FACTORS COMMITTEE APPROVAL ..............131

CONSENT STATEMENT .......................... 132

EDUCATION CURRICULUM ................ ....... 133

SHAM TREATMENT CURRICULUM ................... 146

QUIT SMOKING WALLET CARD .....................148

CERTIFICATE OF PARTICIPATION ................ 150


LIST OF REFERENCES ................ .......... ..... ........ 151

BIOGRAPHICAL SKETCH ........................................ 162














LIST OF TABLES


page

Table 1. Population comparisons .............................. 23

Table 2. Study group comparison ........................ 58

Table 3. Test-retest reliability ......................... 61

Table 4. Treatment group assignments .................... 65

Table 5. Repeated measures design ........................ 77

Table 6. Chi-square frequency table ...................... 77

Table 7. Percent survey completion at each measurement
period .................................................. 80

Table 8. Percentage of smokers in non-respondent group
and original study population.......................... 81

Table 9. Percent of current smokers at each measurement
period .................................................. 82

Table 10. Percent of current smokers by gender and
corresponding relapse rates................ ............ 83

Table 11. Nicotine tolerance levels reported with
corresponding relapse rates ........................... 84

Table 12. Percentage smoking initiation ................. 86

Table 13. Attitude scores at each measurement period
and differences pre to post for all subjects............ 88

Table 14. Attitude scores at each measurement period
and differences pre to post for smokers................ 89

Table 15. Knowledge scores at each measurement period
and differences observed ................................. ... 91

Table 16. Percent of respondents indicating intention
not to smoke in the future ........................... 92

Table 17. Cigarette consumption ........................ 93














Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy


EFFECT OF PREVENTION EDUCATION ON SMOKING RELAPSE FOR NAVY
RECRUITS

By

THOMAS LEE POKORSKI

August, 1992




Chairman: Wei William Chen, PhD
Major Department: Health and Human Performance


This study examined impact of an education program on

smoking knowledge, attitudes, and intentions of Navy recruits

undergoing 8 weeks of training in a normal no-smoking

environment. Also examined were smoking relapse and

cigarette consumption subsequent to recruit graduation.

Specifically the study was designed to (1) add to literature

information on effective educational smoking

prevention/cessation techniques; (2) measure effect of

current no-smoking policy at Recruit Training Center,

Orlando, FL; (3) examine differences in observed levels of

smoking knowledge, attitudes, intentions, and relapse after

intervention; (4) examine smoking initiation rate differences

(for non-smokers prior to recruit training); and (5) examine

variables affecting smoking relapse.


vii









This study included 496 recruits (357 men and 139

women), in seven companies. Companies were randomly assigned

to 4 treatment conditions: (1) policy only comparison; (2)

policy plus education; (3) policy plus education, with a

booster; and (4) policy plus sham treatment. Tobacco use

knowledge/behavior surveys were administered to all subjects

at the beginning of recruit training, at graduation, and

three months after graduation. Subjects in both education

groups received a three-hour education intervention. The

booster group received an additional hour-long booster

program at the end of the training cycle. Cotinine analyses

of randomly selected urine samples were performed

concurrently with pre- and postsurveys.

Data analysis was accomplished using repeated measures

analysis of variance, frequency tables incorporating

Pearson's chi-square statistic, and categorical modeling

procedures (SAS PROC CATMOD). Results indicated significant

educational effects for smoking knowledge and attitude

scores, reduced violation of liberty no-smoking rules, and

cigarette consumption for relapsers. No significant

treatment group differences were noted for relapse rate,

smoking initiation, or smoking intentions.

In summary, the education program used, though not

significantly affecting smoking relapse in the short term,

may positively affect future cessation attempts. The best

predictors of smoking relapse in Navy recruits were nicotine

addiction and heavy prior cigarette consumption. Study


viii









results recommend that smoking prevention/cessation education

be part of recruit training, but further research is needed

to identify more effective ways of reaching the heavier,

addicted smokers entering the Navy.














CHAPTER 1
INTRODUCTION



Cigarette smoking can be linked to 1 in 6 deaths in the

United States each year. Surgeons' General for the past 10

years named cigarette smoking as the most important

preventable cause of death in society (U.S. Department of

Health and Human Services [USDHHS], 1989, 1990).

Specifically, cigarette smoking has been linked to the three

leading causes of death in the U.S. (heart disease, cancer,

and cerebrovascular disease). Likewise, involuntary smoking

causes many of the same diseases associated with active

smokers (USDHHS, 1986). The annual cost to society in

disease, death, and absenteeism related to smoking has been

estimated in excess of $50 billion (Fielding, 1986).

In response to this problem, health professionals have

provided tobacco prevention and smoking cessation programs

for many years. These efforts have shown encouraging results

in the general population. Smoking prevalence has dropped

from 40% in 1965 to 29% in 1987 (USDHHS, 1989). The Surgeon

General reports that while over 50 million Americans continue

to smoke, more than 90 million would be smoking in the

absence of recent changes in the smoking and health

environment (USDHHS, 1989). Smoking cessation produces major

and immediate health benefits for smokers of all ages









(USDHHS, 1990a) but it is not an easy task. Eighty percent

of current smokers indicate they would like to quit, and two-

thirds have made at least one serious attempt to quit

(USDHHS, 1989), but 80-85% of those who try to quit smoking

each year relapse within 12 months of cessation (O'Connell,

1990; Schwartz, 1987).

Certain sub-groups of the general U.S. population have a

higher smoking prevalence. Military personnel are more

likely than civilians to be smokers (Bray, Marsden, &

Peterson, 1991). Though the prevalence of smoking in the

military declined from 51% in 1980 to 41% in 1988, the rate

remains much higher than in the general population (29%).

Bray et al. (1991) indicate the gap is actually less when the

civilian population is standardized to reflect sociode-

mographic distribution of the military (44% military vs. 39%

civilian prevalence), but the difference remains significant.

The population the military primarily draws on for new

members has shown a smoking prevalence leveling off in the

past decade. Smoking prevalence among teen-agers did not

decline during the 1980's and studies have shown smoking

prevalence in high school seniors at 17-32% (Johnston,

O'Malley, & Bachman, 1991; Center for Disease Control [CDC],

1991a) with rates much higher for high school dropouts.

The Surgeon General lists military personnel as one

population to be targeted for prevention and cessation

interventions (USDHHS, 1989). Many factors contribute to

high smoking prevalence in the military. Tradition of









smoking in the military, living conditions, demographic

population makeup, low cigarette cost in military exchanges,

and advertising targeted to young military members represent

factors hypothesized as causes for high military smoking

prevalence.

Smoking prevalence in the Navy (44%) slightly exceeded

the military average in a 1988 survey (Bray et al., 1988).

It has been estimated smoking costs the Navy nearly $25

million a year in higher health care and insurance costs, and

an additional $140 million in lost wages due to absenteeism

(Zolton, 1992). Efforts are underway in the Navy to reduce

the smoking prevalence and the Navy Surgeon General has set a

goal of a smoke-free Navy by the year 2000 (Nelson & Roth,

1991). Surveys of incoming Navy recruits, though, show a

smoking prevalence of between 28% and 40% (Cronan & Conway,

1988; Grochmal, 1990). If the Navy wishes to attain the goal

of being smoke-free not only will current smoking members

need assistance stopping, but the number of new smoking

members must be reduced and eventually eliminated. Current

Navy smoking policies have not yet proven effective in

lowering smoking prevalence to civilian levels. Policy

efforts thus far have only reduced smoking rates from 54% in

1980 to 44% in 1988 (Bray et al., 1988).

A smoking ban at all Recruit Training Commands (RTCs)

seems effective in stopping smoking temporarily for recruits

who enter as smokers (Commander E. Reeves, personal

communication, May 14, 1991). This policy stemmed from study









results showing Navy recruits actually starting to smoke

while in basic training (Cronan et al., 1988). Though a near

100% effective cessation rate is encouraging, smoking relapse

after recruit training is suspected to be very high. A study

to determine current relapse rates is underway at the Naval

Health Research Center (T. L. Conway, personal communication,

May 9, 1991).

The specific problem addressed in the present study

involved finding ways to decrease smoking relapse as recruits

leave boot camp and enter the general Navy population. If

relapse of recruit smoking can be prevented, the number of

new smokers entering the general Navy population can be

reduced. Navy recruits represent a segment of the U.S.

population highly resistant to smoking cessation: young

smokers (Ferrence, 1989). They are usually between 17 and 30

years old with a mean of about 19 years (Cronan, Conway, &

Hervig, 1989; Chief of Naval Technical Training [CNTECHTRA],

1991). Young smokers tend to show less concern about

potential hazards of smoking, though they show a high

awareness of the health risks (Tuakli, Smith, & Heaton,

1990). Therefore, it is a challenge to find effective

methods of lasting smoking cessation for Navy recruits.

Smoking development progresses through several stages

over a course of two or more years (Leventhal, Baker,

Brandon, & Fleming, 1989). Many smoking recruits may not

have reached the final stage of dependence and regular use.

For these individuals smoking relapse rates after recruit









training may be affected several ways: 1) they may have never

considered themselves smokers and may not start again; 2) the

eight week gap may represent a brief lapse in their

development cycle, and they may continue to smoke whether or

not they see themselves as future smokers; or 3) they may

think they can stop just as easily in the future, feel immune

to possible risks, be influenced by smoking friends they

subsequently meet, and eventually progress to the last stage

of development.

Recruits who progress to the last stage of smoking

development before entering the Navy should relapse like any

other ex-smoker in the cessation population. However, one

would expect these recruits to exhibit some relapse

differences in that most have not really quit smoking

voluntarily; they quit, not by choice, but to conform to

existing policy. Since smoking relapse rates have never been

studied for this type of population it is difficult to

predict exactly what will effect reduction of relapse.

The transtheoretical model of behavior change, as

applied to smoking cessation (Prochaska & DiClemente, 1983),

shows that smokers cycle through various stages (pre-

contemplation, contemplation, action, and maintenance) in

their quit attempts. Progression through these stages

requires voluntary incorporation of a number of processes of

change. Smoking recruits are placed into the action stage

and may revert to their pre-recruit stage upon graduation and

reinstitution of free-choice concerning tobacco use.









Physical as well as psychological factors are involved

in relapse (Carmody, 1990; Shiffman, Read, Maltese, Rapkin, &

Jarvik, 1985). For recruits, physical withdrawal symptoms

are gone after eight weeks of training, as peak physical

withdrawal symptoms of tobacco appear to last for about 1 2

weeks (USDHHS, 1988). Therefore, if recruits relapse to

smoking it will probably be from psychological factors, a

belief they never quit, or a willful intention to start

again. Each of these areas were addressed in the present

study.


Statement of the Research Problem


The military population has been targeted as a group in

need of effective smoking prevention and cessation efforts.

Efforts thus far have not succeeded in reducing smoking

prevalence to civilian levels. An attempt has been made to

promote cessation and discourage initiation by banning

tobacco use for all personnel at recruit training centers.

No study results have yet been published concerning the

effect of the policy on smoking after training, and no

efforts have been made to find ways to decrease smoking

relapse for graduating recruits.

In general, military smoking prevalence can be reduced

by addressing current service members and new recruits.

Cessation and prevention efforts for current service members

is vital, but if 40% of new recruits are smokers, the problem









will perpetuate. Specifically, the present study focuses on

reducing the number of smokers in the recruit population. To

do this, the effect of current smoking policy at Recruit

Training Center, Orlando, FL, was examined. Relapse after

graduation, smoking attitudes, and future smoking intentions

were assessed. Changes in smoking relapse and initiation were

then examined for groups exposed to various intervention

conditions.


Purpose of the Study


The purpose of this study was to examine the impact of

an education program on smoking knowledge, attitudes,

intentions, and on smoking relapse rate and subsequent

cigarette consumption. Specifically the study was designed

to

(1) measure effect of the no-smoking policy at

Recruit Training Center, Orlando, FL, on recruit smoking

knowledge, attitudes, intentions, and relapse;

(2) examine differences in observed levels of recruit

smoking knowledge, attitudes, intentions, and relapse

for various treatment conditions;

(3) examine smoking initiation rate differences (for

non-smokers prior to recruit training) for various

treatment conditions; and

(4) examine variables affecting smoking relapse.










Hypotheses


The null hypotheses relating to Navy recruits after

eight weeks in a smoking restricted environment are that no

differences will be observed among treatment conditions for

(1) smoking relapse rate,

(2) smoking attitudes,

(3) smoking knowledge,

(4) smoking intentions,

(5) cigarette consumption, and

(6) smoking initiation after graduation (for

never/former smokers prior to recruit training).


Significance of the Study


Results of this study should assist Navy smoking

cessation efforts by finding effective means of reducing

smoking prevalence in personnel entering the service. This

study was unique in that it was the first to examine smoking

intervention while including the Navy female recruit

population. Secondarily the study was designed to contribute

to literature information on: a) successful techniques to

prevent relapse in young ex-smokers, and b) successful

techniques to prevent smoking initiation in non-smokers

during employment transition.

This study will provide further evidence to support or

refute the theory that policy alone is insufficient to effect









permanent change on smoking decisions. The theory of

prevention education as an effective measure for behavior

change also was tested. This study should prove useful for

determining if subject tailored smoking prevention classes,

in the context of a strict no-smoking policy, reduce

recidivism after the policy is removed.

Since this study was the first smoking relapse

prevention research conducted with military recruits it

should produce new knowledge applicable to all military

training commands. The results will provide a basis for

further research in discovering program variables which

increase success, and subject variables which determine who

is suited for particular interventions. Portions of the

results may also prove applicable to behavior change of other

detrimental health habits (eg. drug and alcohol use, poor

nutrition habits, seat belt usage).

Smoking relapse for recruits will be affected by many

factors they encounter after leaving boot camp. The present

study cannot change any of these factors. However, the

interventions were designed to help participants recognize

and cope with many of these factors. For recruits who

believe they have quit, establishing a firm intention to

remain quit is very important. This aspect of prevention

stems from the theory of reasoned action which states the

best predictor of behavior is a person's intention to perform

the behavior (Ajzen & Fishbein, 1980).









For recruits who believe they have not quit, or are

determined to start again, interventions used in this study

may still be of benefit. If they can realize they have quit

smoking, and the quitting was a beneficial achievement for

them, they may be able to enter the behavior change cycle at

the maintenance stage. If this measure fails, the program

still may be of benefit if it moves smokers from the pre-

contemplation stage toward the contemplation stage in which

they may give serious consideration to quitting at a later

date. If so, these individuals may be more receptive to

Navy-wide smoking policies and programs they will be exposed

to throughout their careers.

Research indicates light smokers often make the

transition to heavy smoking during the first two years after

high school (Johnston et al., 1991). If this transition can

be prevented in Navy accessions, receptiveness to later

cessation efforts also may be assisted. Successful

recidivism prevention and earlier cessation will certainly

boost progress toward the goal of a smoke free Navy by the

year 2000.

Another group that will benefit from the smoking relapse

program includes recruits who have never smoked, especially

those who may already be susceptible to social influences.

According to the National Institutes of Health, information

about the health and social consequences of smoking proves

critical for cessation (Glynn, Boyd, & Gruman, 1991). This

same information has been shown effective in smoking









prevention programs (Flay, 1985; Glynn, 1989). Therefore, a

comprehensive smoking education program addressing the needs

of all recruits, should be effective in reducing the number

of smokers entering the Navy population and assisting future

prevention and cessation efforts.


Delimitations


(1) The curriculum used was submitted for review to

several experts in the fields of health education and

smoking prevention/cessation; the curriculum was

subsequently adjusted to include most of the suggestions

received.

(2) The sample was randomly selected and found to be

representative of a six month sampling of all recruits

at RTC Orlando and all three Navy recruit commands.

(3) Companies involved in the study were randomly

assigned to the four treatment groups.

(4) Cotinine analysis of urine was accomplished on

random samples of participants in conjunction with the

intake and graduation surveys to verify self-reported

tobacco use, and a bogus pipeline procedure was used to

increase validity of self-reported tobacco use.

(5) Companies which had companion companies (combined

classroom periods) received the same study treatment.









(6) Follow-up surveys were mailed to participants'

command, whenever possible, in an effort to increase

response.


Limitations


(1) Because previous research with the study population

was minimal, techniques used successfully with other

populations were adapted for the study.

(2) The original study population was reduced to its

final number due to unavoidable attrition resulting from

medical problems, reading aptitude, drug test results,

voluntary drops, and a number of other factors.

(3) Only recruits from one of the three Navy recruit

training facilities were used.

(4) Several potential threats to internal validity

remained beyond experimental control including company

commander influence, and seasonality differences in

recruits.

(5) Cotinine analysis was not accomplished for each

subject nor for each survey period.

(6) Addresses for follow-up mailings were obtained from

a Navy computerized personnel tracking network which may

be less than 100% accurate.










Assumptions


(1) Recruit company commanders uniformly followed no-

smoking policies set for the command.

(2) The sample population were uniformly exposed to

outside variables which might affect treatment outcome.

(3) Subjects in each treatment group self-reported

tobacco usage with the same degree of truthfulness.

(4) Subjects in differing treatment groups had no

interaction affecting results.


Definition of Terms


The following are working definitions for selected terms

used in this study.

Smoking relapse/recidivism was defined as at least one

puff per day for seven days. This definition was

recommended by a conference of the National Heart, Lung,

and Blood Institute (Carmody, 1990). Relapse does not

necessarily mean a return to the previous smoking rate.

Current smokers were defined for this study as

individuals who have smoked at least 100 cigarettes in

their lifetime and have smoked a cigarette, cigar, or

pipe within 2 months prior to entering the Navy (intake

survey); or since graduation from recruit training (3

month follow-up survey).









Current smokeless tobacco users were defined as having

categorized themselves as users of chewing tobacco or

snuff and have used at least 3 days in the past 12

months.

Former smokers were defined as once current smokers, but

having not smoked a cigarette, cigar, or pipe in the

last 2 months.

Former smokeless tobacco users were defined as once

current users, but having not used chewing tobacco or

snuff in the last 2 months.

Never smokers were defined as having smoked less than

100 cigarettes in their lifetime, indicated they never

regularly smoked, and characterized themselves as having

never used cigarettes, cigars, or pipes.

Never users of smokeless tobacco were defined as having

categorized themselves as never using chewing tobacco or

snuff on a regular basis.

Light smoking was considered using less than one

cigarette per day.

Moderate smoking was considered using from 1 19

cigarettes per day.

Heavy smoking was considered using a pack, or more, of

cigarettes per day.

Smoking relapse rate was determined by dividing the

number of participants (categorized as current smokers

at intake) indicating they started smoking again after










boot camp, by the total number of smokers remaining in

the study.
S start
SRR =
total smokers

Boot camp is a common term used for basic recruit

training in the military. Generally the training

received immediately upon entering the military, which

lasts about 8 weeks.

Sham treatment refers to a placebo treatment similar to

the main intervention only in amount of attention paid

to participants. The material presented is only vaguely

related to the study goal.

Command refers to the actual component of the Navy to

which participants were assigned after recruit training.

Knowledge gain refers to observed change in smoking

knowledge scores between pretest and posttest.














CHAPTER 2
REVIEW OF LITERATURE


WHEN loves grows cool, thy fire still warms me;

When friends are fled, thy presence charms me,

If thou art full, though purse be bare,

I smoke, and cast away all my care

-German Smoking Song


Introduction


The purpose of this chapter is to provide a summary of

what has been learned from other studies regarding smoking

prevention and smoking relapse prevention. Insight as to how

the current study will contribute to a fuller understanding

of the issues is also presented. The chapter starts with a

look at ill effects of tobacco, and tobacco use prevalence

rates in the U.S. population, and military sub-groups.

Several theories of smoking relapse are then reviewed

followed by an examination of how these theories have been

used in the past as basis for research in relapse prevention.

Research on the effects of smoking policy and miscellaneous

relapse research are then examined. Research on smoking

prevention, as it relates to this study, is then reviewed.

Prevention methods which current research has shown effective









are presented, followed by an overview of recent research in

ways of increasing truthfulness of smoking self-report, and

means to verify smoking self-report. A concluding statement

ends this chapter, in which the theoretical framework is

related to the actual experimental design of the study.


Problems Related to Tobacco Use


Cigarette smoking remains a major problem in U. S.

society today. A recent report (CDC, 1991b) says more than

434,000 deaths, and an estimated 1,199,000 years of potential

life lost (YPLL) before age 65, were caused by cigarette

smoking in 1988 in the United States. In 1964, the Surgeon

General reported (Public Health Service [PHS], 1964)

cigarette smoking causes lung and laryngeal cancer in men,

and causes bronchitis. The 1989 Surgeon General's report on

the health consequences of smoking (USDHHS, 1989) showed

cigarette smoking also causes coronary heart disease,

cerebral vascular disease (stroke), atherosclerotic

peripheral vascular disease, lung and laryngeal cancer in

women, oral cancer, esophageal cancer, chronic obstructive

pulmonary disease, intrauterine growth retardation, and low

birth weight babies. Smoking was also found to be a

contributing factor for cancers of the bladder, pancreas, and

kidney; and associated with cancers of the stomach and

uterine cervix (USDHHS, 1989). Research also has established









involuntary smoking as a cause of disease, including lung

cancer, in healthy non-smokers (USDHHS, 1986).

Cigarette smoking is the number one preventable cause of

death in the U.S. today (USDHHS, 1989). Smoking causes more

premature deaths than cocaine, heroin, alcohol, fire,

automobile accidents, homicide, and suicide combined (USDHHS,

1990). It has been estimated that smoking costs society over

$50 billion annually in smoking related diseases, death, and

absenteeism (Fielding, 1986). However, more than 50 million

Americans continue to smoke (USDHHS, 1990b).


Tobacco Use in the U.S.


Smoking prevalence in the adult U.S. population was

about 29% in 1987, which is down from the 40% prevalence seen

in 1965 (USDHHS, 1989). Unfortunately, this decrease in

smoking is not seen uniformly throughout the population. The

Surgeon General reported the prevalence of smoking in women

has declined more slowly than men, and smoking rates will be

about equal for men and women in the mid-1990's (USDHHS,

1989). The report also states female adolescents not

planning on higher education show a much higher smoking

initiation rate than for male adolescents. A higher smoking

prevalence was also reported among black and Hispanic men

than white men. More disturbing is the fact that smoking

prevalence among teenagers has not declined over the past

decade. Johnston, et al. (1991), reporting on their 15th









annual national survey of American high school seniors,

stated that in 1989 29.4% of seniors were current smokers (30

day prevalence of cigarette use), which was the same

proportion as the class of 1981. High school dropouts have

prevalence rates for all types of drugs, including

cigarettes, substantially higher than in-school students

(Johnston, O'Malley, & Bachman, 1989).


Military Tobacco Use and Related Problems


Tobacco use in the military has been quite prevalent for

many years. Tobacco has been part of the traditional rations

given to soldiers during war time (Ferrence, 1989). This

practice started the smoking habit in hundreds of thousands

of Americans and began an association of cigarettes with the

military that persists today. Very little research can be

found in the literature on military smoking cessation and

none can be found on military smoking relapse prevention.

However, this is not a reflection of the magnitude of the

problem. A recent survey of the military found over 40% of

all members are smokers (Bray, et al., 1988). Marsden, Bray,

and Herbold (1988) showed the number of illnesses reported by

U.S. military personnel is significantly related to smoking,

as well as to other substance abuses, such as alcohol. Their

study utilized data from the 1985 worldwide survey of alcohol

and non-medical drug use among military personnel. They

found the number of healthy behaviors practiced was inversely









related to use of alcohol, drugs, and tobacco. Substance

users, particularly heavy users, were more likely to have

experienced ill health during the past 12 months. When

controlling for background variables, which also related to

ill health, number of illnesses was still significantly

related to reported drinking level, drug use, and smoking.

Smokers of one or more packs per day averaged 0.22 more

illnesses per year than non-smokers. Ballweg and Bray (1989)

also reported smokers were more likely than non-smokers to

describe their health as fair or poor. Though the military

smoking rate is high, it reflects a significant decrease from

1980 when 51% of military members smoked (Bray, et al.,

1988).

Many explanations have been hypothesized to account for

the high military smoking prevalence seen today. The

following are descriptions of some of these hypotheses.

-Distinctive military conditions such as relocation

overseas, family separation, or a greater perceived

acceptance of use may foster higher rates of use (Bray

et al., 1991).

-Military personnel are not demographically

representative of the general population (this will be

discussed at length later in this chapter).

-The military has been selecting individuals who are

predisposed to smoke (Gardner, 1991). Smoking can be

predicted by pay-grade, race/ethnicity, education,

service branch, age, poor health practices, and higher









stress at work (Bray, Marsden, Guess, & Herbold, 1989;

Carroll, Lednar, & Carter, 1989).

-Tobacco products are available at much lower prices at

military outlets than in the civilian market (Cronan &

Conway, 1988; Nelson & Roth, 1991). Many programs are

funded by tobacco sales revenue. Fiscal 1988 saw $102.1

million in tobacco sales by Navy exchanges (McBeth,

1989) and in 1989 $20 million of tobacco profits were

given back to Morale Welfare and Recreation funds.

Fiscal 1991 sales topped $126 million (Steigman, 1992).

-Military life brings an increase in interpersonal

communication and social participation due to higher

density in living quarters and increased group

activities. These conditions are conducive to

initiation/continuance of the smoking behavior

(Ferrence, 1989).

-The military encourages cohesiveness and uniformity,

and members may begin smoking to become like each other,

and "one of the group" (Cronan & Conway, 1988).

-Work breaks and other opportunities to relax are often

paired with opportunities to smoke (Cronan & Conway,

1988).

-Civilian publications aimed at the military populations

contain a large amount of sponsorship/advertisement from

the tobacco industry (Nelson & Roth, 1991).










Because of the nature of military employment, any

substance abuse can often cause consequences of graver impact

than in the civilian community. Greater responsibilities are

placed in the hands of younger people in the military than

would ever be allowed in the civilian work force. A twenty

year old may be responsible for actual steerage of a large

naval vessel, for preparation of a multimillion dollar

aircraft for flight, or for emergency medical treatment of a

seriously injured person. If that individual's performance

is hindered because of use of any psychoactive substance,

including tobacco, lives and expensive hardware can be placed

in jeopardy. The U.S. Surgeon General has concluded nicotine

is a psychoactive substance (USDHHS, 1988).

The safety aspects of even legal substances such as

tobacco can be crucial. Smoking is restricted at certain

times on ships. The smoking lamp is either lit or out on

board a naval ship. This refers to a practice years ago

aboard naval vessels in which the captain would order a lamp

lit for sailors to light their cigarettes when their duties

had ended for the day. The lamp is gone but the term is

still used to tell when it is safe or not to smoke. A lit

cigarette can be a hazard around fuel, ordinance, or any

volatile substance. On submarines the air must be

recirculated, and cigarette smoke is a significant

contributor to atmospheric contaminants (Scali, 1989).

The military population is not demographically

representative of the general population, which may account










for some of the difference in smoking prevalence. Table 1

presents a breakdown of some of these differences.



Table 1. Population comparisons

Active Duty Total U.S.

Military Population


RACE

Caucasian

Black

Other

SEX

Male

Female

AGE


17-20

21-25

26-29

30-34

35-39

40 & over


72% (1,557)*

20% (426)

8% (85)


89.5%

10.5%


(1,946)

(228)


17.3% (376)

32.4% (704)

17.8% (387)

14.9% (324)

10.5% (228)

7.2% (157)


84.3%

12.3%

3.4%



48.8%

51.2%


(207,748)

(30,326)

(8,256)



(120,203)

(126,126)


6.1% (15,054)

8.1% (19,981)

7.2% (17,701)

8.9% (21,878)

7.8% (19,194)

37.6% (92,518)


* Numbers are represented in thousands.
Source: U. S. Bureau of the Census, Statistical abstract of the
United States: 1990 (110th edition) Washington DC & Military Market,
October 1989, pp. 46-52.


Service members are younger, most are male, and the

majority of recruits come from the lower socioeconomic

levels. These are factors also associated with higher









smoking prevalence (Bray et al., 1991). Bray et al. (1991)

reported, controlling for key sociodemographic

characteristics known to be associated with substance abuse,

military personnel are in general still substantially more

likely than civilians to be smokers and heavy smokers. They

also reported differences among military and civilian women

are more pronounced than among military and civilian men.

The rates for men differed by 4 and 7 points respectively,

while the rates for women differed by 13 and 14 points.


Navy Tobacco Use


The most recent Worldwide survey of substance abuse and

health behaviors among military personnel (Bray, et al.,

1988) showed prevalence of any smoking in the Navy was 43.8%

in 1988. A 1986 survey of shipboard personnel indicated

49.8% smoked (Conway, & Cronan, 1988). Smokeless tobacco is

used by 16.1% of Naval personnel. A 1987 Navy report (Cronan

& Conway, 1988) found about 28% of incoming recruits were

regular smokers with another 13% claiming to be former

smokers.

An informal tobacco use survey was conducted by the

dental staff at the Orlando Recruit Inprocessing Facility.

The survey was designed by Lieutenant Commander David

Grochmal, Dental Corps, and was accomplished as part of the

dental screening process. The survey was conducted from

March to October, 1990 and included over 13,000 recruits.









This survey found 39.7% (34.1% male and 56.7% female)

reported they were smokers before entering the Navy. Also,

7.4% of the men indicated they were smokeless tobacco users

(Grochmal, 1990).

In 1988 a survey of high school seniors and young adults

(Johnston, et al., 1989) found an 18% prevalence of daily

smoking for seniors and a 29% rate of current (casual)

smokers. This same study reported a drastically higher

smoking rate in respondents 1 4 years past high school who

were not in college. Other studies have shown that smoking

rates are higher for seniors who do not plan on pursuing

higher education (Glynn, 1990; Johnston et al., 1991). Since

the majority of the recruit population comes from this group,

the higher recruit smoking prevalence is not surprising.

Though the vast majority of Navy recruits have a high school

diploma (or equivalent), some have obtained it in a non-

traditional manner, and thus are part of a group at much

higher risk to smoke.











Smoking Relapse

"To cease smoking is the easiest thing I ever did; I

ought to know because I've done it a thousand times"

-Mark Twain


Most relapse does not occur immediately, but rather long

after signs of physiological abstinence have disappeared

(Jarvik & Hatsukami, 1989). Research shows approximately 70%

of successful quitters relapse within 3 months, and an

additional 10-15% relapse between 3 and 12 months after

quitting (Schwartz, 1987; Shiffman et al., 1985). Several

theories have been offered to explain why relapse rates are

so high. Shiffman et al. (1986) have suggested three types

of variables influence relapse proneness: a) enduring

personal characteristics, b) background variables, and c)

precipitants. Craving for nicotine and the positive

reinforcement nicotine brings has also been theorized as

reason for relapse (Carmody, 1990). Gritz, Carr, and Marcus

(1991) conducted a study on tobacco withdrawal syndrome in

unaided quitters. They found tobacco dependence to be a good

indicator of smoking relapse. Higher Fagerstr6m tolerance

scores predicted higher probability of relapse. Their other

main finding was higher cigarette consumption at enrollment

predicted higher short and long term relapse.










Theory of Reasoned Action


One model which has been used to describe likelihood of
behavior change has been termed the theory of reasoned action

(Ajzen & Fishbein, 1980). This theory states the best

predictor of behavior is a person's intention to perform the

behavior. Behavioral intention is seen as a function of two

determinants; the person's attitude toward the behavior, and

the perceived expectation of important others with regard to

performance of the behavior (subjective norm). In a review

of this theory Sutton (1989) said, "In other words, a

person's behavioral intentions, and hence behavior, depend

ultimately on the person's belief concerning; (a) the

possible consequences of the behavior, and (b) the

expectations of important others. It follows that in order

to change behavior it is necessary to change the underlying

beliefs" (p 291). The theory goes on to explain that

external variables can influence intentions, and thus

behavior, but only by influencing attitude toward behavior or

the subjective norm, or the relative importance of the two

components. Since starting or stopping cigarette smoking is

a behavior that falls in the domain of this theory (a

behavior that can be regarded as a decision) intention to

stop/reduce smoking should be a good predictor of behavior.










Transtheoretical Model (Stages of Change)


Prochaska and DiClemente first applied their stages of

change model to self change of smoking habits (Prochaska &

DiClemente, 1983). They believe most behavior involves

repetitive and habitual actions which are quite resistant to

extinction. Further, behavior change requires movement

through discrete stages in order to achieve maintained

cessation or initiation. The five stages of change an

individual cycles through in attempting behavior changes are:

-pre-contemplation

-contemplation

-action

-maintenance

-relapse.

Because changing smoking behavior is highly prone to

relapse, it is theorized that individuals tend to move

through these stages in a cyclical fashion (Prochaska &

DiClemente, 1982). Successful change often requires repeated

recycling through these stages. Research suggests the

average smoker cycles three to four times through the stages

before attaining long-term abstinence (Prochaska &

DiClemente, 1984; Marlatt, Curry, & Gordon, 1988). Those in

relapse and pre-contemplation do not have enough motivation

to change their smoking habits. Those in the contemplation

stage are aware of a need to change, but have not yet taken









action. The key to successful change lies in exiting the

maintenance stage after replacing the behavior in their

lifestyle. If the intervention method is tailored to the

individual's stage of change, the chances of success can be

enhanced. Rimer (1990) says people in the process of change

must have access to interventions which start at their stage

in the change process. Because of this, she says

intervention should include a range of options to reach

people in all stages. Intervention programs may not succeed

in behavior change, but may succeed in moving the individual

to a higher stage, which is important (Prochaska &

DiClemente, 1983). No studies have as yet been reported

concerning any education effect on this recycling phenomenon.


Social Cognitive Theory


Bandura's (1989) social cognitive theory revolves around

smokers' beliefs about ability to exercise control over

events which control their lives. Bandura sees self-efficacy

as influencing thought patterns, motivation, level of stress,

and selection of environments; thus affecting smoking

cessation outcome expectations.



All of these theories have commonalties, and show that

smoking relapse is individualistic and complex. Recruits who

smoked before entering the Navy have been placed in the

action stage of change while in recruit training, even though









they were probably in a lower stage before they came in. No

previous studies have reported or predicted what effect this

will have. It is not known what effect this will have on

their intentions to stay quit. Certainly it will show they

are capable of not smoking for an extended period of time.

What is known is young adult smokers do quit, or at least

attempt to quit, smoking. Thirteen percent of recruits

surveyed indicated they were former smokers (Cronan & Conway,

1988). A prospective cohort study from pre-adolescence to

young adulthood (Swan, 1991) found about 14% of 21 22 year

olds reported being ex-smokers. Another study (Ershler,

Leventhal, Fleming, & Glynn, 1989) states 52% of 6 12 grade

smokers had indicated at least one quit attempt. A survey by

Tuakli et al. (1990) indicated 69% of the 12 20 year old

smokers had tried to quit. The top reasons for quitting

were: 1) didn't enjoy smoking, 2) health concerns, 3)

pregnancy, 4) costs, and 5) parents or friends asked. This

indicates even young smokers are aware of the risks of

smoking, and some may have progressed through the cycle of

changing their smoking behavior.

Relapse is defined in the literature as a smoking

episode after a period of voluntary abstinence that is

followed by a return to continuous smoking (O'Connell, 1990).

To include recruit graduates in this category may be
stretching this definition, but since we now have an all

voluntary armed forces, all recruits enter the Navy of their

own free will. All recruits may not enter with the intention









to permanently quit smoking though, which may affect smoking

relapse seen after graduation.

Relapse Prevention


The topic of relapse prevention has received a lot of

research attention recently. Since most smoking cessation

programs report from 50-80% abstinence at the end of

treatment (Schwartz, 1987) improvement of long-term quit

rates is a logical next step in smoking cessation research.

In reviewing current issues in preventing smoking relapse,

Carmody (1990) found smoking relapse is influenced by a host

of variables, including: physiological factors, withdrawal

symptoms, conditioning processes, stress and negative mood

states, level of commitment and motivation to remain

abstinent, social support, weight gain, and repertoire of

cognitive and behavioral coping strategies in response to

temptations to smoke. He concluded that the primary

theoretical framework for relapse prevention is social

learning theory.

Mazur (1986) points out that social learning theory adds

the principles of observational learning and imitation to

traditional principles of classical and operant conditioning.

He suggests Bandura's social learning theory can help account

for the acquisition of many addictive behaviors including

smoking. Others (Carmody, 1990; Perry, Baranowski, & Parcel,

1990; Rimer, 1990) believe this theory is particularly









valuable to health educators because it illuminates the

dynamics of individual behavior and gives direction for

intervention design in behavior change programs. Bandura

(1989) says people make causal contributions to their own

motivation and action within a system of triadic reciprocal

causation. The model shows action, personal factors, and

environmental events operating as environmental determinants.

In the model, people partly determine the nature of their

environment and are influenced by it.

The preceding theories lend well to the multi-component

interventions thought to be important in relapse prevention

strategies. They can easily be applied to multi-level change

strategies because of inclusion of environmental, personal,

and behavioral constructs.

Social cognitive theory is an outgrowth of social

learning theory (Bandura, 1989). This theory appears to be

useful as a model in studying smoking relapse (Carmody,

1990). People's beliefs about their ability to exercise

control over events that affect their lives are central to

the theory. Wojcik (1988) found the strongest prediction of

abstinence versus relapse in a sample of 75 smokers

attempting to quit on their own was self-efficacy.

Shiffman et al. (1985) emphasize education, assessment,

and coping-skills training in their approach to relapse

prevention. They also found combining cognitive and

behavioral coping enhanced effectiveness of preventing

relapse. Seven types of behavioral coping were listed:










-eating/drinking

-engaging in a distractive activity

-escape

-delay

-engaging in a physical activity

-relaxing

-engaging in any other activity.

Cognitive coping strategies were:

-willpower

-self-punitive thoughts

-positive health consequences

-negative health consequences

-distracting thoughts

-intent to delay

-other self-talk.

People who expect smoking cessation to require active coping

have been shown to be more successful in maintenance

(Shiffman et al., 1986). They determined it is probably most

useful to teach ex-smokers a broad repertoire of coping

responses to prevent relapse.

Other approaches to relapse prevention include

motivational enhancement, social support, coping skills

training, reinforcement, lifestyle balancing, and the use of

various pharmacological agents (Carmody, 1990). Several

studies have shown that use of refusal skill training

techniques is beneficial in maintenance of smoking cessation

(Curry, Marlatt, & Gordon, 1987; Curry, Murray, Gordon, &









Baer, 1988; Shiffman et al., 1985; Stevens & Hollis, 1989).

In a randomized study using skills training and social

support as relapse prevention methods, Stevens and Hollis

(1989) found skills training significantly decreased relapse

rates, while social support showed no significant differences

from a no-treatment control.

In addition to skills training, the National Institutes

of Health (NIH) say information about the health and social

consequences of smoking is critical for cessation (Glynn et

al., 1991). Gibbons, McGovern, and Lando (1991) showed the

utility of including information on the risks of smoking as

well as the benefits of quitting, in a study of relapse in a

smoking cessation clinic. The NIH study states high risk

perception declines significantly over time for those who

fail in their quit attempt. Perception is an important

factor related to cessation commitment and efforts to

counteract this tendency to decline may reduce relapse rates,

or may help relapsers maintain cessation motivation to try

again. Several studies suggest booster sessions may help

maintain motivation to stay quit when used as part of a

multicomponent strategy (Brink, Simons-Morton, Harvey,

Parcel, & Tiernan, 1988; Brownell et al., 1986). Brownell et

al. (1986), suggest booster sessions may be useful in the

perception that one is part of a continuing process of

change. They also point to the usefulness of giving self-

help manuals to those who have quit, as another means of

enhancing vigilance in maintaining non-smoking. They believe









use of self-help manuals may be especially important in the

late maintenance stages of quitting. They state that

although initial abstinence rates from self-help books and

brochures are low, such materials may be effective in keeping

recent quitters from returning to smoking. Curry et al.

(1988) also found self-help materials were helpful in relapse

prevention, for those who used the materials. Motivation is

another factor which has been cited by many studies as

critical in maintaining cessation (Brandon, Tiffany,

Obremski, & Baker, 1990; Brownell et al., 1986; Carmody,

1990; Glynn et al., 1991; Shiffman et al., 1985).

A task force on interventions to prevent relapse

(Brownell et al., 1986) suggest that sustained smoking

cessation requires the modification of a range of social

skills. The removal of an ingrained personal and social

habit leaves a void that must be filled to prevent relapse.

They suggest the void be filled by new reinforcers, new

social skills, or general lifestyle changes. New, more

health oriented reinforcers, may include; exercise,

relaxation training, and meditation. An effort must be made

to find alternatives for which smoking was previously

employed.










Smoking Policy and Effect on Smoking Cessation


Navy recruit training lasts 8 weeks. The current

smoking policy does not allowed anyone to smoke at the

command (CNTECHTRA Instruction 5100.6A, 1991). This includes

recruits, instructors, and all staff members. Therefore, the

recruits who smoked prior to entry, graduate boot camp as ex-

smokers who have successfully quit for 2 months. This 100%

cessation rate, with zero recidivism for 2 months, is far

better than any other cessation program reported in the

literature. However, no other quasi-involuntary cessation

programs have been reported and very little information is

available concerning relapse after leaving this type of

environment. Cronan et al. (1989) compared smoking

intervention techniques in recruit training (the current

smoking policies had not yet been instituted). Four groups

were followed through their training cycle. One group

received an educational intervention, another feedback from

health risk evaluations, and a third was designated no

smoking and were not allowed to smoke during training. A

fourth group was followed as a control. The no smoking

group, although showing the best cessation at the end of

training (measured after their first opportunity to smoke),

still reported a 75% relapse rate.

The only other study examining relapse rate in this area

is ongoing (T. L. Conway, personal communication, June 6,









1991) and results are not yet available. This study began

last year to look at tobacco use in all new Navy accessions.

Participants were surveyed at the beginning of training, at

graduation, and at 1 month follow-up. Interventions were not

included.

The current Navy policy is not as restrictive overall as

it is for recruits, but does meet the Department of Defense

directives. Tobacco use is not permitted in: 1) auditoriums,

conference rooms, classrooms, or libraries; 2) elevators; 3)

official buses, vans, and shuttle vehicles; and 4)

gymnasiums, child care and youth activity centers (SECNAVINST

5100.13A, July 17, 1986). Other limitations are placed on

working areas, eating facilities, aircraft, living quarters,

and medical facilities, but guidelines are left to the

individual Commanding Officer. In contrast though, sales of

tobacco products are still discounted from civilian prices at

Navy Exchange facilities, although they may not be purchased

at medical and dental facilities (USDHHS, 1990b).

There is no evidence that policy alone affects smoking

prevalence. In fact, the 1989 Surgeon General's report

(USDHHS, 1989) reported insufficient research has been

undertaken to determine what effect, if any, smoking

restrictions have had on smoking prevalence. Two studies did

examine a no-smoking policy which has been successful in

decreasing consumption of cigarettes in settings affected by

the policy, but not prevalence rates (Pentz et al., 1989;

Petersen et al., 1988). Policy combined with education does









seem to be more beneficial than policy alone. Pentz et al.

(1989) found a policy which emphasized adolescent education

to prevent and stop smoking, rather than regulating it by

punishment, was significantly related to lower recent

smoking. Education, designed to reorient the ex-smoker's

attitudes toward more realistic expectations about quitting

smoking, is an important first step in relapse prevention

(Carmody, 1990).

A survey to assess short-term impact of Army smoking

policies (Carroll et al., 1989) reported no influence of

policy on decision to quit, though a consumption drop was

reported in some areas. This study also showed intention to

quit is related to knowledge of smoking-related diseases.

The current recruit smoking policy lacks support of a strong

prevention education component (CNTECHTRA, 1991a). Results

of the current recruit policy study may reflect those of the

Army survey because of this fact. The Navy has a long way to

go to meet its goal of being smoke free by the year 2000

(Zolton, 1991). New restrictions are being proposed, but

Navy guidelines must include positive approaches to help

individuals make the decision not to smoke. Vice Admiral

Zimble, the Navy Surgeon General, said: "We want a

positively motivated force that chooses not to smoke"

(Nelson, 1991). Health educators also realize coercion of

positive health behavior is not only unethical, but is

usually not a very successful tactic. The challenge, in this

study of prevention education supplemented with strict









policy, will be to increase the likelihood that recruits will

favorably respond to the education treatments.


Other Relapse Research


Though much is known about relapse in self-quitters and

program aided cessation, very little is known about relapse

in those who involuntarily quit smoking. One related area is

relapse of women who quit smoking during pregnancy. These

women quit voluntarily, but usually not for themselves.

Rather they quit so as to not affect the health of their

babies. Relapse in these women is usually quite high

(McBride & Pirie, 1990; Mullen, Quinn, & Ershoff, 1990) and

has been reported as high as 70% at one year post-cessation

(Fingerhut, Kleinman, & Kendrick, 1990) even though smoking

at this time may still have an indirect effect on the baby.

Several studies have been conducted on smoking cessation for

pregnant women, but none have specifically targeted relapse

prevention.

Another area where involuntary smoking cessation may

occur is in jails/prisons, but no information could be found

in the literature on this subject.


Smoking Prevention


As more and more adult smokers quit, in both the

civilian and military populations, efforts to prevent the

onset of smoking become the next logical step towards the









goal of a smoke-free Navy/society. The Surgeon General

(USDHHS, 1989) reported children and adolescents hold the key

to progress toward curbing tobacco use in future generations.

This report also said there is a growing recognition that

prevention and cessation efforts need to target specific

populations with a high smoking prevalence and a high risk of

smoking related disease. The military population is listed

as one of the groups that needs to be targeted.

Many approaches have been tried over the years, both in

school and community settings, to prevent adolescents from

beginning to smoke. Early campaigns to increase information

and create fear of long term consequences did not succeed.

Although succeeding in changing knowledge, beliefs, and

attitudes, very few programs consistently reduced the onset

of smoking (Flay, 1985). In a review of psychosocial

approaches to smoking prevention, Flay (1985) examined the

success of such programs and the theory involved in their

evolution. He states these programs incorporate complexities

of the psychosocial process of becoming a smoker into the

design of prevention interventions. He lists the following

components as part of a life/social skills approach to

smoking prevention:

-long term consequences of cigarette smoking

-the prevalence of smoking

-correcting students perception of social norms

concerning smoking

-teaching students about the social influences to smoke









-providing behavioral skills to resist influences

-enhancing personal skills and/or self-esteem

-providing general social competence skills.

Flay cites the social inoculation theory as the main

influence for this approach, with added theoretical

bolstering from the attitude change theory and the social

learning theory. Among the program components he felt were

important, based on successful studies, were:

-information on the immediate effects of smoking

-correction about the misrepresentation about the

prevalence of smoking

-discussions of family and media influences on smoking;

and how to deal with them

-a public commitment procedure.

The health belief model is one of the few social

psychological models to be developed expressly to understand

health behaviors (Rimer, 1990). One of the critical

dimensions of this model concerns the failure to believe in

the possibility of having pathology in the absence of

symptoms. This is particularly true with cigarette smokers,

especially young ones. Many of the health problems of

smoking are long term (USDHHS, 1989; USDHHS, 1987). Lung

cancer, emphysema, and cardiovascular diseases do not develop

within the first few years of smoking. Young smokers show a

good knowledge of the connection of smoking with these

diseases (Banspach, Lefebvre, & Carleton, 1989; Johnston et

al., 1989). However, because they are not experiencing any









of the disease symptoms, they feel these effects are a long

way off, and they will be able to stop smoking well before

disease onset. In general, adolescents feel invulnerable to

accidents and chronic diseases (Glanz, Lewis, & Rimer, 1990).

One of the axioms of health education is that knowledge

is necessary, but not sufficient for behavior change.

Information is necessary but not sufficient for knowledge

(Rimer, 1990). Therefore, teaching young students about the

long term effects of smoking may be a good tactic, but by

itself, will not win the prevention war.

In order for people to quit smoking for health reasons,

they must believe cessation will benefit their health, and

also that they are capable of quitting (Rosenstock, 1990).

Knowledge about the risks of smoking is better now than it

ever has been. The 1989 Surgeon General's report (USDHHS,

1989) states the proportion of adults who believed cigarette

smoking increases the risk of emphysema and chronic

bronchitis rose from 50% in 1964 to 81% (chronic bronchitis)

and 89% (emphysema) in 1986. These proportions increased

among current smokers from 42% in 1964 to 75% (chronic

bronchitis) and 85% (emphysema) in 1986. Johnston et al.

(1989) reported that 70% of young adults perceive regular

pack-a-day cigarette smoking as entailing high risk. Despite

these findings, and despite the fact that 80% of all smokers

indicate a desire to quit, over 50 million Americans still

smoke.









Not all adolescents who try a cigarette become regular

smokers; not all who start smoking regularly continue to do

so their entire life. Once an individual has experimented

with smoking, other factors come into play to determine

whether the behavior will become a continuing habit. New

smokers do not become regular smokers immediately. They pass

through the phases of stabilization, acceleration, or

deceleration of their smoking habits (Epstein, Grunberg,

Lichtenstein, & Evans, 1989). Horn (1979) describes the

influence of three groups of factors which bias this choice:

the cost/benefits evaluation of the behavior; common

stereotypes that characterize perception of behavior; and

psychological factors characterizing both personal structure

and personality integration factors, particularly as they

relate to societal demands. The cost of smoking includes the

harmful effects on health, financial cost to the individual

or society, and more recently, a feeling of discrimination in

most public places.

Benefits a smoker may perceive vary even more than the

disadvantages (Horn, 1979). Peer acceptance or facilitation

of social interaction places high on the list for

adolescents. Smokers often smoke to reduce stress, enhance

pleasure, improve their concentration, gain satisfaction from

handling the cigarette, or for numerous other reasons. For

many smokers the benefits do seem to outweigh the costs. The

perceptual stereotypes referred to by Horn develop from a

mystique about what smoking and smokers are like, and why









people smoke. Horn states that, the greater the role played

by these superficial and inaccurate beliefs about the

behavior, the more difficult it becomes for an individual to

develop a sound decision-making process. These stereotypes

are perpetuated by cigarette advertisements. Horn's third

group of factors contains a variety of patterns for

psychological forces which may help determine personal

choices for health behavior, particularly behaviors which

reflect a conflict engendered in individuals between the

demands of society and their own inner desires.

The population entering the Navy consists of current

smokers, former smokers, occasional smokers, and non-smokers

(Cronan & Conway, 1988; Cronan et al. 1989). Studies have

found nearly all smokers start smoking in their teenage years

(USDHHS, 1987; USDHHS, 1989). However, the National Cancer

Institute (NCI) now feel there is a second period where

individuals are at risk for starting smoking. Recent

research indicates there may be another smoking uptake period

in the early 20's as employment transition takes place (T. J.

Glynn, personal communication, September 16, 1991). Cronan

et al. (1989) found that some recruits were starting to smoke

during recruit training (this study was done before the

current no-smoking policy was instituted). It is possible,

since the institution of the no-smoking policy in recruit

training, that smoking initiation may now be taking place in

the training environment after recruit graduation. Because

of possible smoking uptake during employment transition, it









is important that prevention efforts also be presented during

this period. Cronan & Conway (1988) concluded the Navy must

develop and evaluate programs directed toward preventing

personnel from smoking. They felt prevention programs should

probably be implemented as early as recruit training.


Educational Intervention


Because of the mix in smoking status among recruits, a

similarly mixed intervention/prevention strategy may prove

most effective. In a meta-analysis of 39 smoking cessation

interventions Kottke, Battista, DeFriese, and Brekke (1988)

found the most effective programs employed more than one

modality for motivating behavior change. Cronan et al.

(1989) evaluated smoking interventions in recruit training.

They found a one-hour education program significantly reduced

the number of recruits who started smoking during training,

but did not increase the number of smokers who quit. Their

educational intervention stressed the hazards of smoking and

techniques for stopping.

In 1987, the NCI convened an expert advisory panel to

assess the question "What are the essential elements of a

school-based smoking prevention program?" (Glynn, 1989). The

panel concluded that existing programs have been consistently

effective in delaying the onset of smoking. Programs with a

smoking-only focus have about an equal effect as those with a









multicomponent focus. They felt minimum smoking prevention

components should include:

-information about social consequences and short term

physiological effects of tobacco use

-information about social influences on tobacco use,

especially peer, parent, and media influences

-training in refusal skills, including modeling and

practice of resistance skills.

They felt the minimum length of school-based programs should

be two, 5 session blocks with booster sessions in subsequent

years. Doctor Glynn, of the NCI, stated a shorter program

(2-3 hours) would probably be effective with individuals who

had already demonstrated to themselves that they could stop

smoking (T. J. Glynn, personal communication, June 18, 1991).

When used as part of a cessation program, education

intervention may last from 1-4 hours, depending on the length

of the overall program. No studies have been reported in

which length of the education segment was varied, while

attempting to decrease relapse rates or prevent smoking.

The Waterloo Smoking Prevention Project (Flay, 1985)

found previous experience with smoking did not preclude

prevention of further smoking. The study results showed the

program influenced current experimenters to quit smoking, and

remain quit. The prevention curriculum was six hours long

and was designed to influence attitudes towards tobacco and

the acquisition of social skills. The program had three main

components: 1) provide information on the effects of









smoking, 2) focus on social influences to smoke (family,

peer, media), and 3) decision to integrate information on

smoking to individual's own smoking environment and a public

commitment procedure about their decision of whether or not

to smoke. Three booster sessions were included in the

program.

Banspach et al. (1989) assessed two smoking prevention

programs: 1) a five-lesson, video presentation on resisting

pressures to smoke, and 2) a four-lesson teacher led

discussion of smoking and advertising. They found both

programs had a similar positive effect on preventing smoking

in students. The effects seen were significantly different

from those observed in a control group. They concluded that

increasing a student's awareness about the messages they

receive can be enhanced by either a video presentation with

discussion, or a teacher led discussion with student

involvement.


Validation of Smoking Status Self-Report


Cigarette smoking behavior is most often measured by

self-report of frequency and intensity. Researchers find

this procedure simple, efficient, and inexpensive. Murray,

O'Connell, Schmid, and Perry (1987) state because many

adolescents smoke infrequently and episodically, it may be

difficult for them to characterize their usual pattern of

smoking. Adolescents may also try to mislead the









investigator and underreport smoking behavior out of

embarrassment or a desire to please. Self-reports of smoking

status therefore, may not always be accurate, particularly

where smokers feel pressure to give up smoking but may not

have achieved it (Jarvis, Tunstall-Pedoe, Feyerabend, Vesey,

& Saloojee, 1987; Murray et al., 1987). In a study to

validate self-report claims, Jarvis et al. (1987) reported

19% of cotinine confirmed smokers claimed to be non-smokers.

However, other studies found only 2% of smokers claiming to

be non-smokers when not actively persuaded to give up smoking

(Lee, 1987; Thompson, Stone, Nanchahal, & Wald, 1990). For

this reason researchers try various techniques to increase

truthfulness of reporting and to validate self-reports of

smoking.


Bogus Pipeline


One strategy shown effective in increasing validity of

smoking self-reports has been termed the bogus pipeline

method. The rationale for this approach is that individuals

should be more likely to disclose their actual smoking

behavior if they believe the researcher has an independent

and objective means of measuring smoking behavior. Evans,

Hansen, and Mittelmark (1977) were the first to show efficacy

of this procedure with smoking research. Murray et al.

(1987) examined eleven papers on this subject and found five

reported a pipeline effect, while six did not. They









conducted a study to determine effectiveness of the approach

and effectiveness of different methods of message delivery.

Their data supported the hypothesis that adolescent smokers

are more willing to disclose cigarette use under pipeline

conditions. They concluded it is both prudent and

conservative to employ as credible a pipeline procedure as

possible, and use of this procedure offers the best assurance

of a valid assessment.


Biochemical Tests


A number of biochemical markers can be used to validate

smoking self-reports including measures of thiocyanate,

carbon monoxide, nicotine, and cotinine (Fitzpatrick, 1991;

Jarvis et al., 1987; Sepkovic & Haley, 1985). Levels of

carbon monoxide and thiocyanate (a metabolite of hydrogen

cyanide) are easier and less expensive to determine, but may

be raised through exposures unrelated to smoking, such as

auto emissions and diet (USDHHS, 1988; Jarvis et al., 1987).

Neither can they be used as a marker for smokeless tobacco.

All tobacco products contain substantial amounts of nicotine,

which is absorbed from tobacco smoke in the lungs, and from

smokeless tobacco in the mouth and nose. Nicotine is

metabolized in the liver and lungs, and cleared from the body

by the kidneys (USDHHS, 1988). Measures based on nicotine

have the advantage of being tobacco specific (all forms of

tobacco), but require extensive laboratory instrumentation.









Nicotine is a good marker of tobacco use, but its short half-

life in serum (0.5 2 hours) makes it a poor choice.

Nicotine is metabolized to cotinine, trans-3-hydroxycotinine,

and nicotine-l-N-oxide; all of which can theoretically be

used as markers (USDHHS, 1988).

Most investigators agree that cotinine is the analyte of

choice because it is tobacco specific and has a relatively

long half-life (Haley, Axelrad, & Tilton, 1983; Jarvis et

al., 1987; Langone, Cook, Bjercke, & Lifschitz, 1988). The

half-life of cotinine is on average 20 hours (Jarvis et al.,

1987; Langone et al., 1988) which makes sample timing in

relation to cigarette smoking less critical. Cotinine

concentrations in blood are generally tenfold greater than

nicotine, and as a result less sensitive analytical

methodology may be acceptable. Cotinine is metabolized, only

17% is excreted unchanged, but levels may persist for up to

seven days after cessation of habitual smoking (USDHHS,

1988).

Cotinine samples from blood, saliva, and urine are

equally applicable to the whole range of issues requiring

estimates of nicotine exposure from tobacco smoking (Jarvis

et al., 1987). Choice of fluid may depend more on practical

considerations (eg. cost, collection availability) than

pharmokinetic considerations. Because concentrations of

cotinine in urine are tenfold to hundredfold greater than

concentrations in plasma or saliva, a variety of analytic

techniques meet sensitivity requirements (USDHHS, 1988).









Without use of a 24 hour urine sample though, normalization

using creatine excretion is often used (Haley, Colosimo,

Axelrad, Harris, & Sepkovic, 1989). This normalization

requires additional analysis and thus higher costs. Haley et

al. (1989) concluded the additional analyses may not be

necessary when simple validation of nonsmoking status in a

smoking cessation program is the endpoint.

Several analytical techniques have been used to

determine cotinine concentration in biological fluids. The

most frequent used are radioimmunoassay, liquid

chromatography, and gas chromatography (Skarping, Willers, &

Dalene, 1988). The choice depends on the biological fluid to

be assayed; the need for sensitivity, precision, and

accuracy; and economic considerations (USDHHS, 1988).

Immunoassay techniques are simpler, generally require smaller

samples, and may be less expensive. They have been

determined to be best suited for smoking/non-smoking

determinations.

Non-smokers can show low levels of cotinine from

nicotine exposure to environmental tobacco smoke (eg. car,

home, restaurants). Studies have shown passive cotinine

concentrations as high as 32 ng/ml, and active cotinine

concentrations as low as 44 ng/ml (Wall, Johnson, Jacob, &

Benowitz, 1988). Sensitivity for non-smoker analysis is

generally set in the range of 1-25 ng/ml (Thompson et al.,

1990), however cutoff sensitivity and specificity set for

discriminating true has also been set at 50 ng/ml (Jarvis et


~









al., 1987). Other studies have also set non-smoking values

at 50 ng/ml (Fitzpatrick, 1991; Jarvis et al., 1987).

Fitzpatrick sums up nicely the benefits of cotinine

analysis:


The cotinine assay used today can determine either
active or passive exposure to tobacco smoke. It is
specific for exposure to nicotine. It can use urine,
which like saliva, is easy to collect, but it can also
use serum. It has a long half-life of 16 hours so that
a person cannot easily prepare for the test by not
smoking for short periods--ideally, an assay should be
able to detect an individual who has not smoked for 48
hours. It is inexpensive, so that it may be performed
routinely in large screening programs. (Fitzpatrick,
1991, p.11)



There is no biochemical test which can be expected to

yield perfect separation of non-smokers passive smokers, and

active smokers under field conditions. Wall et al. (1988)

give several reasons for this: intersubject variance in

nicotine metabolism, time of day of sample collection,

underreporting of active smoking, adjustment of cigarette

consumption for nicotine content, and perhaps over or

underreporting of passive smoke exposure. However, the use

of biochemical analyses definitely increase the validity of

smoking self-reports.


Concluding Statement


Because of the impact of health, health care costs, and

readiness, the Navy Surgeon General has set a goal of a

Smoke-Free Navy by the year 2000. Prevention efforts in new









accessions, as well as cessation efforts throughout the

ranks, are critical in meeting this goal. Currently the Navy

recruit population shows a higher smoking prevalence than the

general U. S. population. The no-smoking policy in Navy

recruit training provides a perfect opportunity to allow

smokers to stop, but many factors prevent those who quit from

staying quit. Current research reveals many approaches that

show promise in helping these individuals to stay quit, and

non-smokers from ever starting.

Smoking is becoming more and more socially unacceptable,

both in general society, and in the military. However, if

smokers are expected to quit, they must be provided

assistance. Setting policies that provide an environment

conducive to not smoking are beneficial, but alone don't show

high cessation rates. Education programs are an essential

adjunct to no-smoking policies. Quitting smoking is very

difficult and many people cannot do so on their own. Smoking

prevention and smoking relapse prevention programs must be

developed with the characteristics of the Naval population in

mind. They should draw from existing theory and current

research. Programs should provide information designed to

assist individuals in changing behavior intentions to more

health oriented ones. They need to recognize that all

smokers/non-smokers are in different stages of behavior

change and offer varied approaches to reach the entire

audience. This is especially true when groups are to be

addressed and smokers cannot be separated out. Motivation is









crucial in any smoking cessation effort; programs must be

designed around providing motivational incentives and

building self-efficacy.

Health behavior change programs should be guided by
social learning theory to encompass environmental, personal,

and behavioral constructs. Participants must decide for

themselves that smoking is potentially detrimental, recognize

the pressures on them to smoke, and develop their own ways to

cope with these pressures. Alternatives must be presented in

order for informed choices to be made. Recruit smoking

education programs should build on what many recruits will

have already had in their formal education. Misconceptions

about tobacco use must be corrected. Long-term consequences

of smoking should be discussed, but short-term effects also

need to be stressed. Current Navy policy, and future policy

direction, should be discussed to give the new Navy member a

picture of what will be expected of them. Recruits who

entered as smokers have to believe they have actually quit

smoking, if they are expected to stay quit after graduation.

Recruit training is a period when a complete lifestyle

transformation is taking place. Recruits are making

wholesale changes in the ways they live, work, and socialize.

They are taking on added responsibilities, receiving personal

and financial independence, and adjusting many health

practices. They should be encouraged at this time to make

decisions, in all areas, that will lead to self-fulfillment

and better health.














CHAPTER 3
METHODS AND MATERIALS


Introduction


This chapter describes the methods employed to conduct

the study. Subjects are described with a discussion of the

sampling methods used. The survey instruments are described

and validity and reliability are discussed. A detailed

description of the study procedures is given including survey

administration, educational interventions, and the booster

program. A discussion of self-report validation techniques

incorporated in the study is then given. Finally, a

description of how data were handled is presented along with

the plan for data analysis.


Subjects


Seven companies of recruits from the Navy Recruit

Training Center (RTC) in Orlando, FL were used in this study.

Five companies were male and two female. Participants were

357 men and 139 women. The mean age of participants was

19.26 years (standard deviation [SD] = 2.27). Over 99% held

a high school degree or equivalent, 22% had some college or

were trade/technical school graduates, and 2% had a four year

college degree. The mean Armed Forces Qualification Test









(AFQT) score was 65.76 (SD=18.62). The AFQT score provides a

measure of general trainability of recruits. The Navy

requires a minimum AFQT score of 17 with a high school

degree, 31 for other credential holders, and 50 without a

high school diploma (Foley & Rucker, 1989). Seventy-eight

percent of participants were white, 15% were black, 5% were

Hispanic, and 2% were from other ethnic backgrounds.

Recruit training is an intensive 8 week program designed

to indoctrinate the new members as to the ways of Navy life

and prepare them for military duties. The mission of RTC

Orlando is to conduct a training program which will effect a

smooth transition from civilian to Navy life; foster

patriotic behavior; affirm the dignity of the individual;

encourage high standards of personal responsibility, conduct,

manners, and morals; create a desire for self-improvement and

advancement; provide the recruit with knowledge and skills

basic to all naval personnel; develop pride in the unit and

in the Navy and a desire to observe appropriate naval

customs, ceremonies, and traditions; and provide the

Department of the Navy with personnel possessing an effective

level of physical fitness. The mission is carried out

through an intense training and educational program.

The educational program includes health/hygiene classes,

and classes on substance abuse. The current curriculum

however, includes no specific tobacco-use prevention

information (CNTECHTRA, 1991a). There are approximately 75 -

85 recruits in each company and about 5 classes start every









week. A recent tobacco use survey showed that about 28% of

entering recruits are smokers (Cronan & Conway, 1988), which

indicates about 23 members of each study company should be

smokers.

The subject sample was drawn from the total recruit

population. Because of time constraints a purely random

sample of all companies was not feasible. One company,

chosen randomly from a weekly starting group, was used as a

pilot group and went through the research program before the

main study group. The other 7 companies were chosen from all

those starting during adjacent weeks in September 1991.

At RTC, companies are sectioned into training groups.

Each training group contains all companies starting during a

given week (usually 6-7 companies). The training group

progresses through recruit training at the same rate and

graduate on Friday of their eighth week. Companies are

filled as recruits arrive at RTC, without segregation except

by gender. This random assignment to companies allowed for a

random recruit sampling using any training group. Training

Group 47 was selected because of projection for 5 male and 2

female companies. This training group started training

during the week of September 9, 1991. However, the second

female company anticipated did not fill until the following

week, thus the second female company used was part of

Training Group 48.

In an effort to determine if the study population was

representative of the entire Navy recruit population









demographic data were obtained from Naval Technical Training

Command data bases (CNTECHTRA, 1991b). Table 2 is a

comparison of the study group to 6 months of all recruits

going through RTC Orlando, and all 3 Navy RTC's for several

variables.


Table 2. Study group comparison
Education Average Average Percent
level AFQT* Age Minority
score

All RTCs 6 mo 11.69 61.04 19.51 19.37
RTC Orlando 12.07 67.89 19.42 17.8
6mo

T-1 12.05 66.07 19.48 19.12

T-2 12.09 68.48 19.41 14.94

T-3 12.02 64.78 19.40 23.48

Sham 11.95 60.57 20.10 26.58


*Armed Forces Qualification
to all services


Test (AFQT) is required for enlisted entry


This table shows the companies chosen for the study were

fairly representative of all companies going through RTC

Orlando, and the rest of Navy Recruit Training Centers.










Instruments


Smoking history and relapse information were collected

via pencil and paper survey. Surveys were conducted during

the recruits first week of training (P-4 day), after

graduation (8-3 day), and 3 months after graduation. The

surveys used were modified versions of those by the Naval

Health Research Center for their "new accession tobacco use

survey".


Surveys


The Horn-Waingrow Smoking Motives Questionnaire (Girdano

& Dusek, 1988) was added to the intake survey (see Appendix

A) to examine type of smokers who are best helped by this

program. The Fagerstr6m nicotine tolerance questionnaire

(Fagerstr6m, 1978) was also added to examine nicotine

addiction. Questions were added to assess knowledge of and

attitudes toward tobacco use.

The graduation survey (see Appendix B) was much shorter

than the intake survey. Most of the questions were repeats

from the first survey with only a few added to assess change

in knowledge and attitudes. The 3 month follow-up survey

(see Appendix C) was a modified version of the Naval Health

Research Center's 12 month follow-up survey with questions

added to measure change in attitude and knowledge.










Validity and reliability


A test-retest reliability analysis was accomplished with

the intake survey. An extra company (N=84) was chosen to be

a pilot. This company was administered the intake survey on

their P-4 day. They were encouraged to bring any questions

or concerns to the attention of the researcher. All problems

were noted and incorporated into the briefing for the main

study companies. This group completed the same intake survey

three days later. Key questions to be used in the main study

analysis were analyzed here as part of an instrument

reliability test-retest procedure. The questions were

examined for frequency of non-agreement, then Spearman's and

Pearson's correlations were performed to compute reliability.

Table 3 summarizes the results of the instrument reliability

measurements. Nine of the thirteen items tested showed a

correlation of .80 or better (Spearman) and six of twelve

showed a correlation of .80 or better (Pearson). Questions

that showed poor agreement were explained in the briefing to

the main study companies and the wording was changed on some

for subsequent survey versions. In the study analysis

Questions 10 and 11 were scored as correct if responses below

and above exact percentages were answered. Question 5 showed

a low correlation mainly with non-smokers. For this reason

attitude scores were analyzed for all subjects and for

smokers only.









Table 3. Test-retest reliability
Frequency of
Question # Non-agreement Spearman's R Pearson's R

1 10% .93 .90

2 12% .92 .89

3 10% .90 .95

4 9% .75 .75

5 17% .51 .51

6 27% .79 .76

7 34% .65 .62

8 14% .71 .71

9 17% .82 .68

10 38% .80 .79

11 31% .89 .88

12 17% .86 .86

13 25% .92 .93
Question/Variable Key:
1. Smoking status at entry
2. Smokeless tobacco use at entry
3. During the last 30 days prior to entering the Navy how many
cigarettes did you usually smoke on a typical day when you
smoked cigarettes
4. Do you believe cigarette smoking is related to heart disease
5. Are you concerned about the health effects of cigarette
smoking
6. How important is it to you to be a non-user of tobacco
products
7. Over the next year, how likely is it that you'll stop smoking,
if you now smoke
8. In the future, do you see yourself as someone who smokes
9. Would you be in favor of being placed in a smoke-free work
environment
10. What percent of the U.S. population do you believe are current
smokers
11. What percent of all members of the Navy do you believe are
current smokers
12. Should tobacco companies be allowed to target advertising
toward certain groups in order to recruit new customers
13. Fagerstrom nicotine tolerance level









This project, including the instruments and consent

statement, was reviewed and approved by the University of

Florida Institutional Review Board (see Appendix D). The

instruments were destroyed after data analysis to satisfy

Institutional Review Board requirements.


Self-Report Validation Techniques


During the instruction period prior to completion of the

intake survey, participants were briefed on possible self-

report cross checks using urine tests. It was explained that

some of their urine samples submitted upon entry would be

screened for a substance which would tell us their smoking

status. They were also told future random drug screen

samples also might be used to validate follow-up self

reports. Subjects were assured the results would in no way

negatively affect them, but that this procedure was a

requirement of an academic research committee. It was

anticipated this bogus pipeline approach would increase

truthfulness of self-reporting for all three surveys.

Cotinine analysis of urine specimens was accomplished

for a random sampling of participants in the intake and

graduation surveys. Urine specimens provided as part of the

Navy drug screening program were used in the study. All

recruits are required to provide a urine sample within hours

of reporting to recruit training. These samples are tested

locally by means of radioimmunoassay and positive samples are









sent to Navy drug screening laboratories for gas

chromatography-mass spectrometry screening. The samples

testing negative locally are normally disposed of on site.

Normal RTC procedures require that the day after uncontrolled

liberty (after recruit graduation) one company be randomly

selected for a unit drug screen. The same procedures are

again followed for sample collection and testing. For the

purposes of the present study only drug negative samples

provided the basis for a sampling pool.

Fifty urine samples were selected randomly (20 female

and 30 male) by drug screen lab personnel, from participating

companies upon arrival at Recruit Training Command Orlando.

Approximately 10 ml were transferred to a storage vial and

frozen. The same procedure was followed for the company

chosen for the post-liberty recruit urinalysis. Forty-two

samples were collected at this time. All samples were kept

frozen until analyses could be conducted.

Cotinine analysis was conducted utilizing Florescence

Polarization Immunoassay technology. An Abbott TDX automated

fluorescence analyzer (instrument #2, serial L30179) at the

Shands Toxicology laboratory in Gainesville, Florida was

used. Cotinine reagent was purchased from Abbott

Laboratories and was within freshness parameters. The

analyzer was calibrated by Shands lab personnel, according to

the operations manual. Low, medium, and high controls were

run after calibration and results were within acceptable

limits. Each batch analysis run included at least one









control, and all control results were within acceptable

limits.

Results were reported in nanograms per milliliter

(ng/ml). The sensitivity of this analysis, defined as the

lowest measurable concentration which can be distinguished

from zero with 95% confidence, was determined by the

manufacturer to be 50 ng/ml. Indication of smoking was then

set at any result greater than 50 ng/ml. Results were

compared against the self-reported smoking reported on

respective surveys.

Results of cotinine analyses were in 100% agreement with

self-reported tobacco use at pretest, and 96% agreement with

self-reported tobacco use at posttest. This reflects only a

1% misrepresentation of smoking status overall. One subject

indicated no tobacco use but tested high for cotinine; two

others indicated tobacco use but tested low for cotinine.

Self-reported tobacco use and cotinine chemical analyses were

highly correlated (r=.91).


Procedures


After the 7 companies were selected they were randomly

assigned to control or treatment categories. Treatment group

assignment was made before any of the survey data was

processed. One extra company was selected to serve as a

pilot group. This group was used to assist in analysis of

instrument validity and reliability, curriculum










effectiveness, and to uncover any unforeseen problems. Table

4 presents an overview of treatment group assignments.



Table 4. Treatment group assignments

Pilot T1 T2 T3 T4

Company C-175 n=84 C-184 n=81 C-181 n=83 C-183 n=82 C-185 n=79

Number K-079 n=80 C-182 n=88 K-078 n=84
Notes: T1 = Policy only
T2 = Policy + education
T3 = Policy + education + booster
T4 = Policy + sham treatment
Pilot = Policy + education





Intake surveys


All participating companies completed consent forms and

intake surveys on their P-4 day of training (1st week at RTC)

in the same classroom, at the same time of day. Participants

were briefed on what they would be asked to do in the project

and asked to read the consent statement (see Appendix E).

The researcher read the statement aloud to make sure the

subjects knew their participation was voluntary. Information

confidentiality was assured at this point. The intake survey

asked for full name and social security number, but in an
/
effort to assure confidentiality, the follow-up surveys

requested only the last 4 digits of the social security

number as identification. After the explanation, questions

were taken about the project and the consent form.









Participants were then asked to sign the consent forms if

they agreed to participate in the study. The signatures were

witnessed, dated, serialized, and retained for a period of 5

years. The statement portions of the consent forms were

collected and given to the company yeomen (recruit in charge

of all company paperwork) for later re-distribution to the

participants. The intake surveys (see Appendix A) were then

completed by the participants. The pilot group participants

were administered the same intake survey approximately 72

hours later.


Education intervention


The education intervention phase was conducted for

participants on their 2-2 day of training. The curriculum

(see Appendix F) consisted of lecture, video-tapes, visual

aids, demonstrations, and group discussions. Participants

were encouraged to ask questions and participation was

solicited during large group discussions.

The main lecture topic areas were:

*Navy tobacco use policies

*myths about tobacco use

*physiological effects of smoking (short and long

term)

*reasons for choosing to use/not use tobacco

*benefits of not starting/resuming tobacco use

after RTC graduation.









The videos used were:

*"The Performance Edge", from the U.S. Department

of Health and Human Services. It shows the effect

of tobacco and alcohol on performance. A

motivational pitch for non-use is given

*"The Feminine Mistake", from Pyramid films. Shows

the physiological effects of smoking, benefits of

quitting, and long term hazards of smoking

*"Clearing the Air", from the U.S. Navy. Shows

the effects of smoking, Navy tobacco use policies,

and strategies to quit and stay quit.

The videos used were previewed by 12 recruits 7 weeks before

the education intervention began. Positive feedback was

received for their use in the curriculum.

Posters were displayed throughout the classroom. Poster

placement was the same for each lecture period. Those used

were from the American Cancer Society, and included:

*Animals-"It looks as stupid when you do it"

#F-651/90

*Animals-"Butts are gross" #F-652/90

*"Smoking is very debonair" #2163.03-LE

*"Smoking is very sophisticated" #2163.02-LE

*"Smoking is very glamorous" #2163.01-LE

*"Smoking doesn't work" #2418.04-LE

*"Life, the only race you don't win by finishing

first...Don't smoke" #2122.LE

*"Are you a draggin lady?"









*"12 things to do instead of smoking" #2106.LE.

Other visual aids and demonstrations were used during

the lecture periods and the breaks. The following teaching

aids were utilized:

*Consequences of smoking--Display which

graphically depicts detrimental physical effects of

smoking, such as emphysema, lung cancer, and heart

attack

*Second-hand smoke demonstrator--Device which

shows the effect of sitting in a closed room with

smokers, by filtering smoke passively released from

a smoked cigarette

*Mr. Grossmouth--Display which shows the physical

effects of smokeless tobacco to the mouth, tongue,

teeth, and palate

*American Cancer Society pamphlet "50 questions

about smoking".

The education intervention was taught in the same

classroom each time and by the same instructor (the

researcher). Classes started at 7:00 a.m. and ran until

10:00 a.m. Students were told to relax and that the material

was not testable, but they were free to take notes. The

temperature of the room was maintained at 780 F and the

students were allowed to stand, or walk to an in-classroom

drinking fountain, if they got drowsy. Two 15 minute breaks

were given, during which students were asked to discuss

topics for subsequent group discussions. The students were









also encouraged to look at the displays and posters during

the breaks. No unusual external events took place during any

of the class periods.

The entire treatment program was designed to motivate

recruits (both smokers and non-smokers) to not initiate

smoking after graduation. A recent personal communication

with Dr T. J. Glynn (September 16, 1991), of the National

Institutes of Health indicated that the primary component of

this program should be motivation to maintain nonsmoking

status, and to want to do so. The benefits of remaining non-

smokers were stressed, and ex-smokers were challenged to make

the decision to not start again. The program was designed to

instill confidence in the recruit's ability to remain smoke

free. It was stressed that the Navy is anti-smoke and not

anti-smoker, and only the individual can make the choice of

being smoke-free. Every effort was made to ensure the

intervention program was not viewed as coercive.

The intervention curriculum was presented to the

supervisory committee, and to several outside experts for

review. The committee was composed of four health educators

and one experimental behavioral psychologist. The outside

reviewers included:

Carlo DiClemente, Ph D

Behavioral Researcher

University of Houston









Thomas J. Glynn, Ph D

Chief, Cancer Prevention and Control

Extramural Research Branch

National Institutes of Health

National Cancer Institute



Terry L. Conway, Ph D

Health Psychology Department

Naval Health Research Center

All reviewers stated they believed the program to be a sound

design. Many suggestions were given, and most were

incorporated into the existing plan.


Sham treatment


A sham (placebo) treatment was conducted for one company

to analyze the effect of any intervention on the study

population. The idea was to present an educational

intervention, irrelevant to smoking prevention/cessation, but

prefaced by an explanation that the class is part of an

overall program designed to help recruits remain tobacco-free

after graduation from RTC.

This intervention was accomplished on the company's 2.2

day of training, but only for a 40 minute period. The

curriculum (see Appendix G) consisted of a short lecture

about the Navy's commitment to maintain a healthy, productive

workforce, Navy smoking policy, and goals for tobacco use.









Tobacco use was tied in to weight control by the common theme

of heart disease. A 24 minute Navy video entitled "Weight

and fat control/nutrition education" was then shown.

A question and answer period followed the movie. The

class was concluded by a statement about the Navy's

commitment to a healthy workforce and the fact that recruits

should try to make healthy choices in all aspects of their

lives.


Booster


Two companies were given a booster class at the end of

recruit training to reinforce key points of the education

intervention, and to further motivate them not to use tobacco

after graduation. This class was presented on the Friday

before the recruits' departure from RTC. Their formal

graduation ceremony (Pass and Review) was held Friday morning

and the recruits were allowed to go on uncontrolled off-base

liberty starting that evening. The booster class lasted

approximately 45 minutes and was presented mid-afternoon to

both companies in this treatment group.

The booster class incorporated several strategies to

reinforce prior training and increase motivation. Two

pamphlets were distributed to each recruit:

*Smart Move: A Stop Smoking Guide ACS #2515LE









*Clearing the Air: How to Quit Smoking and Quit

for Keeps National Cancer Institute NIH

Publication No. 89-1647.

These pamphlets are comprehensive guides to quitting smoking.

They cover much of the information which was given in class

and contain many suggestions to help avoid relapse. A wallet

card (see Appendix H) was also given to the recruits. This

card lists 5 reasons to remain tobacco-free and 5 ways to

avoid smoking.

The first part of the class period involved going

through the materials distributed. Those who had never

smoked were asked to pass the materials on to a friend or

relative who does smoke, or save it for a smoking shipmate

they may meet later. The ex-smokers were asked to keep the

material for future reference and to place the card in their

purse of wallet for reference as necessary after graduation.

A nineteen minute video (Hazards of Tobacco) was then

shown. This video was made by Captain David Moyer, a Navy

physician who has taught the material in the video to over

50,000 Navy and Marine Corps recruits at training centers in

San Diego, California. This video also covered many of the

same points the education intervention covered, as well as

some different reasons for the recruit to not start/resume

tobacco use.

The recruits were then asked to sign a pledge to assist

the Navy in reaching its goal of being smoke-free by the year

2000. Each recruit received a certificate of participation









in the tobacco prevention program (see Appendix I), but

signing the pledge was voluntary. It was stressed that

signing was not necessarily a promise never to use tobacco,

but rather a promise to do whatever they can to help reach

the goal. The recruits were told the Navy hoped part of this

assistance would be a choice to remain tobacco-free. The

certificate was signed by the researcher, as the program

director, and the Commanding Officer of Recruit Training

Center, Orlando.

All recruits in the booster companies received a T-shirt

courtesy of the American Cancer Society. The T-shirts were

yellow and carried the logo of "Smoke-free class of 2000".

These shirts are being used in the national "Smoke-free class

of 2000" campaign. The recruits were told they are part of

the Navy's smoke-free class of 2000. The recruits were

thanked for their participation, congratulated on graduation,

and reminded of the upcoming follow-up surveys.


Follow-up surveys


Follow-up surveys were administered just before the

participants left RTC, then again 3 months after graduation.

These surveys were designed to measure current tobacco use

habits, knowledge, and attitudes.

The graduation survey (see Appendix B) was administered

by the company commanders after the uncontrolled liberty

weekend. Because some of the questions dealt with possible









rules infractions, the company commanders were asked to leave

the room while the surveys were completed. The company

yeoman collected the completed surveys, sealed them in an

envelope, and returned them to the RTC scheduling office

where the researcher collected them. The female control

company had their graduation surveys mailed to them 3 weeks

after graduation due to confusion in who was to administer.

The 3 month follow-up surveys (see Appendix C) were

mailed to participants at their current command. Those

attending schools located at Naval Training Center, Orlando

were administered the survey during one of their class

periods by a command representative. These surveys were

collected by the command Drug and Alcohol Program Advisor and

mailed to the researcher. The majority of the surveys were

mailed to the participants' Commanding Officer. The

Commanding Officers' representatives were instructed to

distribute the surveys to listed participants, collect the

completed forms, and mail them back to the researcher. One

reminder was sent to the commands which had not responded

within one month of the original mailing. Several commands

not responding to the reminder letter were phoned and

questioned concerning survey status. A number of surveys

(31) had to be re-sent to individuals that had already moved

from their second command. Some surveys (in addition to

those readdressed) were mailed, to individuals (80), with a

self-addressed government envelope and instructions for

return. Participants were not required to pay any postage.










Data Preparation


Once the surveys were completed the answers were

transferred to a 240 item general purpose answer sheet

formatted for optical mark reading. The number of questions

asked on the three surveys totalled 279. Many of the answers

were eliminated or combined so that only 168 data points were

actually coded. The answer sheets had only five response

circles per answer. Some survey questions that had more than

five responses had to be collapsed to fit this requirement.

This was done consistently for questions which were repeated

in surveys. All answers were coded by numbers one through

five (eg. No=1; Yes=2) for data entry, and a survey layout

(codebook) was composed to avoid confusion during analysis.

This layout was used during the coding process to ensure

answers were coded consistently and transferred to the

appropriate circles on the answer sheets. This process was

completed by two individuals who were versed on the

procedure. This process was chosen for a number of reasons

including:

-multiple surveys were involved

-illogical answering could be identified before entry

-the answer sheets could be re-scanned in the event of

data file loss on the computer

-computer entry errors, due to the large data set, could

be minimized.









The completed answer sheets were scanned by a mark reader

which then compiled the data and stored a data file on a

floppy,disk and in a university computer account.

Once the data were in the computer file variables were

range checked for accuracy and improper codes were either

corrected or changed to missing data points. No attempt was

made to impute missing data points.

Data analyses were accomplished using:

-the Statistical Analysis System (SAS) on the University

of Florida VAX cluster

-SAS on the Northeast Regional Data Center computer

Virtual Telecommunications Access Method, and

-Stat View SE + Graphics statistical analysis program on

a Macintosh SE-personal computer.


Analysis Plan


This study was set up on a split plot with repeated

measures design. Table 5 is a presentation of the design

setup. Because tests of the null hypotheses consisted of

both continuous and categorical variables, different testing

procedures were used. Smoking attitudes and smoking

knowledge were examined using a general linear model (GLM)

for repeated measures analysis of variance (ANOVA). Null

hypotheses with categorical variables (relapse rate, smoking

initiation, cigarette consumption, and smoking intentions)

were examined by using frequency tables with the Pearson's










chi-square statistic. This test statistic looks at the

goodness of fit between the distribution observed and the

distribution expected (Aday, 1989).



Table 5. Repeated measures design

Pre-test Post-test 3 Month f/u

0 T 0 O0

O T2 O 0

O T3 O O

O T4 O O


Notes: T1
T2
T3
T4


Policy
Policy
Policy
Policy


only
+ education
+ education + booster
+ sham treatment


Smoking relapse and smoking initiation were examined

according to Table 6, using differences between pretest and

follow-up.


T1

T2

T3


T4


Table 6.


Chi-scuare freuuencv table


Notes:D1=current smoking at pretest ana at follow-up (RELAPSE)
D2=current smoking at pretest but not at follow-up (NON-RELAPSE)
D3=no smoking at pretest or follow-up (NON-INITIATION)
D4=no smoking pretest but current smoking follow-up (INITIATION)


D1 D2 D3 D4










Smoking intentions were examined using differences between

pretest and posttest, observe effect of policy and education.

Cigarette consumption was examined using differences between

pretest and follow-up.

A number of univariate analyses procedures were used to

help describe population variables and draw conclusions about

possible future benefits in research designs with this

population. The significance level for all the tests was set

at p=.10, as the consequences of a Type I error did not

outweigh acceptance of a high probability of making a Type II

error. As this was the first study of its kind with Navy

recruits, the exploratory nature of the educational design

was considered in determining the alpha level.














CHAPTER 4
RESULTS AND DISCUSSION


Introduction


The purpose of this chapter is to present the results of

data analysis and an explanation of how these results support

or do not support the hypotheses. The data presentation and

discussion are organized around individual hypotheses.

The chapter begins with a precise description of the

study population as it evolved through the study period.

Next, the actual results as they apply to each hypothesis are

presented. The last section is an interpretation of the

findings, a discussion of the implications of additional

knowledge in the smoking field, and a discussion of potential

applications of the findings.


Population Description


The study began with a total of 557 subjects in 7

recruit companies. Fourteen percent of these subjects were

lost due to normal attrition from their original recruit

company. This attrition was equally distributed across

subject companies. Therefore, the total number of subjects

who completed a pretest and graduated with their original

company was 496 (only two subjects refused to complete the









pretest survey). Seventy-four percent of this total

completed surveys at graduation (only 50% were completed in

treatment Group 1 due to an administering error in one

company).

Follow-up surveys were mailed to 516 individuals. Of

these surveys 320 were returned completed for a response rate

of 62%. Table 7 summarizes survey completion at each

occasion.



Table 7. Percent survey completion at each measurement
period

Treatment group

1 2 3 4 Total

Pre (140) (151) (136) (69) (496)

Post 50% (70) 85% (128) 82% (112) 81% (56) 74% (366)

F/U 57% (80) 64% (97) 60% (82) 29% (20) 56% (279)
*Notes:Actual numbers are in parentheses.
Treatment: 1 = Policy only
2 = Policy + education
3 = Policy + education + booster
4 = Policy + sham treatment




Treatment Group 4 consisted of only one recruit company and a

poor follow-up return rate of 20 should be noted.

Ten percent of the surveys were reported lost or

undeliverable to participants, and 28% were not returned (not

accounted for) at all. Forty-two of the surveys not returned

had been sent to 13 commands who did not respond to the

initial letter or the reminder, and could not be reached by









phone. The rest of the non-returned surveys had been mailed

directly to individuals. Only a 22% response rate was

obtained when participants' Commanding Officers were not

involved in administering the follow-ups. The increase in

overall follow-up response shows the utility of mailing

surveys via Commanding Officers.

Of the completed surveys at follow-up, 279 were usable

for the main study population. This represented 56% of the

original pretested population The rest were unidentifiable

as study participants. An analysis was performed to

determine if the group of non-respondents was representative

of the whole population with respect to initial smoking

status; Table 8 summarizes the findings.



Table 8. Percentage of smokers in non-respondent group and
original study population

Treatment group

1 2 3 4 Total
Non- 51.7% 46.3% 53.7% 42.9% 48.8%
Respondents (31) (25) (29) (21) (106)
At pretest 50.7% 35.8% 46.3% 39.1% 43.3%
(71) (54) (63) (27) (215)
*Note: Actual numbers in parentheses.



Non-respondents of each treatment group had a higher

percentage of smokers, but the differences from the pretest
results were not significant (X2 = 4.65, p>.l).










Results



Smoking relapse


Participants were asked to respond to questions

regarding current smoking status, as part of each of the

three surveys. Current smoking status for the pretest

reflected status just before entering recruit training. A

summary of current smoking by treatment group, at each

measurement period, is presented in Table 9. This table also

shows the smoking relapse rate for each treatment group.



Table 9. Percent of current smokers at each measurement
period

Treatment group
1 2 3 4 Total
n=161 n=171 n=166 n=69 N=496
Pre 50.7% 35.8% 46.3% 39.1% 43.3%
(71) (54) (63) (27) (215)
Post 27.1% 3.8% 2.6% 18.9% 10.2%
(19) (5) (3) (11) (38)
F/U 42.5% 25.5% 33.7% 25.0% 32.7%
(34) (25) (28) (5) (92)
Relapse
Rate 82.5% 66.6% 76.5% 66.6% 75.5%
*Note: Actual numbers in parentheses




While relapse rates (at follow-up) are lower among

participants in the treatment groups, results of chi-square

statistics calculated for these differences showed they were
not significantly different than the control (X2 = 1.68,

p>.l). Since the RTC smoking policy still applied to









participants at time of posttest, indications of current

smoking were considered violations of rules (smoking on

liberty) rather than relapse. The education treatment groups

(Groups 2 & 3) showed lower violation of smoking rules and

results of chi-square analysis showed these differences to be

significant (X2 = 22.08, p<.001).

Several variables were examined that may have confounded

the relapse results: participant gender, AFQT scores,

Fagerstr6m nicotine tolerance scores, age started smoking,

and cigarette consumption prior to entry. Covariance of the

continuous variables (AFQT and Fagerstr6m scores) was

initially examined by a general linear means procedure (SAS

PROC GLM) to determine if further analysis was warranted.

Categorical modeling procedures were then run

controlling for the variables of possible significance.

Table 10 summarizes the smoking status at entry and relapse

rate by gender, for the study population.



Table 10. Percent of current smokers by gender and
corresponding relapse rates

Male Female
Current smokers at 40.9% 49.6%
entry

Relapse rate 72.6% 79.2%




The differences seen in relapse rate by gender were found not
to be significant (X2 = .634, p>.l).









The Fagerstr6m scores were transformed to categorical

form by creating two levels:

low tolerance (Fagerstr6m scores 1 6)

corresponding to low nicotine addiction

high tolerance (Fagerstr6m scores 7 11)

corresponding to high nicotine addiction.

Table 11 summarizes nicotine tolerance level reported at

entry and corresponding relapse rates.



Table 11. Nicotine tolerance levels reported with
corresponding relapse rates

Nicotine Tolerance Level

Low High

Reported at entry 74.7% 25.3%

Relapse Rate 76.1% 96.8%




The data seen in Table 11 seems to indicate that smokers

reporting a high nicotine tolerance relapsed to smoking at a

higher rate. The differences seen in relapse rate by
nicotine tolerance level were found to be significant (X2 =

3.58, p<.l).

Another category that seems to affect smoking relapse is

the number of cigarettes smoked prior to entry in recruit

training. Figure 1 summarizes the relapse rates for given

categories on smoking at entry.





85


100


80


60
i 6 o0 Relapse
Q rate


20


02----0 no-- -
1 2 3 4 5
Cigarettes smoked
*Note: 1 = no smoking
2 = <1 per day
3 = 1-5 per day
4 = 6-20 per day
5 = >20 per day

Figure 1. Percent relapse for corresponding entry smoking
levels




Some relapses are found in cigarette consumption

category "none" because those indicating they quit within two

months prior to recruit entry were considered current

smokers. An obvious trend is seen in that relapse increases

with an increase in cigarette consumption. The differences

seen in relapse rate by prior cigarette consumption were

found to be significant (X2 = 35.85, p<.001). Analysis of

age smokers started and their AFQT scores did not reveal any

significant results.

To determine if relapse was affected by increased

knowledge scores an analysis of variance (ANOVA) was

conducted modeling relapse with knowledge gain. Possible









knowledge score range was zero to six. The mean knowledge

gain for non-relapsers was 0.95 (16%) and for relapsers was

0.34 (6%). This difference was significant (F = 5.09, df =

1, 77, p<.l).

In an effort to understand why recruits start smoking

again after boot camp, participants were asked to list

reasons they began smoking again. The top five reasons

relapsers listed for starting smoking after boot camp were:

"It calmed me" 81%

"I liked the taste" 56%

"Parents or friends back home smoke" 53%

"Friends smoked" 49%

"I had no desire to quit" 44%.


Smoking initiation


The other side of the smoking status analysis concerned

non/former smokers who began smoking during the three month

follow-up period. Table 12 is a summary of smoking

initiation by treatment group.



Table 12. Percentage smoking initiation

Treatment group

1 2 3 4 Total
Smoking 2.5% 7.3% 4.1% 7.1% 5.3%
started (1) (5) (2) (1) (9)
*Note: Actual numbers in parentheses









A chi-square procedure was used to analyze differences

between groups. The differences observed were found to be
not significant (X2 = 1.44, p>.l).


Smoking attitudes


The attitude score was obtained by summing adjusted

values for the following variables: concern about cigarettes,

concern about pipe smoking, concern about chewing tobacco,

concern about snuff use, the importance of being a non-

smoker, feeling about working in a smoke-free environment,

and attitude toward targeted cigarette advertising. The

range of possible scores was zero to ten (ten being the most

positive attitude toward not smoking).

Two sets of analyses were conducted for attitude

changes. Smoking attitude scores for all participants were

examined, then scores were examined for those participants

who were current smokers at entry to the Navy. Table 13

presents the attitude score means and standard deviations

observed (for all participants) at each measurement period by

treatment group.








Table 13. Attitude scores at each measurement period and
differences pre to post for all subjects

Treatment group

1 2 3 4 Total
6.31 6.37 6.33 6.23 6.32
Pre (2.88) (2.80) (2.99) (2.99) (2.89)
6.46 7.41 7.36 6.87 7.12
Post (2.93) (2.58) (2.65) (2.73) (2.71)
6.66 6.49 7.05 6.65 6.71
F/U (3.09) (2.94) (2.77) (2.89) (2.92)
Diff.** 0.25 1.05 0.91 0.89 0.83
post-pre (2.33) (2.36) (2.69) (2.87) (2.55)
*Note: -Standard deviations in parentheses
**Differences reflect only subjects completing both pre and post
tests.




Repeated measures ANOVA were performed to determine if

time, treatment group, or interaction effects were present.

A significant time effect was observed for all groups (F =

4.38, df = 6, 394, p<.l). Treatment effect differences were

not significant (F = 0.5, df = 3, 197, p>.1), but interaction

effects were significant (F = 1.89, df = 6, 394, p<.l). This

indicates the changes seen through time on the smoking

attitude scores of all subjects were different depending on

which treatment group the subject was in. Separate critical

F values were then calculated for paired attitude scores

based on the significant interaction analysis. Pretest

scores were not significantly different for any two treatment

groups, which was also the case for follow-up scores. For

this reason, only attitude differences pre to post are

reported. The only significant treatment differences seen

occurred on the posttest and are summarized below.









TRT 1 TRT 2 F = 13.36, p < .10

Posttest TRT 1 TRT 3 F = 11.37, p < .10

scores TRT 4 TRT 2 F = 3.96, p < .10

TRT 4 TRT 3 F = 2.92, p < .10

Table 14 presents the attitude score means and standard

deviations observed (for smokers at entry) at each

measurement period by treatment group.



Table 14. Attitude scores at each measurement period and
differences pre to post for smokers

Treatment group

1 2 3 4 Total
4.63 4.41 4.17 4.33 4.40
Pre (2.52) (2.44) (2.51) (3.10) (2.57)
4.95 5.89 5.84 5.75 5.63
Post (2.72) (2.47) (2.77) (2.64) (2.66)
4.77 4.23 5.02 6.0 4.77
F/U (2.83) (2.42) (2.47) (2.90) (2.61)
Diff.** 0.18 1.51 1.50 1.50 1.19
post-pre (2.36) (2.47) (3.26) (2.527) (2.76)
*Note: Standard deviations in parentheses
**Differences reflect only subjects completing both pre and post
tests.




Repeated measures ANOVA were performed to determine if

time, treatment group, or interaction effects were present.

A significant time effect was observed for all groups (F =

5.74, df = 6, 148, p<.l). Treatment effect differences were

not significant (F = 0.61, df = 3, 74, p>.l). Interaction

effects were also not significant (F = 1.38, df = 6, 148,

p>.l). Separate critical F values were calculated for paired

attitude scores. Pretest scores were not significantly









different for any two treatment groups. The only significant

differences seen for posttest and follow-up scores are

summarized below:

TRT 1 TRT 2 F = 5.59, p < .10

Posttest TRT 1 TRT 3 F = 5.13, p < .10

scores TRT 1 TRT 4 F = 6.19, p < .10



Follow-up TRT 2 TRT 3 F = 3.07, p < .10

scores TRT 2 TRT 4 F = 4.57, p < .10


Smoking Knowledge


Knowledge on certain aspects of tobacco use were

examined for all treatment groups. The knowledge score was

obtained by summing adjusted values for the following

variables: smoking effect on heart disease, smoking effect

on cancer, smoking effect on emphysema, smoking

addictiveness, smoking prevalence in U.S. population, and

smoking prevalence in Navy population. The possible range

for scores was zero to six. A score of six indicated a high

level of smoking knowledge and a score of zero indicated a

low knowledge.

Table 15 presents the mean scores and standard

deviations observed at each occasion by treatment group along

with the differences observed between occasions.








Table 15. Knowledge scores at each measurement period and
differences observed

Treatment group

1 2 3 4 Total
4.01 4.06 4.07 3.93 4.03
Pre (1.08) (1.17) (1.02) (1.13) (1.10)
4.29 4.59 4.57 4.25 4.48
Post (0.83) (0.85) (0.85) (1.00) (0.89)
4.14 4.39 4.56 4.05 4.35
F/U (1.02) (1.00) (0.93) (0.39) (0.98)
Diff.** 0.19 0.54 0.45 0.29 0.41
post-pre (1.21) (1.09) (1.11) (1.12) (1.13)
Diff.*** -0.22 -0.25 -0.07 -0.35 -0.19
f/u-post (1.24) (1.04) (1.10) (0.70) (1.07)
*Note: Standard deviations are in parentheses.
**Differences reflect only subjects completing both pre and post
tests
***Differences reflect only subjects completing both pre and
follow-up.




Repeated measures ANOVA were performed to determine if

time, treatment group, or interaction effects were present.

A significant time effect was seen for the entire population

(F = 8.46, df = 6, 398, p<.l). Treatment effect was also

significant (F = 2.27, df = 3, 199, p<.l) but interaction

effect was not significant (F = 1.31, df = 6, 398, p>.l). A

knowledge difference variable (knowledge gain) was produced

by subtracting the pretest knowledge score from the posttest

knowledge score. An ANOVA (SAS PROC GLM) was conducted

modeling knowledge gain with treatment level. Post-hoc tests

revealed a significant difference only between treatment

Groups 1 and 2. A knowledge difference variable (knowledge

retention) was produced by subtracting pretest scores from

follow-up. Results of knowledge retention show the booster




Full Text
41
-providing behavioral skills to resist influences
-enhancing personal skills and/or self-esteem
-providing general social competence skills.
Flay cites the social inoculation theory as the main
influence for this approach, with added theoretical
bolstering from the attitude change theory and the social
learning theory. Among the program components he felt were
important, based on successful studies, were:
-information on the immediate effects of smoking
-correction about the misrepresentation about the
prevalence of smoking
-discussions of family and media influences on smoking;
and how to deal with them
-a public commitment procedure.
The health belief model is one of the few social
psychological models to be developed expressly to understand
health behaviors (Rimer, 1990). One of the critical
dimensions of this model concerns the failure to believe in
the possibility of having pathology in the absence of
symptoms. This is particularly true with cigarette smokers,
especially young ones. Many of the health problems of
smoking are long term (USDHHS, 1989; USDHHS, 1987). Lung
cancer, emphysema, and cardiovascular diseases do not develop
within the first few years of smoking. Young smokers show a
good knowledge of the connection of smoking with these
diseases (Banspach, Lefebvre, & Carletn, 1989; Johnston et
al., 1989). However, because they are not experiencing any


6
Physical as well as psychological factors are involved
in relapse (Carmody, 1990; Shiftman, Read, Maltese, Rapkin, &
Jarvik, 1985). For recruits, physical withdrawal symptoms
are gone after eight weeks of training, as peak physical
withdrawal symptoms of tobacco appear to last for about 1-2
weeks (USDHHS, 1988). Therefore, if recruits relapse to
smoking it will probably be from psychological factors, a
belief they never quit, or a willful intention to start
again. Each of these areas were addressed in the present
study.
Statement of the Research Problem
The military population has been targeted as a group in
need of effective smoking prevention and cessation efforts.
Efforts thus far have not succeeded in reducing smoking
prevalence to civilian levels. An attempt has been made to
promote cessation and discourage initiation by banning
tobacco use for all personnel at recruit training centers.
No study results have yet been published concerning the
effect of the policy on smoking after training, and no
efforts have been made to find ways to decrease smoking
relapse for graduating recruits.
In general, military smoking prevalence can be reduced
by addressing current service members and new recruits.
Cessation and prevention efforts for current service members
is vital, but if 40% of new recruits are smokers, the problem


120
Please indicate in the above boxee the
last 4 digits of your social security
number,
52. Do you intend to use cigarettes after
graduation from training, when the smoking
policy allows you the choice to do so?
O No O Yes
53. Would you be in favor of being placed
in a smoke-free work environment after
leaving training?
0 No O Yes
54. What percent of the U. S. population
do you think are current smokers?
020% 030% 0 40%
050% 060% 075%
55. What percent of all members of the
Navy do you believe are current smokers?
020% O30% 0 40%
0 50% 0 60% O70%
56. Should tobacco companies be allowed
to target advertising toward certain
groups in order to recruit new customers?
O No O Yes
57. Do you expect to complete a college
degree sometime in the future?
O No 0 Yes
58. Do you plan to make the Navy a
career?
Ono OYes
60. On average, how many cigarettes did
you smoke per day before entering the
Navy?
cigarettes per day
61. What brand of cigarettes did you
smoke?
62. Did you inhale?
O always
O sometimes
O never
63. Did you smoke more in the morning
than during the rest of the day?
ONo OYes
64. How soon after waking up did you
smoke your first cigarette?
Owithin 5 minutes
O within 30 minutes
Onot until after breakfast
65. Which cigarette will be the hardest
for you to give up?
O first one in the morning
O the one after meals
O the one while on the phone
O other
66. Did you find it difficult to refrain
from smoking in places where it was
forbidden (example: church, library, work,
plane) ?
O No O Yes
67. Did you smoke if you were so ill that
you were in bed most of the day?
Ono OYes
If you indicated that you have never
smoked cigarettes STOP here. If you
indicated you have EVER regularly smokad Continue on reverse
please answer the rest of the questions
based on prior smoking habits.
59.How do you think the smoke-free
policy at this training command will
influence your tobacco use after you
leave?
OWill help me STOP using tobacco
OWill help me REDUCE my tobacco use
O Will NOT CHANGE my tobacco use
Owill PROBABLY INCREASE my tobacco
use when I leave
U 0 i 7 3


7
will perpetuate. Specifically, the present study focuses on
reducing the number of smokers in the recruit population. To
do this, the effect of current smoking policy at Recruit
Training Center, Orlando, FL, was examined. Relapse after
graduation, smoking attitudes, and future smoking intentions
were assessed. Changes in smoking relapse and initiation were
then examined for groups exposed to various intervention
conditions.
Purpose of the Study
The purpose of this study was to examine the impact of
an education program on smoking knowledge, attitudes,
intentions, and on smoking relapse rate and subsequent
cigarette consumption. Specifically the study was designed
to
(1) measure effect of the no-smoking policy at
Recruit Training Center, Orlando, FL, on recruit smoking
knowledge, attitudes, intentions, and relapse;
(2) examine differences in observed levels of recruit
smoking knowledge, attitudes, intentions, and relapse
for various treatment conditions;
(3) examine smoking initiation rate differences (for
non-smokers prior to recruit training) for various
treatment conditions; and
(4) examine variables affecting smoking relapse.


APPENDIX D
HUMAN FACTORS COMMITTEE APPROVAL


114
-conducting education sessions later in training
cycle when recruits have abstained from smoking
longer
-breaking education classes into one hour sessions
to allow time to process smaller portions of
information and formulate questions for later
sessions
-incorporating refusal skills training and role
playing into curriculum
-incorporating some correct "no" answers into
knowledge questions.


128
18.On the average, how often did you
smoke cigars?
0 Never/Don't use them 0
0 Once or twice in the O
last 5 months 0
0 3-6 days in the 0
last 5 months 0
0 7-11 days in the O
last 5 months
Appx once/month
2-3 days/month
1-2 days/week
3-4 days a week
5-6 days a week
About every day
19.On the days you smoked cigars, how
many did you smoke?
ONA 0 2 04 06 08
01 03 05 07 0 9+
IF YOU HA VI VIVIR USED AVI TOBACCO
PRODUCTS, PLIABI 00 TO QUESTION #21
20.Below is a list of reasons people
give for STAITIIG to use CIGARITTI8,
CIGARS, and/or PIPIS, and CIIiUIG
TOBACCO, SIUFF, and/or DIP.
For each possible reason, mark VO or
YES for both the CIGARETTES, CIGARS,
and/or PIPES" (C,C6/orP) column, and
the "CHEWING TOBACCO, SNUFF, and/or DIP"
(CT,84/orD) column to indicate whether
it was a reason why you C,C CT,
started to use any of these & S 6
tobacco products after or or
recruit training. P D
VI VI
n) Parents/friends back
home smoke/use smokeless
tobacco
o) I wanted to be able to
take a break
p) I had no desire to stay
tobacco-free after boot
camp
q) I was curious
r) Smokeless tobacco was
less noticeable to use in
"restricted" areas than
cigarettes
8) Smokeless tobacco was
less offensive to non-
smokers
0 0
0 O
0 0
0 0
0 0
0 0
0 0
0 0
0 0
o o
RESTRICTIONS
21. Bow do you think that the smoke-free
policy at your recruit training contnand
influenced your tobacco use during the 3
months after leaving that command?
0 NA-I was not a tobacco user
0 It helped me STOP using tobacco
0 It helped me REDUCE my tobacco use
0 It did NOT CHANGE my tobacco use
0 It PROBABLY INCREASED my use when I left
22. How do you think the smoking education
classes offered at your recruit training
camnand influenced your tobacco use during
the 3 months after leaving that coomand?
0 NA-I was not a tobacco user
0 It helped me STOP using tobacco
0 It helped me REDUCE my tobacco use
0 It did NOT CHANGE my tobacco use
0 It PROBABLY INCREASED my use when I left
23. Do you think it is a good policy to
prohibit tobacco use during recruit
training?
0 No 0 Yes
24. a. Are there restrictions on tobacco
use in your current work
environment?
0 No 0 Yes
b. If YES, how often are these
restrictions enforced
0 Never 0 Sometimes 0 Always
0 Rarely 0 Usually
25. Are you in favor of a smoke-free work
environment?
0 No 0 Yes


143
Cigarette smoking and other tobacco use can become addicting. It is
physically addicting because of the drug nicotine, and psychologically
addicting because it has become part of the lifestyle of the tobacco
user. We discussed some reasons people start using tobacco, but let us
now discuss some reasons they continue to use, as these reasons are
different and often need to be overcome to successfully quit:
-to cope with stresses (phone, car, work, etc.)
-to calm them (relief from nicotine withdrawal)
-to help concentrate on a task
-as a reward for accomplishing things
-increasing enjoyment of other things
-addicted to nicotine many long time smokers say they would like
to quit smoking but feel they are addicted and just dont believe
they can do it
The key to changing any health behavior is first believing you can
do it. If you used tobacco products before entry, and thought you could
never quit, you now know you can as you've been tobacco-free for over 2
weeks and by the time you graduate you will indeed accomplished
something, that for most people, is very difficult, something millions
of Americans wish the could accomplish; stopping smoking or other
tobacco use.
During the next break I'd like you to discuss your feelings about
having quit tobacco products. If you never used tobacco, lend an ear
and share ways that you have used to stay tobacco-free. All of you
should discuss strategies that can be used after graduation, when you
enter the general Navy population of 40% smokers, to not be
influenced to start using tobacco.
*** 10 MINUTE BREAK ***
ASK ABOUT FEELINGS OF QUITTING (10 minutes)
List strategies to stay quit
-what strategies do you think will work?


156
Hughes, J. R., & Hatsukami, D. K. (1986). Signs and symptoms
of tobacco withdrawal. Archives of General Psychiatry.
43, 289-294.
Jarvik, M. E., & Hatsukami, D. K. (1989). Tobacco dependence.
In T. Ney & A. Gale (Eds.), Smoking and human behavior
(pp. 57-68). Chichester, England: John Wiley & Sons.
Jarvis, M. J., Tunstall-Pedoe, H., Feyerabend, C., Vesey, C.,
& Saloojee, Y. (1987). Comparison of tests used to
distinguish smokers from nonsmokers. American Journal of
Public Health. 77, 1435-1438.
Johnston, L. D., O'Malley, P. M., & Bachman, J. G. (1989).
Drug use among high school seniors, college students.
and young adults (DHHS Publication No. ADM 89-1638).
Washington, DC: U.S. Government Printing Office.
Johnston, L. D., O'Malley, P. M., & Bachman, J. G. (1991).
Drug use among high school seniors, college students.
and voung adults (DHHS Publication No. ADM 91-1835).
Washington, DC: U.S. Government Printing Office.
Kottke, T. E., Battista, R. N., DeFriese, G. H., & Brekke, M.
L. (1988). Attributes of successful smoking cessation
interventions in medical practice. Journal of the
American Medical Association. 259. 2883-2889.
Langone, J. J., Cook, G., Bjercke, R. J., & Lifschitz, M. H.
(1988). Monoclonal antibody ELISA for cotinine in saliva
and urine of active and passive smokers. Journal of
Immunological Methods. 114. 73-78.
Lee, P. N. (1987). Lung cancer and passive smoking:
Association an artifact due to misclassification of
smoking habits? Toxicology Letters. 35. 517-524.
Leventhal, H., Baker, T., Brandon, T., & Fleming, R. (1989).
Intervening and preventing cigarette smoking. In T. Ney
& A. Gale (Eds.), Smoking and human behavior (pp. 313-
336). Chichester, England: John Wiley & Sons.


APPENDIX I
CERTIFICATE OF PARTICIPATION


158
Pentz, M. A., Brannon, B. R., Charlin, V. L., Barrett, E. J.,
MacKinnon, D. P., & Flay, B. R. (1989). The power of
policy: The relationship of smoking policy to adolescent
smoking. American Journal of Public Health. 79. 857-862.
Perry, C. L., Baranowski, T., & Parcel, G. S. (1990). How
individuals, environments, and health behavior interact:
Social Learning Theory. In K. Glanz, F. M. Lewis, & B.
K. Rimer (Eds.), Health behavior and health education
(pp. 161-186). San Francisco: Josey-Bass.
Petersen, L. R., Helgerson, S. D., Gibbons, C. M., Calhoun,
C. R., Ciacco, K. H., & Pitchford, K. C. (1988).
Employee smoking behavior change and attitudes following
a restrictive policy on worksite smoking in a large
company. Public Health Reports. 103. 115-120.
Prochaska, J. O., & Diclemente, C. C. (1982).
Transtheoretical therapy: Toward a more integrative
model of change. Psychotherapy: Theory, Research, and
Practice, 19, 276-288.
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and
processes of self-change of smoking: Toward an
integrative model of change. Journal of Consulting and
Clinical Psychology. 51. 390-395.
Prochaska, J. 0., & DiClemente, C. C. (1984). The
transtheoretical approach: Crossing traditional
boundaries of therapy. Pacific Grove, CA: Brooks/Cole.
Rimer, B. K. (1990). Perspectives on interpersonal theories
in health education and health behavior. In K. Glanz, F.
M. Lewis, & B. K. Rimer (Eds.), Health behavior and
health education (pp. 140-158). San Francisco: Josey-
Bass.
Rosenstock, I. M. (1990). The Health Belief model: Explaining
health behavior through expectancies. In K. Glanz, F. M.
Lewis, & B. K. Rimer (Eds.), Health behavior and health
education (pp. 39-62). San Francisco: Josey-Bass.
Scali, W. K. (1989). A submarine shipboard smoking cessation
program. Military Medicine. 154. 551-552.


136
2. Polluted air is just as bad as smoking
No, Although it is hazardous to breathe, it is no where as concentrated
as cigarette smoke 1200 toxic chemicals have been identified as
product of tobacco smoke. Air pollution is controlled much tighter than
cigarette smoking,
3. Cigarette smoking makes one glamorous?
ASK How many non-smokers would not date a smoker?
4. No reason to worry what will happen to your body as it takes
several years for any harm to occur?
- True, that cancer does not occur overnight but your body is harmed
with cigarettes( eg. Smoker's cough develops pretty quick)
- other short-term problems seen in video later.
shortness of breath, increased heart rate, bad breath, smelly
clothes
5. Cigarettes relax a person?
-Nicotine is a stimulant, increases heart rate and blood pressure
-Relaxing effect mostly comes from addiction process
-Nicotine withdrawal symptoms can occur within hours of the last
cigarette and smoking the next cigarette is a way of relieving the
symptoms
6. Once you start you can't kick the habit?
-It is very hard to do but millions of people are successful each
year.
-At graduation, all smokers will have quit for 8 weeks- a
tremendous accomplishment
- At graduation you need to make the choice whether it is
beneficial to start again.
-Boot Camp may be the easiest place to quit because the option
to start is removed for eight weeks. People pay good money to be
placed in treatment programs like a boot camp environment.


ACKNOWLEDGEMENTS
I wish to express my sincere gratitude to Dr. W. William
Chen, chairman of my dissertation committee. His guidance
during the past three years, especially during the
dissertation process, has been invaluable. I would also like
to extend my appreciation to Dr. R. Morgan Pigg, Dr. Claudia
Probart, Dr. Steve Dorman, and Dr. Marc Branch for serving as
members of my doctoral committee. Without the guidance and
assistance of my committee I would never have been able to
complete this work, nor retain my sanity. I also appreciate
the statistical assistance provided by Dr. David Miller, and
the help of Dr. Roger Bertholf in cotinine analysis.
I wish to thank my parents, Pat and Joe Pokorski, for
lifelong support of all my endeavors. I'd like to
acknowledge the patience my children, Mike and Nicole, have
shown over the past few years while having to deal with a
"part-time" dad. I would especially like to thank my wife
Liz for her understanding, patience, editorial assistance,
and completion of over 600 scantron forms.
I'd like to recognize the assistance provided by the
Navy's Office of Health and Physical Readiness. Without the
financial assistance provided by this office the study could
not have been as comprehensive. I'd like also to thank the
ii


19
annual national survey of American high school seniors,
stated that in 1989 29.4% of seniors were current smokers (30
day prevalence of cigarette use), which was the same
proportion as the class of 1981. High school dropouts have
prevalence rates for all types of drugs, including
cigarettes, substantially higher than in-school students
(Johnston, O'Malley, & Bachman, 1989).
Military Tobacco Use and Related Problems
Tobacco use in the military has been quite prevalent for
many years. Tobacco has been part of the traditional rations
given to soldiers during war time (Ferrence, 1989). This
practice started the smoking habit in hundreds of thousands
of Americans and began an association of cigarettes with the
military that persists today. Very little research can be
found in the literature on military smoking cessation and
none can be found on military smoking relapse prevention.
However, this is not a reflection of the magnitude of the
problem. A recent survey of the military found over 40% of
all members are smokers (Bray, et al., 1988). Marsden, Bray,
and Herbold (1988) showed the number of illnesses reported by
U.S. military personnel is significantly related to smoking,
as well as to other substance abuses, such as alcohol. Their
study utilized data from the 1985 worldwide survey of alcohol
and non-medical drug use among military personnel. They
found the number of healthy behaviors practiced was inversely


43
Not all adolescents who try a cigarette become regular
smokers; not all who start smoking regularly continue to do
so their entire life. Once an individual has experimented
with smoking, other factors come into play to determine
whether the behavior will become a continuing habit. New
smokers do not become regular smokers immediately. They pass
through the phases of stabilization, acceleration, or
deceleration of their smoking habits (Epstein, Grunberg,
Lichtenstein, & Evans, 1989). Horn (1979) describes the
influence of three groups of factors which bias this choice:
the cost/benefits evaluation of the behavior; common
stereotypes that characterize perception of behavior; and
psychological factors characterizing both personal structure
and personality integration factors, particularly as they
relate to societal demands. The cost of smoking includes the
harmful effects on health, financial cost to the individual
or society, and more recently, a feeling of discrimination in
most public places.
Benefits a smoker may perceive vary even more than the
disadvantages (Horn, 1979). Peer acceptance or facilitation
of social interaction places high on the list for
adolescents. Smokers often smoke to reduce stress, enhance
pleasure, improve their concentration, gain satisfaction from
handling the cigarette, or for numerous other reasons. For
many smokers the benefits do seem to outweigh the costs. The
perceptual stereotypes referred to by Horn develop from a
mystique about what smoking and smokers are like, and why


155
Glasgow, R. E., & Lichtenstein, E. (1987). Long-term effects
of behavioral smoking cessation interventions. Behavior
Therapy. 18, 297-324.
Glynn, T. J. (1989). Essential elements of school-based
smoking prevention programs. Journal of School Health.
59, 181-188.
Glynn, T. J. (1990). School programs to prevent smoking: The
National Cancer Institute guide to strategies that
succeed (NIH Publication No. 90-500). Washington, DC:
U.S. Government Printing Office.
Glynn, T. J., Boyd, G. M., & Gruman, J. C. (1991). Self-
guided strategies for smoking cessation (NIH Publication
No. 91-3104). Washington, DC: U.S. Government Printing
Office.
Gritz, E. R., Carr, C. R., & Marcus, A. C. (1991). The
tobacco withdrawal syndrome in unaided quitters. British
Journal of Addictions. 86. 57-69.
Grochmal, D. (1990). [Tobacco use prevalence among Navy
recruits: Recruit Training Center, Orlando]. Unpublished
raw data.
Haley, N. J., Axelrad, C. M., & Tilton, K. A. (1983).
Validation of self-reported smoking behavior:
Biochemical analyses of cotinine and thiocyanate.
American Journal of Public Health. 73. 1204-1207.
Haley, N. J., Colosimo, S. G., Axelrad, C. M., Harris, R., &
Sepkovic, D. W. (1989). Biochemical validation of self-
reported exposure to environmental tobacco smoke.
Environmental Research. 49. 127-135.
Horn, D. (1979). Psychological analysis of establishment and
maintenance of the smoking habit. In N. A. Krasnegor
(Ed.), Cigarette smoking as a dependent process. NIDA
Monograph No. 23. (DHEW Publication No. ADM 79-800).
Washington, DC: U.S. Government Printing Office.


137
7. Passive Smoking does not harm anyone
-can be harmful being around others who smoke
-non smokers married to smokers have a 30% greater risk of
developing lung cancer.
-Cigarette smoke is an irritant and causes discomfort for most non-
smokers .
-It deceases the performance of others around the smoker.
PASSIVE SMOKE DEMO & MECHANICAL LUNG DEMO
For this reason, many policies are in effect which protect non-smokers
health:
-Smoking is now banned in many public places and each year more
policies are instituted which further restrict where smoking is
permitted.
"When I smoke I feel like an outcastM... PFA participant
The Navy is also banning smoking from many areas. Currently tobacco use
is banned:
-In auditoriums, conference rooms, classrooms, and libraries
-Elevators
-Official buses, vans and shuttle vehicles
-Gymnasiums, child care centers and youth centers
Other policies are implemented by the local commanding officers and may
include banning smoking in:
-Work spaces
-Berthing areas
-Messing areas
In the future, entire commands may be designated as no smoking areas
- as have all Navy RTC's
- Explain RTC policy
Why does the Navy do this?
-Not anti-smoker but anti-smoke (Official Navy position)


63
sent to Navy drug screening laboratories for gas
chromatography-mass spectrometry screening. The samples
testing negative locally are normally disposed of on site.
Normal RTC procedures require that the day after uncontrolled
liberty (after recruit graduation) one company be randomly
selected for a unit drug screen. The same procedures are
again followed for sample collection and testing. For the
purposes of the present study only drug negative samples
provided the basis for a sampling pool.
Fifty urine samples were selected randomly (20 female
and 30 male) by drug screen lab personnel, from participating
companies upon arrival at Recruit Training Command Orlando.
Approximately 10 ml were transferred to a storage vial and
frozen. The same procedure was followed for the company
chosen for the post-liberty recruit urinalysis. Forty-two
samples were collected at this time. All samples were kept
frozen until analyses could be conducted.
Cotinine analysis was conducted utilizing Florescence
Polarization Immunoassay technology. An Abbott TDX automated
fluorescence analyzer (instrument #2, serial L30179) at the
Shands Toxicology laboratory in Gainesville, Florida was
used. Cotinine reagent was purchased from Abbott
Laboratories and was within freshness parameters. The
analyzer was calibrated by Shands lab personnel, according to
the operations manual. Low, medium, and high controls were
run after calibration and results were within acceptable
limits. Each batch analysis run included at least one


78
Smoking intentions were examined using differences between
pretest and posttest, observe effect of policy and education.
Cigarette consumption was examined using differences between
pretest and follow-up.
A number of univariate analyses procedures were used to
help describe population variables and draw conclusions about
possible future benefits in research designs with this
population. The significance level for all the tests was set
at p=.10, as the consequences of a Type I error did not
outweigh acceptance of a high probability of making a Type II
error. As this was the first study of its kind with Navy
recruits, the exploratory nature of the educational design
was considered in determining the alpha level.


53
accessions, as well as cessation efforts throughout the
ranks, are critical in meeting this goal. Currently the Navy
recruit population shows a higher smoking prevalence than the
general U. S. population. The no-smoking policy in Navy
recruit training provides a perfect opportunity to allow
smokers to stop, but many factors prevent those who quit from
staying quit. Current research reveals many approaches that
show promise in helping these individuals to stay quit, and
non-smokers from ever starting.
Smoking is becoming more and more socially unacceptable,
both in general society, and in the military. However, if
smokers are expected to quit, they must be provided
assistance. Setting policies that provide an environment
conducive to not smoking are beneficial, but alone don't show
high cessation rates. Education programs are an essential
adjunct to no-smoking policies. Quitting smoking is very
difficult and many people cannot do so on their own. Smoking
prevention and smoking relapse prevention programs must be
developed with the characteristics of the Naval population in
mind. They should draw from existing theory and current
research. Programs should provide information designed to
assist individuals in changing behavior intentions to more
health oriented ones. They need to recognise that all
smokers/non-smokers are in different stages of behavior
change and offer varied approaches to reach the entire
audience. This is especially true when groups are to be
addressed and smokers cannot be separated out. Motivation is


TOBACCO USE SURVEY
Dear Participant:
As you may recall, we are conducting an ongoing study of tobacco use among new Navy
members. You completed surveys at the beginning of recruit training and at graduation. This
survey is designed to measure your tobacco usage, and attitudes toward tobacco use and Nav**
smoking policies at this point in time. This project is providing valuable information to
Navy policy makers and we hope you will continue to participate by taking 15 minutes to
complete this survey and returning it either in the envelope provided or to the class
coordinator you received it from.
Please answer questions honestly and to the best of your ability. As mentioned
previously, your answers are for research purposes only and will be kept strictly
confidential. For this reason the only mdentifying information we ask you to list is the
last 4 digits of your social security number, in the blocks designated. Data will be reported
so that no individual participant can be identified. Participation is voluntary and you do
not have to answer any question you do not wish to answer. We do ask that all surveys be
returned, completed or not, so that all can be accounted for. If you have any questions about
this survey, please contact LCDR T.L.Pokorski, University of Florida, Department of Health
Science Education, #4 FLG, Gainesville, FL 32611/(904)372-7574.
Thank you very much for your continued cooperation in this project!
UNIVERSITY OP FLORIDA
DEPARTMENT OP HEALTH SCIENCE
#4 FLG (CODE P)
GAINESVILLE, FL 32611
OPNAV Approval: Reports Control Symbol 6100-6
EDUCATION
Directionsi
Use a NO. 2 pencil
Fill in circles completely or enter information in blocks provided
*Do not make any stray marks on this form
-Return survey as soon as possible in envelope provided, or seal it in the envelope and
return it to the class coordinator from whom you received it
Make sure you have entered the last 4 digits of your social security number where
indicated
1,Enter the last 4 digits of your 4. Today's Date:
social security number*
month / day / year
5. Enter your recruit company number
2.Enter your enlisted rating.
(example: SM, HA, ET3, etc) T 1 1~1
3.Pay Grade
0 E-l O E-2 O E-3
O E-4 O E-5
126


57
week. A recent tobacco use survey showed that about 28% of
entering recruits are smokers (Cronan & Conway, 1988), which
indicates about 23 members of each study company should be
smokers.
The subject sample was drawn from the total recruit
population. Because of time constraints a purely random
sample of all companies was not feasible. One company,
chosen randomly from a weekly starting group, was used as a
pilot group and went through the research program before the
main study group. The other 7 companies were chosen from all
those starting during adjacent weeks in September 1991.
At RTC, companies are sectioned into training groups.
Each training group contains all companies starting during a
given week (usually 6-7 companies). The training group
progresses through recruit training at the same rate and
graduate on Friday of their eighth week. Companies are
filled as recruits arrive at RTC, without segregation except
by gender. This random assignment to companies allowed for a
random recruit sampling using any training group. Training
Group 47 was selected because of projection for 5 male and 2
female companies. This training group started training
during the week of September 9, 1991. However, the second
female company anticipated did not fill until the following
week, thus the second female company used was part of
Training Group 48.
In an effort to determine if the study population was
representative of the entire Navy recruit population


60
Validity and reliability
A test-retest reliability analysis was accomplished with
the intake survey. An extra company (N=84) was chosen to be
a pilot. This company was administered the intake survey on
their P-4 day. They were encouraged to bring any questions
or concerns to the attention of the researcher. All problems
were noted and incorporated into the briefing for the main
study companies. This group completed the same intake survey
three days later. Key questions to be used in the main study
analysis were analyzed here as part of an instrument
reliability test-retest procedure. The questions were
examined for frequency of non-agreement, then Spearman's and
Pearson's correlations were performed to compute reliability.
Table 3 summarizes the results of the instrument reliability
measurements. Nine of the thirteen items tested showed a
correlation of .80 or better (Spearman) and six of twelve
showed a correlation of .80 or better (Pearson). Questions
that showed poor agreement were explained in the briefing to
the main study companies and the wording was changed on some
for subsequent survey versions. In the study analysis
Questions 10 and 11 were scored as correct if responses below
and above exact percentages were answered. Question 5 showed
a low correlation mainly with non-smokers. For this reason
attitude scores were analyzed for all subjects and for
smokers only.


121
Please circle the appropriate
response
Always Haver
68. I smoke cigarettes in 54321
order to keep myself from
slowing down.
69. Handling a cigarette is 54321
part of the enjoyment of
smoking it.
70. Smoking cigarette is 54321
pleasant and relaxing.
71. I light up a cigarette 5 3 2 1
when I feel angry about
something.
72.When I have run out of 54321
cigarettes 1 find it almost
unbearable until I can get
them.
73. I smoke cigarettes 54321
automatically without even
being aware of it.
74. I smoke cigarettes to 54321
stimulate me, to perk myself
up.
75. Part of the enjoyment 54321
of smoking a cigarette comes
from the steps I take to
light up.
76. I find cigarettes 54321
pleasurable.
77. When I feel 54321
uncomfortable or upset about
something, I light up a
cigarette.
78. I am very much aware of 5 4 3 2 1
the fact when I am not
smoking a cigarette.
79. Z light up a cigarette 54321
without realizing I still
have one burning in the
ashtray.
80. I smoke cigarettes to 54321
give me a "lift".
81.When I smoke a
cigarette, part of the
enjoyment is watching the
smoke as I exhale it.
82. I want a cigarette most 54321
when I am comfortable and
relaxed.
83. When I feel "blue" or 54321
want to take my mind off
cares and worries, I smoke
cigarettes.
84. I get a real gnawing 54321
hunger for a cigarette when
I haven't smoked for a
while.
85.I've found a cigarette 54321
in my mouth and didn't
remember putting it there.
86.Do you intend to resume smoking after
graduation?
0 probably not
O probably will
O definitely will
Thank you for
your Cooperation
5 4 3 2 1


36
Smoking Policy and Effect on Smoking Cessation
Navy recruit training lasts 8 weeks. The current
smoking policy does not allowed anyone to smoke at the
command (CNTECHTRA Instruction 5100.6A, 1991). This includes
recruits, instructors, and all staff members. Therefore, the
recruits who smoked prior to entry, graduate boot camp as ex
smokers who have successfully quit for 2 months. This 100%
cessation rate, with zero recidivism for 2 months, is far
better than any other cessation program reported in the
literature. However, no other quasi-involuntary cessation
programs have been reported and very little information is
available concerning relapse after leaving this type of
environment. Cronan et al. (1989) compared smoking
intervention techniques in recruit training (the current
smoking policies had not yet been instituted). Four groups
were followed through their training cycle. One group
received an educational intervention, another feedback from
health risk evaluations, and a third was designated no
smoking and were not allowed to smoke during training. A
fourth group was followed as a control. The no smoking
group, although showing the best cessation at the end of
training (measured after their first opportunity to smoke),
still reported a 75% relapse rate.
The only other study examining relapse rate in this area
is ongoing (T. L. Conway, personal communication, June 6,


95
-A breakdown of current smoking by educational level
showed the following:
- GED
78%
(ID
- High School
40%
(171)
- Trade School/ some college
41%
(52)
- College Graduate
33%
(4).
-For all participants who indicated they ever smoked,
84% indicated they began smoking before the age of 18,
39% before the age of 14.
Discussion *
The potential to affect tobacco use behavior during
recruit training is tremendous. Smoking prevalence in the
Navy can be drastically reduced if fewer personnel entering
the service smoke. This study sought to find ways of
decreasing prevalence through increasing maintenance of
tobacco abstinence after recruit training. The study
examined an education program designed to decrease smoking
relapse through increasing smoking knowledge, increasing
motivation to remain tobacco free, and furthering smokers in
their behavior change process of becoming ex-smokers.
Smoking relapse
Smoking relapse rates for most smoking cessation
programs average 70% at 3 months and increase another 10 -
15% between 3 and 12 months (Schwartz, 1987; Shiftman et al.,


28
Transtheoretical Model (Stages of Change)
Prochaska and DiClemente first applied their stages of
change model to self change of smoking habits (Prochaska &
DiClemente, 1983). They believe most behavior involves
repetitive and habitual actions which are quite resistant to
extinction. Further, behavior change requires movement
through discrete stages in order to achieve maintained
cessation or initiation. The five stages of change an
individual cycles through in attempting behavior changes are:
-pre-contemplation
-contemplation
-action
-maintenance
-relapse.
Because changing smoking behavior is highly prone to
relapse, it is theorized that individuals tend to move
through these stages in a cyclical fashion (Prochaska &
DiClemente, 1982). Successful change often requires repeated
recycling through these stages. Research suggests the
average smoker cycles three to four times through the stages
before attaining long-term abstinence (Prochaska &
DiClemente, 1984; Marlatt, Curry, & Gordon, 1988). Those in
relapse and pre-contemplation do not have enough motivation
to change their smoking habits. Those in the contemplation
stage are aware of a need to change, but have not yet taken


108
Participants in the study numbered 496 (357 men and 139
women), in seven recruit companies. The companies were
randomly assigned to 4 treatment conditions: (1) policy only
comparison (n = 140); (2) policy plus education (n = 151);
(3) policy plus education with a booster (n = 136); and (4)
policy plus sham treatment (n = 69). Tobacco use knowledge
and behavior surveys were administered to all subjects at the
beginning of recruit training, at graduation, and three
months after graduation. The subjects in both education
groups received a three hour education intervention during
recruit training. The booster group received an hour long
booster program at the end of their training cycle, which
included signing a pledge to assist Navy smoking cessation
efforts. Subjects in the sham treatment group received an
hour long education program, unrelated to smoking, to measure
the effect of any intervention on the study population. A
random selection of urine samples was analyzed for cotinine
levels to validate self-reported tobacco use. Cotinine
analyses were concurrently accomplished with pre- and
postsurvey completion.
Treatment group differences for smoking attitude and
knowledge change were analyzed with one-way and repeated
measures (3) analysis of variance (ANOVA). Treatment group
differences for smoking relapse, smoking initiation,
cigarette consumption change, and smoking intentions were
analyzed by using frequency tables with the Pearson's


23
for some of the difference in smoking prevalence. Table 1
presents a breakdown of some of these differences.
Table 1. Population comparisons
Active Duty
Military
Total U.S.
Population
RACE
Caucasian
72% (1,557)*
84.3% (207,748)
Black
20% (426)
12.3% (30,326)
Other
8% (85)
3.4% (8,256)
SEX
Male
89.5% (1,946)
48.8% (120,203)
Female
10.5% (228)
51.2% (126,126)
AGE
17-20
17.3% (376)
6.1% (15,054)
21-25
32.4% (704)
8.1% (19,981)
26-29
17.8% (387)
7.2% (17,701)
30-34
14.9% (324)
8.9% (21,878)
35-39
10.5% (228)
7.8% (19,194)
40 & over
7.2% (157)
37.6% (92,518)
* Numbers are represented in thousands.
Source: U. S. Bureau of the Census, Statistical abstract of the
United States: 1990 (110th edition) Washington DC & Military Market,
October 1989, pp. 46-52.
Service members are younger, most are male, and the
majority of recruits come from the lower socioeconomic
levels. These are factors also associated with higher


2
(USDHHS, 1990a) but it is not an easy task. Eighty percent
of current smokers indicate they would like to quit, and two-
thirds have made at least one serious attempt to quit
(USDHHS, 1989), but 80-85% of those who try to quit smoking
each year relapse within 12 months of cessation (O'Connell,
1990; Schwartz, 1987).
Certain sub-groups of the general U.S. population have a
higher smoking prevalence. Military personnel are more
likely than civilians to be smokers (Bray, Marsden, &
Peterson, 1991). Though the prevalence of smoking in the
military declined from 51% in 1980 to 41% in 1988, the rate
remains much higher than in the general population (29%).
Bray et al. (1991) indicate the gap is actually less when the
civilian population is standardized to reflect sociode
mographic distribution of the military (44% military vs. 39%
civilian prevalence), but the difference remains significant.
The population the military primarily draws on for new
members has shown a smoking prevalence leveling off in the
past decade. Smoking prevalence among teen-agers did not
decline during the 1980's and studies have shown smoking
prevalence in high school seniors at 17-32% (Johnston,
OMalley, & Bachman, 1991; Center for Disease Control [CDC],
1991a) with rates much higher for high school dropouts.
The Surgeon General lists military personnel as one
population to be targeted for prevention and cessation
interventions (USDHHS, 1989). Many factors contribute to
high smoking prevalence in the military. Tradition of


65
effectiveness, and to uncover any unforeseen problems. Table
4 presents an overview of treatment group assignments.
Table 4. Treatment group assignments
Pilot
T1
T2
T3
T 4
Company
C-175 n=84
C-184 n=81
C-181 n=83
C-183 n=82
C-185 n=79
Number
K-079 n=80
C-182 n=88
K-078 n=84
Notes: T1 = Policy only
T2 = Policy + education
T3 = Policy + education + booster
T4 = Policy + sham treatment
Pilot = Policy + education
Intake surveys
All participating companies completed consent forms and
intake surveys on their P-4 day of training (1st week at RTC)
in the same classroom, at the same time of day. Participants
were briefed on what they would be asked to do in the project
and asked to read the consent statement (see Appendix E).
The researcher read the statement aloud to make sure the
subjects knew their participation was voluntary. Information
confidentiality was assured at this point. The intake survey
asked for full name and social security number, but in an
/
effort to assure confidentiality, the follow-up surveys
requested only the last 4 digits of the social security
number as identification. After the explanation, questions
were taken about the project and the consent form.


64
control, and all control results were within acceptable
limits.
Results were reported in nanograms per milliliter
(ng/ml). The sensitivity of this analysis, defined as the
lowest measurable concentration which can be distinguished
from zero with 95% confidence, was determined by the
manufacturer to be 50 ng/ml. Indication of smoking was then
set at any result greater than 50 ng/ml. Results were
compared against the self-reported smoking reported on
respective surveys.
Results of cotinine analyses were in 100% agreement with
self-reported tobacco use at pretest, and 96% agreement with
self-reported tobacco use at posttest. This reflects only a
1% misrepresentation of smoking status overall. One subject
indicated no tobacco use but tested high for cotinine; two
others indicated tobacco use but tested low for cotinine.
Self-reported tobacco use and cotinine chemical analyses were
highly correlated (r=.91).
Procedures
After the 7 companies were selected they were randomly
assigned to control or treatment categories. Treatment group
assignment was made before any of the survey data was
processed. One extra company was selected to serve as a
pilot group. This group was used to assist in analysis of
instrument validity and reliability, curriculum


APPENDIX B
GRADUATION SURVEY


147
INTRODUCTION (10 min)
Introduce yourself
Remind them about tobacco use survey from previous week
"Your company is part of a trial program to help improve your
health after graduation and we believe this program will help you
remain tobacco free after boot camp*"
Explain Navys concern about its members use of tobacco products
- hence RTC no-smoking policy
- hence the Navy's overall goal of having a healthy work-force
Explain that as they progress through training they will have other
classes that will discuss tobacco use and other ways to improve health
Tie in Video to smoking
-Describe video
-made by Navy
-discusses weight control and effect of being overfat on
risk of heart disease
-tobacco use has also been found to contribute to increasing the
risk of heart disease
-pay attention to things in the movie that you can do when you
leave boot camp, that can decrease your risk of heart disease
SHOW VIDEO (24 minutes)
Any questions on the video?
Wrap up (6 minutes)
-use all the things you learn at RTC to help you make healthy
decisions that will affect the rest of you life
-the Navy is very concerned about maintaining a healthy,
productive workforce
-in light of recent budget cutsthe Navy needs everyone to be
able to perform at peak potential
-we want you to make healthy choices with respect to tobacco,
alcohol, nutrition, and exercise
-we can't force you to be healthyonly you can make a commitment
to health1


39
policy, will be to increase the likelihood that recruits will
favorably respond to the education treatments.
Other Relapse Research
Though much is known about relapse in self-quitters and
program aided cessation, very little is known about relapse
in those who involuntarily quit smoking. One related area is
relapse of women who quit smoking during pregnancy. These
women quit voluntarily, but usually not for themselves.
Rather they quit so as to not affect the health of their
babies. Relapse in these women is usually quite high
(McBride & Pirie, 1990; Mullen, Quinn, & Ershoff, 1990) and
has been reported as high as 70% at one year post-cessation
(Fingerhut, Kleinman, & Kendrick, 1990) even though smoking
at this time may still have an indirect effect on the baby.
Several studies have been conducted on smoking cessation for
pregnant women, but none have specifically targeted relapse
prevention.
Another area where involuntary smoking cessation may
occur is in jails/prisons, but no information could be found
in the literature on this subject.
Smoking Prevention
As more and more adult smokers quit, in both the
civilian and military populations, efforts to prevent the
onset of smoking become the next logical step towards the


EFFECT OF PREVENTION EDUCATION ON SMOKING RELAPSE FOR NAVY
RECRUITS
BY
THOMAS LEE POKORSKI
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1992


11
prevention programs (Flay, 1985; Glynn, 1989). Therefore, a
comprehensive smoking education program addressing the needs
of all recruits, should be effective in reducing the number
of smokers entering the Navy population and assisting future
prevention and cessation efforts.
Delimitations
(1) The curriculum used was submitted for review to
several experts in the fields of health education and
smoking prevention/cessation; the curriculum was
subsequently adjusted to include most of the suggestions
received.
(2) The sample was randomly selected and found to be
representative of a six month sampling of all recruits
at RTC Orlando and all three Navy recruit commands.
(3) Companies involved in the study were randomly
assigned to the four treatment groups.
(4) Cotinine analysis of urine was accomplished on
random samples of participants in conjunction with the
intake and graduation surveys to verify self-reported
tobacco use, and a bogus pipeline procedure was used to
increase validity of self-reported tobacco use.
(5) Companies which had companion companies (combined
classroom periods) received the same study treatment.


50
Nicotine is a good marker of tobacco use, but its short half-
life in serum (0.5 2 hours) makes it a poor choice.
Nicotine is metabolized to cotinine, trans-3-hydroxycotinine,
and nicotine-1-N-oxide; all of which can theoretically be
used as markers (USDHHS, 1988).
Most investigators agree that cotinine is the analyte of
choice because it is tobacco specific and has a relatively
long half-life (Haley, Axelrad, & Tilton, 1983; Jarvis et
al., 1987; Langone, Cook, Bjercke, & Lifschitz, 1988). The
half-life of cotinine is on average 20 hours (Jarvis et al.,
1987; Langone et al., 1988) which makes sample timing in
relation to cigarette smoking less critical. Cotinine
concentrations in blood are generally tenfold greater than
nicotine, and as a result less sensitive analytical
methodology may be acceptable. Cotinine is metabolized, only
17% is excreted unchanged, but levels may persist for up to
seven days after cessation of habitual smoking (USDHHS,
1988).
Cotinine samples from blood, saliva, and urine are
equally applicable to the whole range of issues requiring
estimates of nicotine exposure from tobacco smoking (Jarvis
et al., 1987). Choice of fluid may depend more on practical
considerations (eg. cost, collection availability) than
pharmokinetic considerations. Because concentrations of
cotinine in urine are tenfold to hundredfold greater than
concentrations in plasma or saliva, a variety of analytic
techniques meet sensitivity requirements (USDHHS, 1988).


74
rules infractions, the company commanders were asked to leave
the room while the surveys were completed. The company
yeoman collected the completed surveys, sealed them in an
envelope, and returned them to the RTC scheduling office
where the researcher collected them. The female control
company had their graduation surveys mailed to them 3 weeks
after graduation due to confusion in who was to administer.
The 3 month follow-up surveys (see Appendix C) were
mailed to participants at their current command. Those
attending schools located at Naval Training Center, Orlando
were administered the survey during one of their class
periods by a command representative. These surveys were
collected by the command Drug and Alcohol Program Advisor and
mailed to the researcher. The majority of the surveys were
mailed to the participants' Commanding Officer. The
Commanding Officers1 representatives were instructed to
distribute the surveys to listed participants, collect the
completed forms, and mail them back to the researcher. One
reminder was sent to the commands which had not responded
within one month of the original mailing. Several commands
not responding to the reminder letter were phoned and
questioned concerning survey status. A number of surveys
(31) had to be re-sent to individuals that had already moved
from their second command. Some surveys (in addition to
those readdressed) were mailed, to individuals (80), with a
self-addressed government envelope and instructions for
return. Participants were not required to pay any postage.


15
boot camp, by the total number of smokers remaining in
the study.
start
total smokers
Boot camp is a common term used for basic recruit
training in the military. Generally the training
received immediately upon entering the military, which
lasts about 8 weeks.
Sham treatment refers to a placebo treatment similar to
the main intervention only in amount of attention paid
to participants. The material presented is only vaguely
related to the study goal.
Command refers to the actual component of the Navy to
which participants were assigned after recruit training.
Knowledge gain refers to observed change in smoking
knowledge scores between pretest and posttest.


102
probably will relapse was 78%, and for those answering
definitely will relapse was 100%. A firm intention to engage
in behavior is not easily influenced by external factors.
The key to changing smoking behavior is changing intentions.
The results of the present study agree with intention results
reported by Ajzen and Fishbein (1980).
Cigarette Consumption
The results of the present study display a significant
reduction in cigarettes smoked by those who relapsed. This
reduction was demonstrated by examining a drop in category
(no/light, moderate, heavy) rather than actual numbers of
cigarettes. Most studies report an overall percent reduction
in baseline smoking which confounds results due to subjects
who quit completely versus those who only show reduction
(Glasgow & Lichtenstein, 1987). The way results were reported
for the present study reflect an actual decrease in smoking
for relapsers. Since all heavy smokers relapsed after boot
camp, the changes observed from the heavy category to light
or moderate can only reflect an actual cigarette consumption
drop.
The results of a cigarette consumption reduction are in
agreement with an Army study by Carroll et al. (1989) who
found a majority of smokers had decreased consumption after
institution of major smoking policies. The only individual
treatment group difference that was significant in the


76
The completed answer sheets were scanned by a mark reader
which then compiled the data and stored a data file on a
floppy ^disk and in a university computer account.
Once the data were in the computer file variables were
range checked for accuracy and improper codes were either
corrected or changed to missing data points. No attempt was
made to impute missing data points.
Data analyses were accomplished usings
-the Statistical Analysis System (SAS) on the University
of Florida VAX cluster
-SAS on the Northeast Regional Data Center computer
Virtual Telecommunications Access Method, and
-Stat View SE + Graphics statistical analysis program on
a Macintosh SE personal computer.
Analysis Plan
This study was set up on a split plot with repeated
measures design. Table 5 is a presentation of the design
setup. Because tests of the null hypotheses consisted of
both continuous and categorical variables, different testing
procedures were used. Smoking attitudes and smoking
knowledge were examined using a general linear model (GLM)
for repeated measures analysis of variance (ANOVA). Null
hypotheses with categorical variables (relapse rate, smoking
initiation, cigarette consumption, and smoking intentions)
were examined by using frequency tables with the Pearsons


98
individuals to a higher stage of change, which is just as
important.
Differences in knowledge gain score were found to be
significantly related to relapse. Though knowledge gain
group differences were not significant, a trend was observed
with the education groups exhibiting a greater change than
the control and sham groups. Comparing the education only
(Treatment 2) to the control (Treatment 1), both show similar
scores on the two main relapse predictors; nicotine tolerance
level and prior cigarette consumption. Yet the control group
shows a higher relapse rate. This may be explained in that
the education group had the higher knowledge gain score.
The relapse trend between education and control indicate
the education intervention could affect relapse. The theory
of reasoned action (Ajzen & Fishbein, 1980) states a change
in behavioral beliefs leads to behavior change. In the
present study, knowledge gain measured positive changes in
beliefs that smoking is detrimental to health. Though an
educational effect on relapse could not be confirmed in the
present study, the trend observed is encouraging.
Smoking initiation
Perhaps the most encouraging result of the present study
involves the low reported initiation of smoking by non/former
smokers. Only 5% (9 of 171) of the entry non-smokers
reported being current smokers at follow-up.


142
-social pressures not to use tobacco
-hassles related to smoking-resticted areas
-few friends/peers use tobacco
-cost (figure cost for pack a day smoker for year
$1,79 x 365 days = $653.35 Discuss PX pricing policy)
The next video I'm going to show is entitled "The Feminine Mistake".
Although the film is directed toward females, most of the information is
applicable to anyone who smokes. Except for the pregnancy part, the
physiology changes described can happen in both sexes. Pay particular
attention to the physiological changes that occur with smoking and to
effects shown.
*** SHOW "FEMININE MISTAKE" *** (24 minutes)
Any questions on the video
Quitting smoking (9 minutes)
-Quitting cigarettes or other tobacco products is very difficult
and becomes more difficult the longer a person uses them
The most important part of a successful quit attempt making the
commitment to quit and deciding to quit for yourself, as
opposed to quitting to please someone else or to conform to a policy
-those of you who made a conscious decision to quit before you
entered the Navy will be more committed to stay quit after
graduation
-those who have never used tobacco will have a very strong
motivation to remain tobacco free
-but those who were regular tobacco users prior to entry need to
make a commitment now, if you wish to remain tobacco after
graduation. Yes you have quit, and by the time you graduate you
will have made it through what is typically the most trying time for
those who try to stop.


89
TRT
1 TRT
2
F =
13.36,
P
<
.10
Posttest
TRT
1 TRT
3
F =
11.37,
P
<
.10
scores
TRT
4 TRT
2
F =
3.96,
P
<
.10
TRT
4 TRT
3
F =
2.92,
P
<
.10
Table 14 presents the attitude score means and standard
deviations observed (for smokers at entry) at each
measurement period by treatment group.
Table 14. Attitude scores at each measurement period and
differences pre to post for smokers
Treatment
qroup
Total
1
2
3
4
4.63
4.41
4.17
4.33"
4.40
Pre
(2.52)
(2.44)
(2.51)
(3.10)
(2.57)
4.95
5.89
5.84
5.75
5.63
Post
(2.72)
(2.47)
(2.77)
(2.64)
(2.66)
4.77
4.23
5.02
6.0
4.77
F/U
(2.83)
(2.42)
(2.47)
(2.90)
(2.61)
Diff.**
0.18
1.51
1.50
1.50
1.19
post-pre
(2-36)
(2.47)
(3.26)
(2.527)
(2.76)
Note: Standard deviations in parentheses
Differences reflect only subjects completing both pre and post
tests.
Repeated measures ANOVA were performed to determine if
time, treatment group, or interaction effects were present.
A significant time effect was observed for all groups (F =
5.74, df = 6, 148, pc.l). Treatment effect differences were
not significant (F = 0.61, df = 3, 74, p>.l). Interaction
effects were also not significant (F = 1.38, df = 6, 148,
p>.1). Separate critical F values were calculated for paired
attitude scores. Pretest scores were not significantly


American Cancer Society, especially Roberta Moss and Marsha
Nenno, for providing the shirts, pamphlets, and posters used
in the study.
I would like to thank Captain Kathleen M. Bruyere, U.S.
Navy, and her fine staff at Recruit Training Center, Orlando,
Florida. The assistance I received while conducting this
study was tremendous. I am especially grateful for all the
efforts of PHCM Breece, without which this study could not
have been done.
Finally, I would like to thank all the fine Navy
recruits who participated in this project and made the study
the success it was.
in


110
Conclusions
Analysis of data collected in this study justify the
following conclusions.
{1) The current Recruit Training Command no-smoking
policy has been effective in reducing smoking
initiation, after graduation.
(2) Smoking education significantly affects attitudes
toward smoking for Navy recruits.
(3) Smoking education and placebo education
significantly affect attitudes toward smoking for Navy
recruits who were current smokers upon entering recruit
training.
(4) Smoking education significantly affects smoking
knowledge among Navy recruits.
(5) Smoking education significantly affects cigarette
consumption for Navy recruits who relapse to smoking.
(6) Nicotine addiction and prior cigarette consumption
were the best indicators of relapse for Navy recruits.
In this study sufficient evidence for a conclusion was
not observed for the following:
(1) effect of smoking education on smoking relapse rates
of Navy recruits
(2) effect of smoking education on future smoking
intentions of Navy recruits


TOBACCO USE SURVEY
u 0 0 4 5
Dear Participant:
Aa you may recall, we ara conducting an ongoing study of tobacco uaa among new Navy membara.
You completad a survey at tha baginning of recruit training and ve ask for your cooperation
again. This survey is designed to measure your tobacco usage, and attitudes toward tobacco
use and Navy smoking policies at this point in time. This project is providing valuable
information to Navy policy makers and we hope you will continue to participate by taking 15
minutes to complete it.
Please answer the questions honestly and to the best of your ability. Answers will be kept
strictly confidential and the only identifying information we ask for is the last 4 digits of
your social security number. Your command will not have access to any of the individual data.
Participation is still voluntary and you do not have to answer any question you do not wish to
answer.
Thank you very much for your continued cooperation in this project 1
Directionsi
Use a NO. 2 pencil
Pill in circles completely or enter information in blocks provided
Do not make any stray marks on this form
Make sure you have entered the last 4 digits of your social security number where
indicated
1.Enter the last 4 digits of your
social security number.
2.Enter your recruit company amber
rrm
3.Today's Date:
month / day /
year
[TOBACCO USE
Please indicate past and current tobacco use
by marking NO or YES for each tobacco product
4.Before entering the Havy were you a
user of ...?
NO
YES
a) Cigarettes
0
0
b) Cigars
0
0
c) Pipe tobacco
0
0
d) Chewing Tobacco
0
0
e) Snuff/Dip
o
0
5.During recruit training
did \
NO
YES
a) Cigarettes
o
0
b) Cigars
0
0
c) Pipe tobacco
o
0
d) Chewing Tobacco
0
0
e) Snuff/Dip
0
0
you use7
6.Has your company had your
"uncontrolled liberty weekend"?
0 No 0 Yes
a) If YES, did you use tobacco products
when allowed off base?
0 No 0 Yea
[AMOUNT of tobacco products used
7.When was the aost recent tine you
saoked a cigarette?
0 Never smoked a 0 4-6 months ago
cigarette 0 8-9 weeks ago
0 2 or more years 0 1-8 weeks ago
ago 0 During the past
0 1-2 years ago 7 days
0 7-11 months ago 0 Today
8.During the last 30 daysr how aany
cigarettes did you usually saoke on a
typical day when you saoked
cigarettes ?
O Did not smoke any
cigarettes
O Fewer than 1, on
the average
O 1-5 cigarettes
0 6-10 cigarettes
9.When was the most
smoked a cigar?
0 Never smoked a
cigar
0 2 or more years
ago
O 1-2 years ago
O 7-11 months ago
O 11-15
O 16-20
O 20-25
O 26 or more
cigarettes
recent time you
O 4-6 months ago
O 8-9 weeks ago
O 1-8 weeks ago
O During the past
7 days
O Today
10.When was the
used smokeless
0 Never used
smokeless tobacco
0 2 or more years
ago
O 1-2 years ago
O 7-11 months ago
aost recent tine you
tobacco?
O 4-6 months ago
O 8-9 weeks ago
O 1-8 weeks ago
O During the past
7 days
O Today
...Continue on back.
123


46
multicomponent focus. They felt minimum smoking prevention
components should include:
-information about social consequences and short term
physiological effects of tobacco use
-information about social influences on tobacco use,
especially peer, parent, and media influences
-training in refusal skills, including modeling and
practice of resistance skills.
They felt the minimum length of school-based programs should
be two, 5 session blocks with booster sessions in subsequent
years. Doctor Glynn, of the NCI, stated a shorter program
(2-3 hours) would probably be effective with individuals who
had already demonstrated to themselves that they could stop
smoking (T. J. Glynn, personal communication, June 18, 1991).
When used as part of a cessation program, education
intervention may last from 1-4 hours, depending on the length
of the overall program. No studies have been reported in
which length of the education segment was varied, while
attempting to decrease relapse rates or prevent smoking.
The Waterloo Smoking Prevention Project (Flay, 1985)
found previous experience with smoking did not preclude
prevention of further smoking. The study results showed the
program influenced current experimenters to quit smoking, and
remain quit. The prevention curriculum was six hours long
and was designed to influence attitudes towards tobacco and
the acquisition of social skills. The program had three main
components: 1) provide information on the effects of


145
Weve discussed the fact that stopping smoking, or the use of any
tobacco product, is not easy. For the Navy to reach its year 2000 goal,
a total team effort will be required.
-A commitment on the part of smokers is needed.
-A commitment on the part of non-smokers is also needed to
encourage and help smokers to stop. This is particularly true for ex
smokers, as they can have a great influence on current smokers, as we
saw in the last video.
Successful quitting requires a great deal of support, but that is what
the "Navy family" is all about. You all entered the Navy with the
expectation of bettering yourself in one way or another. RTC
graduation will mark a great accomplishment for all of you. You
will have bested many mental and physical challenges. You will have
done so by yourselves, without the support of parents, without the
crutch of tobacco, alcohol, or any other drugs you may have used in
the past. You will have drawn on the support of your fellow
company members for any assistance needed.
When you graduate, recognize your achievements, congratulate
yourself, and make the commitment to become a strong member of the
Navy team. Those who smoke have accomplished something else that will
affect your lives. You have control over your life. Make the
choices that are right for you. Dont let others pressure you into
unhealthy habits. Remember the benefits of remaining tobacco-free and
incorporate what you have learned here today into a commitment to
health for the rest of your life.
QUESTIONS
*** REMIND ABOUT THE FOLLOW-UP SURVEY ***


81
phone. The rest of the non-returned surveys had been mailed
directly to individuals. Only a 22% response rate was
obtained when participants' Commanding Officers were not
involved in administering the follow-ups. The increase in
overall follow-up response shows the utility of mailing
surveys via Commanding Officers.
Of the completed surveys at follow-up, 279 were usable
for the main study population. This represented 56% of the
original pretested population The rest were unidentifiable
as study participants. An analysis was performed to
determine if the group of non-respondents was representative
of the whole population with respect to initial smoking
status; Table 8 summarizes the findings.
Table 8. Percentage of smokers in non-respondent group and
_ original study population
Treatment group
1
2
3
4
Total
Non-
51.7%
46.3%
53.7%
42.9%
48.8%
Respondents
(31)
(25)
(29)
(21)
(106)
At pretest
50.7%
35.8%
46.3%
39.1%
43.3%
U
(54)
(63)
(27)
.-(215)
Note: Actual numbers in parentheses.
Non-respondents of each treatment group had a higher
percentage of smokers, but the differences from the pretest
results were not significant (x2 = 4.65, p>.l).


48
investigator and underreport smoking behavior out of
embarrassment or a desire to please. Self-reports of smoking
status therefore, may not always be accurate, particularly
where smokers feel pressure to give up smoking but may not
have achieved it (Jarvis, Tunstal1-Pedoe, Feyerabend, Vesey,
& Saloojee, 1987; Murray et al., 1987). In a study to
validate self-report claims, Jarvis et al. (1987) reported
19% of cotinine confirmed smokers claimed to be non-smokers.
However, other studies found only 2% of smokers claiming to
be non-smokers when not actively persuaded to give up smoking
(Lee, 1987; Thompson, Stone, Nanchahal, & Wald, 1990). For
this reason researchers try various techniques to increase
truthfulness of reporting and to validate self-reports of
smoking.
Bogus Pipeline
One strategy shown effective in increasing validity of
smoking self-reports has been termed the bogus pipeline
method. The rationale for this approach is that individuals
should be more likely to disclose their actual smoking
behavior if they believe the researcher has an independent
and objective means of measuring smoking behavior. Evans,
Hansen, and Mittelmark (1977) were the first to show efficacy
of this procedure with smoking research. Murray et al.
(1987) examined eleven papers on this subject and found five
reported a pipeline effect, while six did not. They


EFFECT OF PREVENTION EDUCATION ON SMOKING RELAPSE FOR NAVY
RECRUITS
BY
THOMAS LEE POKORSKI
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1992

ACKNOWLEDGEMENTS
I wish to express my sincere gratitude to Dr. W. William
Chen, chairman of my dissertation committee. His guidance
during the past three years, especially during the
dissertation process, has been invaluable. I would also like
to extend my appreciation to Dr. R. Morgan Pigg, Dr. Claudia
Probart, Dr. Steve Dorman, and Dr. Marc Branch for serving as
members of my doctoral committee. Without the guidance and
assistance of my committee I would never have been able to
complete this work, nor retain my sanity. I also appreciate
the statistical assistance provided by Dr. David Miller, and
the help of Dr. Roger Bertholf in cotinine analysis.
I wish to thank my parents, Pat and Joe Pokorski, for
lifelong support of all my endeavors. I'd like to
acknowledge the patience my children, Mike and Nicole, have
shown over the past few years while having to deal with a
"part-time" dad. I would especially like to thank my wife
Liz for her understanding, patience, editorial assistance,
and completion of over 600 scantron forms.
I'd like to recognize the assistance provided by the
Navy's Office of Health and Physical Readiness. Without the
financial assistance provided by this office the study could
not have been as comprehensive. I'd like also to thank the
11

American Cancer Society, especially Roberta Moss and Marsha
Nenno, for providing the shirts, pamphlets, and posters used
in the study.
I would like to thank Captain Kathleen M. Bruyere, U.S.
Navy, and her fine staff at Recruit Training Center, Orlando,
Florida. The assistance I received while conducting this
study was tremendous. I am especially grateful for all the
efforts of PHCM Breece, without which this study could not
have been done.
Finally, I would like to thank all the fine Navy
recruits who participated in this project and made the study
the success it was.
in

TABLE OF CONTENTS
page
ACKNOWLEDGEMENTS ii
LIST OF TABLES vi
ABSTRACT VÜ
INTRODUCTION 1
Statement of the Research Problem 6
Purpose of the Study 7
Hypotheses 8
Significance of the Study 8
Delimitations 11
Limitations 12
Assumptions 13
Definition of Terms 13
REVIEW OF LITERATURE 16
Introduction 16
Problems Related to Tobacco Use 17
Tobacco Use in the U.S 18
Military Tobacco Use and Related Problems 19
Navy Tobacco Use 24
Smoking Relapse 26
Smoking Policy and Effect on Smoking Cessation 36
Other Relapse Research 39
Smoking Prevention 39
Educational Intervention 45
Validation of Smoking Status Self-Report 47
Bogus Pipeline 48
Biochemical Tests 49
Concluding Statement 52
METHODS AND MATERIALS 55
Introduction 55
Subjects 55
Instruments 59
Self-Report Validation Techniques 62
Procedures 64
Data Preparation 75
Analysis Plan 76
IV

RESULTS AND DISCUSSION
79
Introduction 79
Population Description 79
Results 82
Discussion 95
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS 107
Summary 107
Conclusions 110
Recommendations 113
APPENDIX A INTAKE SURVEY 116
APPENDIX B GRADUATION SURVEY 123
APPENDIX C THREE MONTH FOLLOW-UP SURVEY 126
APPENDIX D HUMAN FACTORS COMMITTEE APPROVAL 131
APPENDIX E CONSENT STATEMENT 132
APPENDIX F EDUCATION CURRICULUM 133
APPENDIX G SHAM TREATMENT CURRICULUM 146
APPENDIX H QUIT SMOKING WALLET CARD 148
APPENDIX I CERTIFICATE OF PARTICIPATION 150
LIST OF REFERENCES 151
BIOGRAPHICAL SKETCH 162
v

LIST OF TABLES
page
Table 1. Population comparisons 23
Table 2. Study group comparison 58
Table 3. Test-retest reliability 61
Table 4. Treatment group assignments 65
Table 5. Repeated measures design 77
Table 6. Chi-square frequency table 77
Table 7. Percent survey completion at each measurement
period 80
Table 8. Percentage of smokers in non-respondent group
and original study population 81
Table 9. Percent of current smokers at each measurement
period 82
Table 10. Percent of current smokers by gender and
corresponding relapse rates 83
Table 11. Nicotine tolerance levels reported with
corresponding relapse rates 84
Table 12. Percentage smoking initiation 86
Table 13. Attitude scores at each measurement period
and differences pre to post for all subjects 88
Table 14. Attitude scores at each measurement period
and differences pre to post for smokers 89
Table 15. Knowledge scores at each measurement period
and differences observed 91
Table 16. Percent of respondents indicating intention
not to smoke in the future 92
Table 17. Cigarette consumption 93
vi

Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
EFFECT OF PREVENTION EDUCATION ON SMOKING RELAPSE FOR NAVY
RECRUITS
By
THOMAS LEE POKORSKI
August, 1992
Chairman: Wei William Chen, PhD
Major Department: Health and Human Performance
This study examined impact of an education program on
smoking knowledge, attitudes, and intentions of Navy recruits
undergoing 8 weeks of training in a normal no-smoking
environment. Also examined were smoking relapse and
cigarette consumption subsequent to recruit graduation.
Specifically the study was designed to (1) add to literature
information on effective educational smoking
prevention/cessation techniques; (2) measure effect of
current no-smoking policy at Recruit Training Center,
Orlando, FL; (3) examine differences in observed levels of
smoking knowledge, attitudes, intentions, and relapse after
intervention; (4) examine smoking initiation rate differences
(for non-smokers prior to recruit training); and (5) examine
variables affecting smoking relapse.
Vll

This study included 496 recruits (357 men and 139
women), in seven companies. Companies were randomly assigned
to 4 treatment conditions: (1) policy only comparison; (2)
policy plus education; (3) policy plus education, with a
booster; and (4) policy plus sham treatment. Tobacco use
knowledge/behavior surveys were administered to all subjects
at the beginning of recruit training, at graduation, and
three months after graduation. Subjects in both education
groups received a three-hour education intervention. The
booster group received an additional hour-long booster
program at the end of the training cycle. Cotinine analyses
of randomly selected urine samples were performed
concurrently with pre- and postsurveys.
Data analysis was accomplished using repeated measures
analysis of variance, frequency tables incorporating
Pearson's chi-square statistic, and categorical modeling
procedures (SAS PROC CATMOD). Results indicated significant
educational effects for smoking knowledge and attitude
scores, reduced violation of liberty no-smoking rules, and
cigarette consumption for relapsers. No significant
treatment group differences were noted for relapse rate,
smoking initiation, or smoking intentions.
In summary, the education program used, though not
significantly affecting smoking relapse in the short term,
may positively affect future cessation attempts. The best
predictors of smoking relapse in Navy recruits were nicotine
addiction and heavy prior cigarette consumption. Study
viii

results recommend that smoking prevention/cessation education
be part of recruit training, but further research is needed
to identify more effective ways of reaching the heavier,
addicted smokers entering the Navy.
IX

CHAPTER 1
INTRODUCTION
Cigarette smoking can be linked to 1 in 6 deaths in the
United States each year. Surgeons' General for the past 10
years named cigarette smoking as the most important
preventable cause of death in society (U.S. Department of
Health and Human Services [USDHHS], 1989, 1990).
Specifically, cigarette smoking has been linked to the three
leading causes of death in the U.S. (heart disease, cancer,
and cerebrovascular disease). Likewise, involuntary smoking
causes many of the same diseases associated with active
smokers (USDHHS, 1986). The annual cost to society in
disease, death, and absenteeism related to smoking has been
estimated in excess of $50 billion (Fielding, 1986).
In response to this problem, health professionals have
provided tobacco prevention and smoking cessation programs
for many years. These efforts have shown encouraging results
in the general population. Smoking prevalence has dropped
from 40% in 1965 to 29% in 1987 (USDHHS, 1989). The Surgeon
General reports that while over 50 million Americans continue
to smoke, more than 90 million would be smoking in the
absence of recent changes in the smoking and health
environment (USDHHS, 1989). Smoking cessation produces major
and immediate health benefits for smokers of all ages
1

2
(USDHHS, 1990a) but it is not an easy task. Eighty percent
of current smokers indicate they would like to quit, and two-
thirds have made at least one serious attempt to quit
(USDHHS, 1989), but 80-85% of those who try to quit smoking
each year relapse within 12 months of cessation (O'Connell,
1990; Schwartz, 1987).
Certain sub-groups of the general U.S. population have a
higher smoking prevalence. Military personnel are more
likely than civilians to be smokers (Bray, Marsden, &
Peterson, 1991). Though the prevalence of smoking in the
military declined from 51% in 1980 to 41% in 1988, the rate
remains much higher than in the general population (29%).
Bray et al. (1991) indicate the gap is actually less when the
civilian population is standardized to reflect sociode¬
mographic distribution of the military (44% military vs. 39%
civilian prevalence), but the difference remains significant.
The population the military primarily draws on for new
members has shown a smoking prevalence leveling off in the
past decade. Smoking prevalence among teen-agers did not
decline during the 1980's and studies have shown smoking
prevalence in high school seniors at 17-32% (Johnston,
O'Malley, & Bachman, 1991; Center for Disease Control [CDC],
1991a) with rates much higher for high school dropouts.
The Surgeon General lists military personnel as one
population to be targeted for prevention and cessation
interventions (USDHHS, 1989). Many factors contribute to
high smoking prevalence in the military. Tradition of

3
smoking in the military, living conditions, demographic
population makeup, low cigarette cost in military exchanges,
and advertising targeted to young military members represent
factors hypothesized as causes for high military smoking
prevalence.
Smoking prevalence in the Navy (44%) slightly exceeded
the military average in a 1988 survey (Bray et al., 1988).
It has been estimated smoking costs the Navy nearly $25
million a year in higher health care and insurance costs, and
an additional $140 million in lost wages due to absenteeism
(Zolton, 1992). Efforts are underway in the Navy to reduce
the smoking prevalence and the Navy Surgeon General has set a
goal of a smoke-free Navy by the year 2000 (Nelson & Roth,
1991). Surveys of incoming Navy recruits, though, show a
smoking prevalence of between 28% and 40% (Cronan & Conway,
1988; Grochmal, 1990). If the Navy wishes to attain the goal
of being smoke-free not only will current smoking members
need assistance stopping, but the number of new smoking
members must be reduced and eventually eliminated. Current
Navy smoking policies have not yet proven effective in
lowering smoking prevalence to civilian levels. Policy
efforts thus far have only reduced smoking rates from 54% in
1980 to 44% in 1988 (Bray et al., 1988).
A smoking ban at all Recruit Training Commands (RTCs)
seems effective in stopping smoking temporarily for recruits
who enter as smokers (Commander E. Reeves, personal
communication, May 14, 1991). This policy stemmed from study

4
results showing Navy recruits actually starting to smoke
while in basic training (Cronan et al., 1988). Though a near
100% effective cessation rate is encouraging, smoking relapse
after recruit training is suspected to be very high. A study
to determine current relapse rates is underway at the Naval
Health Research Center (T. L. Conway, personal communication,
May 9, 1991).
The specific problem addressed in the present study
involved finding ways to decrease smoking relapse as recruits
leave boot camp and enter the general Navy population. If
relapse of recruit smoking can be prevented, the number of
new smokers entering the general Navy population can be
reduced. Navy recruits represent a segment of the U.S.
population highly resistant to smoking cessation: young
smokers (Ferrence, 1989). They are usually between 17 and 30
years old with a mean of about 19 years (Cronan, Conway, &
Hervig, 1989; Chief of Naval Technical Training [CNTECHTRA],
1991). Young smokers tend to show less concern about
potential hazards of smoking, though they show a high
awareness of the health risks (Tuakli, Smith, & Heaton,
1990). Therefore, it is a challenge to find effective
methods of lasting smoking cessation for Navy recruits.
Smoking development progresses through several stages
over a course of two or more years (Leventhal, Baker,
Brandon, & Fleming, 1989). Many smoking recruits may not
have reached the final stage of dependence and regular use.
For these individuals smoking relapse rates after recruit

5
training may be affected several ways: 1) they may have never
considered themselves smokers and may not start again; 2) the
eight week gap may represent a brief lapse in their
development cycle, and they may continue to smoke whether or
not they see themselves as future smokers; or 3) they may
think they can stop just as easily in the future, feel immune
to possible risks, be influenced by smoking friends they
subsequently meet, and eventually progress to the last stage
of development.
Recruits who progress to the last stage of smoking
development before entering the Navy should relapse like any
other ex-smoker in the cessation population. However, one
would expect these recruits to exhibit some relapse
differences in that most have not really quit smoking
voluntarily; they quit, not by choice, but to conform to
existing policy. Since smoking relapse rates have never been
studied for this type of population it is difficult to
predict exactly what will effect reduction of relapse.
The transtheoretical model of behavior change, as
applied to smoking cessation (Prochaska & DiClemente, 1983),
shows that smokers cycle through various stages (pre¬
contemplation, contemplation, action, and maintenance) in
their quit attempts. Progression through these stages
requires voluntary incorporation of a number of processes of
change. Smoking recruits are placed into the action stage
and may revert to their pre-recruit stage upon graduation and
reinstitution of free-choice concerning tobacco use.

6
Physical as well as psychological factors are involved
in relapse (Carmody, 1990; Shiftman, Read, Maltese, Rapkin, &
Jarvik, 1985). For recruits, physical withdrawal symptoms
are gone after eight weeks of training, as peak physical
withdrawal symptoms of tobacco appear to last for about 1-2
weeks (USDHHS, 1988). Therefore, if recruits relapse to
smoking it will probably be from psychological factors, a
belief they never quit, or a willful intention to start
again. Each of these areas were addressed in the present
study.
Statement of the Research Problem
The military population has been targeted as a group in
need of effective smoking prevention and cessation efforts.
Efforts thus far have not succeeded in reducing smoking
prevalence to civilian levels. An attempt has been made to
promote cessation and discourage initiation by banning
tobacco use for all personnel at recruit training centers.
No study results have yet been published concerning the
effect of the policy on smoking after training, and no
efforts have been made to find ways to decrease smoking
relapse for graduating recruits.
In general, military smoking prevalence can be reduced
by addressing current service members and new recruits.
Cessation and prevention efforts for current service members
is vital, but if 40% of new recruits are smokers, the problem

7
will perpetuate. Specifically, the present study focuses on
reducing the number of smokers in the recruit population. To
do this, the effect of current smoking policy at Recruit
Training Center, Orlando, FL, was examined. Relapse after
graduation, smoking attitudes, and future smoking intentions
were assessed. Changes in smoking relapse and initiation were
then examined for groups exposed to various intervention
conditions.
Purpose of the Study
The purpose of this study was to examine the impact of
an education program on smoking knowledge, attitudes,
intentions, and on smoking relapse rate and subsequent
cigarette consumption. Specifically the study was designed
to
(1) measure effect of the no-smoking policy at
Recruit Training Center, Orlando, FL, on recruit smoking
knowledge, attitudes, intentions, and relapse;
(2) examine differences in observed levels of recruit
smoking knowledge, attitudes, intentions, and relapse
for various treatment conditions;
(3) examine smoking initiation rate differences (for
non-smokers prior to recruit training) for various
treatment conditions; and
(4) examine variables affecting smoking relapse.

8
Hypotheses
The null hypotheses relating to Navy recruits after
eight weeks in a smoking restricted environment are that no
differences will be observed among treatment conditions for
(1) smoking relapse rate,
(2) smoking attitudes,
(3) smoking knowledge,
(4) smoking intentions,
(5) cigarette consumption, and
(6) smoking initiation after graduation (for
never/former smokers prior to recruit training).
Significance of the Study
Results of this study should assist Navy smoking
cessation efforts by finding effective means of reducing
smoking prevalence in personnel entering the service. This
study was unique in that it was the first to examine smoking
intervention while including the Navy female recruit
population. Secondarily the study was designed to contribute
to literature information on: a) successful techniques to
prevent relapse in young ex-smokers, and b) successful
techniques to prevent smoking initiation in non-smokers
during employment transition.
This study will provide further evidence to support or
refute the theory that policy alone is insufficient to effect

9
permanent change on smoking decisions. The theory of
prevention education as an effective measure for behavior
change also was tested. This study should prove useful for
determining if subject tailored smoking prevention classes,
in the context of a strict no-smoking policy, reduce
recidivism after the policy is removed.
Since this study was the first smoking relapse
prevention research conducted with military recruits it
should produce new knowledge applicable to all military
training commands. The results will provide a basis for
further research in discovering program variables which
increase success, and subject variables which determine who
is suited for particular interventions. Portions of the
results may also prove applicable to behavior change of other
detrimental health habits (eg. drug and alcohol use, poor
nutrition habits, seat belt usage).
Smoking relapse for recruits will be affected by many
factors they encounter after leaving boot camp. The present
study cannot change any of these factors. However, the
interventions were designed to help participants recognize
and cope with many of these factors. For recruits who
believe they have quit, establishing a firm intention to
remain quit is very important. This aspect of prevention
stems from the theory of reasoned action which states the
best predictor of behavior is a person's intention to perform
the behavior (Ajzen & Fishbein, 1980).

10
For recruits who believe they have not quit, or are
determined to start again, interventions used in this study
may still be of benefit. If they can realize they have quit
smoking, and the quitting was a beneficial achievement for
them, they may be able to enter the behavior change cycle at
the maintenance stage. If this measure fails, the program
still may be of benefit if it moves smokers from the pre¬
contemplation stage toward the contemplation stage in which
they may give serious consideration to quitting at a later
date. If so, these individuals may be more receptive to
Navy-wide smoking policies and programs they will be exposed
to throughout their careers.
Research indicates light smokers often make the
transition to heavy smoking during the first two years after
high school (Johnston et al., 1991). If this transition can
be prevented in Navy accessions, receptiveness to later
cessation efforts also may be assisted. Successful
recidivism prevention and earlier cessation will certainly
boost progress toward the goal of a smoke free Navy by the
year 2000.
Another group that will benefit from the smoking relapse
program includes recruits who have never smoked, especially
those who may already be susceptible to social influences.
According to the National Institutes of Health, information
about the health and social consequences of smoking proves
critical for cessation (Glynn, Boyd, & Gruman, 1991). This
same information has been shown effective in smoking

11
prevention programs (Flay, 1985; Glynn, 1989). Therefore, a
comprehensive smoking education program addressing the needs
of all recruits, should be effective in reducing the number
of smokers entering the Navy population and assisting future
prevention and cessation efforts.
Delimitations
(1) The curriculum used was submitted for review to
several experts in the fields of health education and
smoking prevention/cessation; the curriculum was
subsequently adjusted to include most of the suggestions
received.
(2) The sample was randomly selected and found to be
representative of a six month sampling of all recruits
at RTC Orlando and all three Navy recruit commands.
(3) Companies involved in the study were randomly
assigned to the four treatment groups.
(4) Cotinine analysis of urine was accomplished on
random samples of participants in conjunction with the
intake and graduation surveys to verify self-reported
tobacco use, and a bogus pipeline procedure was used to
increase validity of self-reported tobacco use.
(5) Companies which had companion companies (combined
classroom periods) received the same study treatment.

12
(6) Follow-up surveys were mailed to participants'
command, whenever possible, in an effort to increase
response.
Limitations
(1) Because previous research with the study population
was minimal, techniques used successfully with other
populations were adapted for the study.
(2) The original study population was reduced to its
final number due to unavoidable attrition resulting from
medical problems, reading aptitude, drug test results,
voluntary drops, and a number of other factors.
(3) Only recruits from one of the three Navy recruit
training facilities were used.
(4) Several potential threats to internal validity
remained beyond experimental control including company
commander influence, and seasonality differences in
recruits.
(5) Cotinine analysis was not accomplished for each
subject nor for each survey period.
(6) Addresses for follow-up mailings were obtained from
a Navy computerized personnel tracking network which may
be less than 100% accurate.

13
Assumptions
(1) Recruit company commanders uniformly followed no¬
smoking policies set for the command.
(2) The sample population were uniformly exposed to
outside variables which might affect treatment outcome.
(3) Subjects in each treatment group self-reported
tobacco usage with the same degree of truthfulness.
(4) Subjects in differing treatment groups had no
interaction affecting results.
Definition of Terms
The following are working definitions for selected terms
used in this study.
Smoking relapse/recidivism was defined as at least one
puff per day for seven days. This definition was
recommended by a conference of the National Heart, Lung,
and Blood Institute (Carmody, 1990). Relapse does not
necessarily mean a return to the previous smoking rate.
Current smokers were defined for this study as
individuals who have smoked at least 100 cigarettes in
their lifetime and have smoked a cigarette, cigar, or
pipe within 2 months prior to entering the Navy (intake
survey); or since graduation from recruit training (3
month follow-up survey).

14
Current smokeless tobacco users were defined as having
categorized themselves as users of chewing tobacco or
snuff and have used at least 3 days in the past 12
months.
Former smokers were defined as once current smokers, but
having not smoked a cigarette, cigar, or pipe in the
last 2 months.
Former smokeless tobacco users were defined as once
current users, but having not used chewing tobacco or
snuff in the last 2 months.
Never smokers were defined as having smoked less than
100 cigarettes in their lifetime, indicated they never
regularly smoked, and characterized themselves as having
never used cigarettes, cigars, or pipes.
Never users of smokeless tobacco were defined as having
categorized themselves as never using chewing tobacco or
snuff on a regular basis.
Light smoking was considered using less than one
cigarette per day.
Moderate smoking was considered using from 1-19
cigarettes per day.
Heavy smoking was considered using a pack, or more, of
cigarettes per day.
Smoking relapse rate was determined by dividing the
number of participants (categorized as current smokers
at intake) indicating they started smoking again after

15
boot camp, by the total number of smokers remaining in
the study.
„„„ start
SRR —
total smokers
Boot camp is a common term used for basic recruit
training in the military. Generally the training
received immediately upon entering the military, which
lasts about 8 weeks.
Sham treatment refers to a placebo treatment similar to
the main intervention only in amount of attention paid
to participants. The material presented is only vaguely
related to the study goal.
Command refers to the actual component of the Navy to
which participants were assigned after recruit training.
Knowledge gain refers to observed change in smoking
knowledge scores between pretest and posttest.

CHAPTER 2
REVIEW OF LITERATURE
WHEN loves grows cool, thy fire still warms me;
When friends are fled, thy presence charms me,
If thou art full, though purse be bare,
I smoke, and cast away all my care!
-German Smoking Song
Introduction
The purpose of this chapter is to provide a summary of
what has been learned from other studies regarding smoking
prevention and smoking relapse prevention. Insight as to how
the current study will contribute to a fuller understanding
of the issues is also presented. The chapter starts with a
look at ill effects of tobacco, and tobacco use prevalence
rates in the U.S. population, and military sub-groups.
Several theories of smoking relapse are then reviewed
followed by an examination of how these theories have been
used in the past as basis for research in relapse prevention.
Research on the effects of smoking policy and miscellaneous
relapse research are then examined. Research on smoking
prevention, as it relates to this study, is then reviewed.
Prevention methods which current research has shown effective
16

17
are presented, followed by an overview of recent research in
ways of increasing truthfulness of smoking self-report, and
means to verify smoking self-report. A concluding statement
ends this chapter, in which the theoretical framework is
related to the actual experimental design of the study.
Problems Related to Tobacco Use
Cigarette smoking remains a major problem in U. S.
society today. A recent report (CDC, 1991b) says more than
434,000 deaths, and an estimated 1,199,000 years of potential
life lost (YPLL) before age 65, were caused by cigarette
smoking in 1988 in the United States. In 1964, the Surgeon
General reported (Public Health Service [PHS], 1964)
cigarette smoking causes lung and laryngeal cancer in men,
and causes bronchitis. The 1989 Surgeon General's report on
the health consequences of smoking (USDHHS, 1989) showed
cigarette smoking also causes coronary heart disease,
cerebral vascular disease (stroke), atherosclerotic
peripheral vascular disease, lung and laryngeal cancer in
women, oral cancer, esophageal cancer, chronic obstructive
pulmonary disease, intrauterine growth retardation, and low
birth weight babies. Smoking was also found to be a
contributing factor for cancers of the bladder, pancreas, and
kidney; and associated with cancers of the stomach and
uterine cervix (USDHHS, 1989). Research also has established

18
involuntary smoking as a cause of disease, including lung
cancer, in healthy non-smokers (USDHHS, 1986).
Cigarette smoking is the number one preventable cause of
death in the U.S. today (USDHHS, 1989). Smoking causes more
premature deaths than cocaine, heroin, alcohol, fire,
automobile accidents, homicide, and suicide combined (USDHHS,
1990). It has been estimated that smoking costs society over
$50 billion annually in smoking related diseases, death, and
absenteeism (Fielding, 1986). However, more than 50 million
Americans continue to smoke (USDHHS, 1990b).
Tobacco Use in the U.S.
Smoking prevalence in the adult U.S. population was
about 29% in 1987, which is down from the 40% prevalence seen
in 1965 (USDHHS, 1989). Unfortunately, this decrease in
smoking is not seen uniformly throughout the population. The
Surgeon General reported the prevalence of smoking in women
has declined more slowly than men, and smoking rates will be
about equal for men and women in the mid-1990's (USDHHS,
1989). The report also states female adolescents not
planning on higher education show a much higher smoking
initiation rate than for male adolescents. A higher smoking
prevalence was also reported among black and Hispanic men
than white men. More disturbing is the fact that smoking
prevalence among teenagers has not declined over the past
decade. Johnston, et al. (1991), reporting on their 15th

19
annual national survey of American high school seniors,
stated that in 1989 29.4% of seniors were current smokers (30
day prevalence of cigarette use), which was the same
proportion as the class of 1981. High school dropouts have
prevalence rates for all types of drugs, including
cigarettes, substantially higher than in-school students
(Johnston, O'Malley, & Bachman, 1989).
Military Tobacco Use and Related Problems
Tobacco use in the military has been quite prevalent for
many years. Tobacco has been part of the traditional rations
given to soldiers during war time (Ferrence, 1989). This
practice started the smoking habit in hundreds of thousands
of Americans and began an association of cigarettes with the
military that persists today. Very little research can be
found in the literature on military smoking cessation and
none can be found on military smoking relapse prevention.
However, this is not a reflection of the magnitude of the
problem. A recent survey of the military found over 40% of
all members are smokers (Bray, et al., 1988). Marsden, Bray,
and Herbold (1988) showed the number of illnesses reported by
U.S. military personnel is significantly related to smoking,
as well as to other substance abuses, such as alcohol. Their
study utilized data from the 1985 worldwide survey of alcohol
and non-medical drug use among military personnel. They
found the number of healthy behaviors practiced was inversely

20
related to use of alcohol, drugs, and tobacco. Substance
users, particularly heavy users, were more likely to have
experienced ill health during the past 12 months. When
controlling for background variables, which also related to
ill health, number of illnesses was still significantly
related to reported drinking level, drug use, and smoking.
Smokers of one or more packs per day averaged 0.22 more
illnesses per year than non-smokers. Ballweg and Bray (1989)
also reported smokers were more likely than non-smokers to
describe their health as fair or poor. Though the military
smoking rate is high, it reflects a significant decrease from
1980 when 51% of military members smoked (Bray, et al.,
1988).
Many explanations have been hypothesized to account for
the high military smoking prevalence seen today. The
following are descriptions of some of these hypotheses.
-Distinctive military conditions such as relocation
overseas, family separation, or a greater perceived
acceptance of use may foster higher rates of use (Bray
et al., 1991).
-Military personnel are not demographically
representative of the general population (this will be
discussed at length later in this chapter).
-The military has been selecting individuals who are
predisposed to smoke (Gardner, 1991). Smoking can be
predicted by pay-grade, race/ethnicity, education,
service branch, age, poor health practices, and higher

21
stress at work (Bray, Marsden, Guess, & Herbold, 1989;
Carroll, Lednar, & Carter, 1989).
-Tobacco products are available at much lower prices at
military outlets than in the civilian market (Cronan &
Conway, 1988; Nelson & Roth, 1991). Many programs are
funded by tobacco sales revenue. Fiscal 1988 saw $102.1
million in tobacco sales by Navy exchanges (McBeth,
1989) and in 1989 $20 million of tobacco profits were
given back to Morale Welfare and Recreation funds.
Fiscal 1991 sales topped $126 million (Steigman, 1992).
-Military life brings an increase in interpersonal
communication and social participation due to higher
density in living quarters and increased group
activities. These conditions are conducive to
initiation/continuance of the smoking behavior
(Ferrence, 1989).
-The military encourages cohesiveness and uniformity,
and members may begin smoking to become like each other,
and "one of the group" (Cronan & Conway, 1988).
-Work breaks and other opportunities to relax are often
paired with opportunities to smoke (Cronan & Conway,
1988).
-Civilian publications aimed at the military populations
contain a large amount of sponsorship/advertisement from
the tobacco industry (Nelson & Roth, 1991).

22
Because of the nature of military employment, any
substance abuse can often cause consequences of graver impact
than in the civilian community. Greater responsibilities are
placed in the hands of younger people in the military than
would ever be allowed in the civilian work force. A twenty
year old may be responsible for actual steerage of a large
naval vessel, for preparation of a multimillion dollar
aircraft for flight, or for emergency medical treatment of a
seriously injured person. If that individual's performance
is hindered because of use of any psychoactive substance,
including tobacco, lives and expensive hardware can be placed
in jeopardy. The U.S. Surgeon General has concluded nicotine
is a psychoactive substance (USDHHS, 1988).
The safety aspects of even legal substances such as
tobacco can be crucial. Smoking is restricted at certain
times on ships. The smoking lamp is either lit or out on
board a naval ship. This refers to a practice years ago
aboard naval vessels in which the captain would order a lamp
lit for sailors to light their cigarettes when their duties
had ended for the day. The lamp is gone but the term is
still used to tell when it is safe or not to smoke. A lit
cigarette can be a hazard around fuel, ordinance, or any
volatile substance. On submarines the air must be
recirculated, and cigarette smoke is a significant
contributor to atmospheric contaminants (Scali, 1989).
The military population is not demographically
representative of the general population, which may account

23
for some of the difference in smoking prevalence. Table 1
presents a breakdown of some of these differences.
Table 1. Population comparisons
Active Duty
Military
Total U.S.
Population
RACE
Caucasian
72% (1,557)*
84.3% (207,748)
Black
20% (426)
12.3% (30,326)
Other
8% (85)
3.4% (8,256)
SEX
Male
89.5% (1,946)
48.8% (120,203)
Female
10.5% (228)
51.2% (126,126)
AGE
17-20
17.3% (376)
6.1% (15,054)
21-25
32.4% (704)
8.1% (19,981)
26-29
17.8% (387)
7.2% (17,701)
30-34
14.9% (324)
8.9% (21,878)
35-39
10.5% (228)
7.8% (19,194)
40 & over
7.2% (157)
37.6% (92,518)
* Numbers are represented in thousands.
Source: U. S. Bureau of the Census, Statistical abstract of the
United States: 1990 (110th edition) Washington DC & Military Market,
October 1989, pp. 46-52.
Service members are younger, most are male, and the
majority of recruits come from the lower socioeconomic
levels. These are factors also associated with higher

24
smoking prevalence (Bray et al., 1991). Bray et al. (1991)
reported, controlling for key sociodemographic
characteristics known to be associated with substance abuse,
military personnel are in general still substantially more
likely than civilians to be smokers and heavy smokers. They
also reported differences among military and civilian women
are more pronounced than among military and civilian men.
The rates for men differed by 4 and 7 points respectively,
while the rates for women differed by 13 and 14 points.
Navy Tobacco Use
The most recent Worldwide survey of substance abuse and
health behaviors among military personnel (Bray, et al.,
1988) showed prevalence of any smoking in the Navy was 43.8%
in 1988. A 1986 survey of shipboard personnel indicated
49.8% smoked (Conway, & Cronan, 1988). Smokeless tobacco is
used by 16.1% of Naval personnel. A 1987 Navy report (Cronan
& Conway, 1988) found about 28% of incoming recruits were
regular smokers with another 13% claiming to be former
smokers.
An informal tobacco use survey was conducted by the
dental staff at the Orlando Recruit Inprocessing Facility.
The survey was designed by Lieutenant Commander David
Grochmal, Dental Corps, and was accomplished as part of the
dental screening process. The survey was conducted from
March to October, 1990 and included over 13,000 recruits.

25
This survey found 39.7% (34.1% male and 56.7% female)
reported they were smokers before entering the Navy. Also,
7.4% of the men indicated they were smokeless tobacco users
(Grochmal, 1990).
In 1988 a survey of high school seniors and young adults
(Johnston, et al., 1989) found an 18% prevalence of daily
smoking for seniors and a 29% rate of current (casual)
smokers. This same study reported a drastically higher
smoking rate in respondents 1-4 years past high school who
were not in college. Other studies have shown that smoking
rates are higher for seniors who do not plan on pursuing
higher education (Glynn, 1990; Johnston et al., 1991). Since
the majority of the recruit population comes from this group,
the higher recruit smoking prevalence is not surprising.
Though the vast majority of Navy recruits have a high school
diploma (or equivalent), some have obtained it in a non-
traditional manner, and thus are part of a group at much
higher risk to smoke.

26
Smoking Relapse
"To cease smoking is the easiest thing I ever did; I
ought to know because I've done it a thousand times"
-Mark Twain
Most relapse does not occur immediately, but rather long
after signs of physiological abstinence have disappeared
(Jarvik & Hatsukami, 1989). Research shows approximately 70%
of successful quitters relapse within 3 months, and an
additional 10-15% relapse between 3 and 12 months after
quitting (Schwartz, 1987; Shiffman et al., 1985). Several
theories have been offered to explain why relapse rates are
so high. Shiffman et al. (1986) have suggested three types
of variables influence relapse proneness: a) enduring
personal characteristics, b) background variables, and c)
precipitants. Craving for nicotine and the positive
reinforcement nicotine brings has also been theorized as
reason for relapse (Carmody, 1990). Gritz, Carr, and Marcus
(1991) conducted a study on tobacco withdrawal syndrome in
unaided quitters. They found tobacco dependence to be a good
indicator of smoking relapse. Higher Fagerstrom tolerance
scores predicted higher probability of relapse. Their other
main finding was higher cigarette consumption at enrollment
predicted higher short and long term relapse.

27
Theory of Reasoned Action
One model which has been used to describe likelihood of
behavior change has been termed the theory of reasoned action
(Ajzen & Fishbein, 1980). This theory states the best
predictor of behavior is a person's intention to perform the
behavior. Behavioral intention is seen as a function of two
determinants; the person's attitude toward the behavior, and
the perceived expectation of important others with regard to
performance of the behavior (subjective norm). In a review
of this theory Sutton (1989) said, "In other words, a
person's behavioral intentions, and hence behavior, depend
ultimately on the person's belief concerning; (a) the
possible consequences of the behavior, and (b) the
expectations of important others. It follows that in order
to change behavior it is necessary to change the underlying
beliefs" (p 291). The theory goes on to explain that
external variables can influence intentions, and thus
behavior, but only by influencing attitude toward behavior or
the subjective norm, or the relative importance of the two
components. Since starting or stopping cigarette smoking is
a behavior that falls in the domain of this theory (a
behavior that can be regarded as a decision) intention to
stop/reduce smoking should be a good predictor of behavior.

28
Transtheoretical Model (Stages of Change)
Prochaska and DiClemente first applied their stages of
change model to self change of smoking habits (Prochaska &
DiClemente, 1983). They believe most behavior involves
repetitive and habitual actions which are quite resistant to
extinction. Further, behavior change requires movement
through discrete stages in order to achieve maintained
cessation or initiation. The five stages of change an
individual cycles through in attempting behavior changes are:
-pre-contemplation
-contemplation
-action
-maintenance
-relapse.
Because changing smoking behavior is highly prone to
relapse, it is theorized that individuals tend to move
through these stages in a cyclical fashion (Prochaska &
DiClemente, 1982). Successful change often requires repeated
recycling through these stages. Research suggests the
average smoker cycles three to four times through the stages
before attaining long-term abstinence (Prochaska &
DiClemente, 1984; Marlatt, Curry, & Gordon, 1988). Those in
relapse and pre-contemplation do not have enough motivation
to change their smoking habits. Those in the contemplation
stage are aware of a need to change, but have not yet taken

29
action. The key to successful change lies in exiting the
maintenance stage after replacing the behavior in their
lifestyle. If the intervention method is tailored to the
individual's stage of change, the chances of success can be
enhanced. Rimer (1990) says people in the process of change
must have access to interventions which start at their stage
in the change process. Because of this, she says
intervention should include a range of options to reach
people in all stages. Intervention programs may not succeed
in behavior change, but may succeed in moving the individual
to a higher stage, which is important (Prochaska &
DiClemente, 1983). No studies have as yet been reported
concerning any education effect on this recycling phenomenon.
Social Cognitive Theory
Bandura's (1989) social cognitive theory revolves around
smokers' beliefs about ability to exercise control over
events which control their lives. Bandura sees self-efficacy
as influencing thought patterns, motivation, level of stress,
and selection of environments; thus affecting smoking
cessation outcome expectations.
All of these theories have commonalties, and show that
smoking relapse is individualistic and complex. Recruits who
smoked before entering the Navy have been placed in the
action stage of change while in recruit training, even though

30
they were probably in a lower stage before they came in. No
previous studies have reported or predicted what effect this
will have. It is not known what effect this will have on
their intentions to stay quit. Certainly it will show they
are capable of not smoking for an extended period of time.
What is known is young adult smokers do quit, or at least
attempt to quit, smoking. Thirteen percent of recruits
surveyed indicated they were former smokers (Cronan & Conway,
1988). A prospective cohort study from pre-adolescence to
young adulthood (Swan, 1991) found about 14% of 21 - 22 year
olds reported being ex-smokers. Another study (Ershler,
Leventhal, Fleming, & Glynn, 1989) states 52% of 6 - 12 grade
smokers had indicated at least one quit attempt. A survey by
Tuakli et al. (1990) indicated 69% of the 12 - 20 year old
smokers had tried to quit. The top reasons for quitting
were: 1) didn't enjoy smoking, 2) health concerns, 3)
pregnancy, 4) costs, and 5) parents or friends asked. This
indicates even young smokers are aware of the risks of
smoking, and some may have progressed through the cycle of
changing their smoking behavior.
Relapse is defined in the literature as a smoking
episode after a period of voluntary abstinence that is
followed by a return to continuous smoking (O'Connell, 1990).
To include recruit graduates in this category may be
stretching this definition, but since we now have an all
voluntary armed forces, all recruits enter the Navy of their
own free will. All recruits may not enter with the intention

31
to permanently quit smoking though, which may affect smoking
relapse seen after graduation.
Relapse Prevention
The topic of relapse prevention has received a lot of
research attention recently. Since most smoking cessation
programs report from 50-80% abstinence at the end of
treatment (Schwartz, 1987) improvement of long-term quit
rates is a logical next step in smoking cessation research.
In reviewing current issues in preventing smoking relapse,
Carmody (1990) found smoking relapse is influenced by a host
of variables, including: physiological factors, withdrawal
symptoms, conditioning processes, stress and negative mood
states, level of commitment and motivation to remain
abstinent, social support, weight gain, and repertoire of
cognitive and behavioral coping strategies in response to
temptations to smoke. He concluded that the primary
theoretical framework for relapse prevention is social
learning theory.
Mazur (1986) points out that social learning theory adds
the principles of observational learning and imitation to
traditional principles of classical and operant conditioning.
He suggests Bandura's social learning theory can help account
for the acquisition of many addictive behaviors including
smoking. Others (Carmody, 1990; Perry, Baranowski, & Parcel,
1990; Rimer, 1990) believe this theory is particularly

32
valuable to health educators because it illuminates the
dynamics of individual behavior and gives direction for
intervention design in behavior change programs. Bandura
(1989) says people make causal contributions to their own
motivation and action within a system of triadic reciprocal
causation. The model shows action, personal factors, and
environmental events operating as environmental determinants.
In the model, people partly determine the nature of their
environment and are influenced by it.
The preceding theories lend well to the multi-component
interventions thought to be important in relapse prevention
strategies. They can easily be applied to multi-level change
strategies because of inclusion of environmental, personal,
and behavioral constructs.
Social cognitive theory is an outgrowth of social
learning theory (Bandura, 1989). This theory appears to be
useful as a model in studying smoking relapse (Carmody,
1990). People's beliefs about their ability to exercise
control over events that affect their lives are central to
the theory. Wojcik (1988) found the strongest prediction of
abstinence versus relapse in a sample of 75 smokers
attempting to quit on their own was self-efficacy.
Shiffman et al. (1985) emphasize education, assessment,
and coping-skills training in their approach to relapse
prevention. They also found combining cognitive and
behavioral coping enhanced effectiveness of preventing
relapse. Seven types of behavioral coping were listed:

33
-eating/drinking
-engaging in a distractive activity
-escape
-delay
-engaging in a physical activity
-relaxing
-engaging in any other activity.
Cognitive coping strategies were:
-willpower
-self-punitive thoughts
-positive health consequences
-negative health consequences
-distracting thoughts
-intent to delay
-other self-talk.
People who expect smoking cessation to require active coping
have been shown to be more successful in maintenance
(Shiftman et al., 1986). They determined it is probably most
useful to teach ex-smokers a broad repertoire of coping
responses to prevent relapse.
Other approaches to relapse prevention include
motivational enhancement, social support, coping skills
training, reinforcement, lifestyle balancing, and the use of
various pharmacological agents (Carmody, 1990). Several
studies have shown that use of refusal skill training
techniques is beneficial in maintenance of smoking cessation
(Curry, Marlatt, & Gordon, 1987; Curry, Murray, Gordon, &

34
Baer, 1988; Shiftman et al., 1985; Stevens & Hollis, 1989).
In a randomized study using skills training and social
support as relapse prevention methods, Stevens and Hollis
(1989) found skills training significantly decreased relapse
rates, while social support showed no significant differences
from a no-treatment control.
In addition to skills training, the National Institutes
of Health (NIH) say information about the health and social
consequences of smoking is critical for cessation (Glynn et
al., 1991). Gibbons, McGovern, and Lando (1991) showed the
utility of including information on the risks of smoking as
well as the benefits of quitting, in a study of relapse in a
smoking cessation clinic. The NIH study states high risk
perception declines significantly over time for those who
fail in their quit attempt. Perception is an important
factor related to cessation commitment and efforts to
counteract this tendency to decline may reduce relapse rates,
or may help relapsers maintain cessation motivation to try
again. Several studies suggest booster sessions may help
maintain motivation to stay quit when used as part of a
multicomponent strategy (Brink, Simons-Morton, Harvey,
Parcel, & Tiernan, 1988; Brownell et al., 1986). Brownell et
al. (1986), suggest booster sessions may be useful in the
perception that one is part of a continuing process of
change. They also point to the usefulness of giving self-
help manuals to those who have quit, as another means of
enhancing vigilance in maintaining non-smoking. They believe

35
use of self-help manuals may be especially important in the
late maintenance stages of quitting. They state that
although initial abstinence rates from self-help books and
brochures are low, such materials may be effective in keeping
recent quitters from returning to smoking. Curry et al.
(1988) also found self-help materials were helpful in relapse
prevention, for those who used the materials. Motivation is
another factor which has been cited by many studies as
critical in maintaining cessation (Brandon, Tiffany,
Obremski, & Baker, 1990; Brownell et al., 1986; Carmody,
1990; Glynn et al., 1991; Shiftman et al., 1985).
A task force on interventions to prevent relapse
(Brownell et al., 1986) suggest that sustained smoking
cessation requires the modification of a range of social
skills. The removal of an ingrained personal and social
habit leaves a void that must be filled to prevent relapse.
They suggest the void be filled by new reinforcers, new
social skills, or general lifestyle changes. New, more
health oriented reinforcers, may include; exercise,
relaxation training, and meditation. An effort must be made
to find alternatives for which smoking was previously
employed.

36
Smoking Policy and Effect on Smoking Cessation
Navy recruit training lasts 8 weeks. The current
smoking policy does not allowed anyone to smoke at the
command (CNTECHTRA Instruction 5100.6A, 1991). This includes
recruits, instructors, and all staff members. Therefore, the
recruits who smoked prior to entry, graduate boot camp as ex¬
smokers who have successfully quit for 2 months. This 100%
cessation rate, with zero recidivism for 2 months, is far
better than any other cessation program reported in the
literature. However, no other quasi-involuntary cessation
programs have been reported and very little information is
available concerning relapse after leaving this type of
environment. Cronan et al. (1989) compared smoking
intervention techniques in recruit training (the current
smoking policies had not yet been instituted). Four groups
were followed through their training cycle. One group
received an educational intervention, another feedback from
health risk evaluations, and a third was designated no
smoking and were not allowed to smoke during training. A
fourth group was followed as a control. The no smoking
group, although showing the best cessation at the end of
training (measured after their first opportunity to smoke),
still reported a 75% relapse rate.
The only other study examining relapse rate in this area
is ongoing (T. L. Conway, personal communication, June 6,

37
1991) and results are not yet available. This study began
last year to look at tobacco use in all new Navy accessions.
Participants were surveyed at the beginning of training, at
graduation, and at 1 month follow-up. Interventions were not
included.
The current Navy policy is not as restrictive overall as
it is for recruits, but does meet the Department of Defense
directives. Tobacco use is not permitted in: 1) auditoriums,
conference rooms, classrooms, or libraries; 2) elevators; 3)
official buses, vans, and shuttle vehicles; and 4)
gymnasiums, child care and youth activity centers (SECNAVINST
5100.13A, July 17, 1986). Other limitations are placed on
working areas, eating facilities, aircraft, living quarters,
and medical facilities, but guidelines are left to the
individual Commanding Officer. In contrast though, sales of
tobacco products are still discounted from civilian prices at
Navy Exchange facilities, although they may not be purchased
at medical and dental facilities (USDHHS, 1990b).
There is no evidence that policy alone affects smoking
prevalence. In fact, the 1989 Surgeon General's report
(USDHHS, 1989) reported insufficient research has been
undertaken to determine what effect, if any, smoking
restrictions have had on smoking prevalence. Two studies did
examine a no-smoking policy which has been successful in
decreasing consumption of cigarettes in settings affected by
the policy, but not prevalence rates (Pentz et al., 1989;
Petersen et al., 1988). Policy combined with education does

38
seem to be more beneficial than policy alone. Pentz et al.
(1989) found a policy which emphasized adolescent education
to prevent and stop smoking, rather than regulating it by
punishment, was significantly related to lower recent
smoking. Education, designed to reorient the ex-smoker's
attitudes toward more realistic expectations about quitting
smoking, is an important first step in relapse prevention
(Carmody, 1990).
A survey to assess short-term impact of Army smoking
policies (Carroll et al., 1989) reported no influence of
policy on decision to quit, though a consumption drop was
reported in some areas. This study also showed intention to
quit is related to knowledge of smoking-related diseases.
The current recruit smoking policy lacks support of a strong
prevention education component (CNTECHTRA, 1991a). Results
of the current recruit policy study may reflect those of the
Army survey because of this fact. The Navy has a long way to
go to meet its goal of being smoke free by the year 2000
(Zolton, 1991). New restrictions are being proposed, but
Navy guidelines must include positive approaches to help
individuals make the decision not to smoke. Vice Admiral
Zimble, the Navy Surgeon General, said: "We want a
positively motivated force that chooses not to smoke"
(Nelson, 1991). Health educators also realize coercion of
positive health behavior is not only unethical, but is
usually not a very successful tactic. The challenge, in this
study of prevention education supplemented with strict

39
policy, will be to increase the likelihood that recruits will
favorably respond to the education treatments.
Other Relapse Research
Though much is known about relapse in self-quitters and
program aided cessation, very little is known about relapse
in those who involuntarily quit smoking. One related area is
relapse of women who quit smoking during pregnancy. These
women quit voluntarily, but usually not for themselves.
Rather they quit so as to not affect the health of their
babies. Relapse in these women is usually quite high
(McBride & Pirie, 1990; Mullen, Quinn, & Ershoff, 1990) and
has been reported as high as 70% at one year post-cessation
(Fingerhut, Kleinman, & Kendrick, 1990) even though smoking
at this time may still have an indirect effect on the baby.
Several studies have been conducted on smoking cessation for
pregnant women, but none have specifically targeted relapse
prevention.
Another area where involuntary smoking cessation may
occur is in jails/prisons, but no information could be found
in the literature on this subject.
Smoking Prevention
As more and more adult smokers quit, in both the
civilian and military populations, efforts to prevent the
onset of smoking become the next logical step towards the

40
goal of a smoke-free Navy/society. The Surgeon General
(USDHHS, 1989) reported children and adolescents hold the key
to progress toward curbing tobacco use in future generations.
This report also said there is a growing recognition that
prevention and cessation efforts need to target specific
populations with a high smoking prevalence and a high risk of
smoking related disease. The military population is listed
as one of the groups that needs to be targeted.
Many approaches have been tried over the years, both in
school and community settings, to prevent adolescents from
beginning to smoke. Early campaigns to increase information
and create fear of long term consequences did not succeed.
Although succeeding in changing knowledge, beliefs, and
attitudes, very few programs consistently reduced the onset
of smoking (Flay, 1985). In a review of psychosocial
approaches to smoking prevention, Flay (1985) examined the
success of such programs and the theory involved in their
evolution. He states these programs incorporate complexities
of the psychosocial process of becoming a smoker into the
design of prevention interventions. He lists the following
components as part of a life/social skills approach to
smoking prevention:
-long term consequences of cigarette smoking
-the prevalence of smoking
-correcting students perception of social norms
concerning smoking
-teaching students about the social influences to smoke

41
-providing behavioral skills to resist influences
-enhancing personal skills and/or self-esteem
-providing general social competence skills.
Flay cites the social inoculation theory as the main
influence for this approach, with added theoretical
bolstering from the attitude change theory and the social
learning theory. Among the program components he felt were
important, based on successful studies, were:
-information on the immediate effects of smoking
-correction about the misrepresentation about the
prevalence of smoking
-discussions of family and media influences on smoking;
and how to deal with them
-a public commitment procedure.
The health belief model is one of the few social
psychological models to be developed expressly to understand
health behaviors (Rimer, 1990). One of the critical
dimensions of this model concerns the failure to believe in
the possibility of having pathology in the absence of
symptoms. This is particularly true with cigarette smokers,
especially young ones. Many of the health problems of
smoking are long term (USDHHS, 1989; USDHHS, 1987). Lung
cancer, emphysema, and cardiovascular diseases do not develop
within the first few years of smoking. Young smokers show a
good knowledge of the connection of smoking with these
diseases (Banspach, Lefebvre, & Carleton, 1989; Johnston et
al., 1989). However, because they are not experiencing any

42
of the disease symptoms, they feel these effects are a long
way off, and they will be able to stop smoking well before
disease onset. In general, adolescents feel invulnerable to
accidents and chronic diseases (Glanz, Lewis, & Rimer, 1990).
One of the axioms of health education is that knowledge
is necessary, but not sufficient for behavior change.
Information is necessary but not sufficient for knowledge
(Rimer, 1990). Therefore, teaching young students about the
long term effects of smoking may be a good tactic, but by
itself, will not win the prevention war.
In order for people to quit smoking for health reasons,
they must believe cessation will benefit their health, and
also that they are capable of quitting (Rosenstock, 1990).
Knowledge about the risks of smoking is better now than it
ever has been. The 1989 Surgeon General's report (USDHHS,
1989) states the proportion of adults who believed cigarette
smoking increases the risk of emphysema and chronic
bronchitis rose from 50% in 1964 to 81% (chronic bronchitis)
and 89% (emphysema) in 1986. These proportions increased
among current smokers from 42% in 1964 to 75% (chronic
bronchitis) and 85% (emphysema) in 1986. Johnston et al.
(1989) reported that 70% of young adults perceive regular
pack-a-day cigarette smoking as entailing high risk. Despite
these findings, and despite the fact that 80% of all smokers
indicate a desire to quit, over 50 million Americans still
smoke.

43
Not all adolescents who try a cigarette become regular
smokers; not all who start smoking regularly continue to do
so their entire life. Once an individual has experimented
with smoking, other factors come into play to determine
whether the behavior will become a continuing habit. New
smokers do not become regular smokers immediately. They pass
through the phases of stabilization, acceleration, or
deceleration of their smoking habits (Epstein, Grunberg,
Lichtenstein, & Evans, 1989). Horn (1979) describes the
influence of three groups of factors which bias this choice:
the cost/benefits evaluation of the behavior; common
stereotypes that characterize perception of behavior; and
psychological factors characterizing both personal structure
and personality integration factors, particularly as they
relate to societal demands. The cost of smoking includes the
harmful effects on health, financial cost to the individual
or society, and more recently, a feeling of discrimination in
most public places.
Benefits a smoker may perceive vary even more than the
disadvantages (Horn, 1979). Peer acceptance or facilitation
of social interaction places high on the list for
adolescents. Smokers often smoke to reduce stress, enhance
pleasure, improve their concentration, gain satisfaction from
handling the cigarette, or for numerous other reasons. For
many smokers the benefits do seem to outweigh the costs. The
perceptual stereotypes referred to by Horn develop from a
mystique about what smoking and smokers are like, and why

44
people smoke. Horn states that, the greater the role played
by these superficial and inaccurate beliefs about the
behavior, the more difficult it becomes for an individual to
develop a sound decision-making process. These stereotypes
are perpetuated by cigarette advertisements. Horn's third
group of factors contains a variety of patterns for
psychological forces which may help determine personal
choices for health behavior, particularly behaviors which
reflect a conflict engendered in individuals between the
demands of society and their own inner desires.
The population entering the Navy consists of current
smokers, former smokers, occasional smokers, and non-smokers
(Cronan & Conway, 1988; Cronan et al. 1989). Studies have
found nearly all smokers start smoking in their teenage years
(USDHHS, 1987; USDHHS, 1989). However, the National Cancer
Institute (NCI) now feel there is a second period where
individuals are at risk for starting smoking. Recent
research indicates there may be another smoking uptake period
in the early 20's as employment transition takes place (T. J.
Glynn, personal communication, September 16, 1991). Cronan
et al. (1989) found that some recruits were starting to smoke
during recruit training (this study was done before the
current no-smoking policy was instituted). It is possible,
since the institution of the no-smoking policy in recruit
training, that smoking initiation may now be taking place in
the training environment after recruit graduation. Because
of possible smoking uptake during employment transition, it

45
is important that prevention efforts also be presented during
this period. Cronan & Conway (1988) concluded the Navy must
develop and evaluate programs directed toward preventing
personnel from smoking. They felt prevention programs should
probably be implemented as early as recruit training.
Educational Intervention
Because of the mix in smoking status among recruits, a
similarly mixed intervention/prevention strategy may prove
most effective. In a meta-analysis of 39 smoking cessation
interventions Kottke, Battista, DeFriese, and Brekke (1988)
found the most effective programs employed more than one
modality for motivating behavior change. Cronan et al.
(1989) evaluated smoking interventions in recruit training.
They found a one-hour education program significantly reduced
the number of recruits who started smoking during training,
but did not increase the number of smokers who quit. Their
educational intervention stressed the hazards of smoking and
techniques for stopping.
In 1987, the NCI convened an expert advisory panel to
assess the question "What are the essential elements of a
school-based smoking prevention program?" (Glynn, 1989). The
panel concluded that existing programs have been consistently
effective in delaying the onset of smoking. Programs with a
smoking-only focus have about an equal effect as those with a

46
multicomponent focus. They felt minimum smoking prevention
components should include:
-information about social consequences and short term
physiological effects of tobacco use
-information about social influences on tobacco use,
especially peer, parent, and media influences
-training in refusal skills, including modeling and
practice of resistance skills.
They felt the minimum length of school-based programs should
be two, 5 session blocks with booster sessions in subsequent
years. Doctor Glynn, of the NCI, stated a shorter program
(2-3 hours) would probably be effective with individuals who
had already demonstrated to themselves that they could stop
smoking (T. J. Glynn, personal communication, June 18, 1991).
When used as part of a cessation program, education
intervention may last from 1-4 hours, depending on the length
of the overall program. No studies have been reported in
which length of the education segment was varied, while
attempting to decrease relapse rates or prevent smoking.
The Waterloo Smoking Prevention Project (Flay, 1985)
found previous experience with smoking did not preclude
prevention of further smoking. The study results showed the
program influenced current experimenters to quit smoking, and
remain quit. The prevention curriculum was six hours long
and was designed to influence attitudes towards tobacco and
the acquisition of social skills. The program had three main
components: 1) provide information on the effects of

47
smoking, 2) focus on social influences to smoke (family,
peer, media), and 3) decision to integrate information on
smoking to individual's own smoking environment and a public
commitment procedure about their decision of whether or not
to smoke. Three booster sessions were included in the
program.
Banspach et al. (1989) assessed two smoking prevention
programs: 1) a five-lesson, video presentation on resisting
pressures to smoke, and 2) a four-lesson teacher led
discussion of smoking and advertising. They found both
programs had a similar positive effect on preventing smoking
in students. The effects seen were significantly different
from those observed in a control group. They concluded that
increasing a student's awareness about the messages they
receive can be enhanced by either a video presentation with
discussion, or a teacher led discussion with student
involvement.
Validation of Smoking Status Self-Report
Cigarette smoking behavior is most often measured by
self-report of frequency and intensity. Researchers find
this procedure simple, efficient, and inexpensive. Murray,
O'Connell, Schmid, and Perry (1987) state because many
adolescents smoke infrequently and episodically, it may be
difficult for them to characterize their usual pattern of
smoking. Adolescents may also try to mislead the

48
investigator and underreport smoking behavior out of
embarrassment or a desire to please. Self-reports of smoking
status therefore, may not always be accurate, particularly
where smokers feel pressure to give up smoking but may not
have achieved it (Jarvis, Tunstall-Pedoe, Feyerabend, Vesey,
& Saloojee, 1987; Murray et al., 1987). In a study to
validate self-report claims, Jarvis et al. (1987) reported
19% of cotinine confirmed smokers claimed to be non-smokers.
However, other studies found only 2% of smokers claiming to
be non-smokers when not actively persuaded to give up smoking
(Lee, 1987; Thompson, Stone, Nanchahal, & Wald, 1990). For
this reason researchers try various techniques to increase
truthfulness of reporting and to validate self-reports of
smoking.
Bogus Pipeline
One strategy shown effective in increasing validity of
smoking self-reports has been termed the bogus pipeline
method. The rationale for this approach is that individuals
should be more likely to disclose their actual smoking
behavior if they believe the researcher has an independent
and objective means of measuring smoking behavior. Evans,
Hansen, and Mittelmark (1977) were the first to show efficacy
of this procedure with smoking research. Murray et al.
(1987) examined eleven papers on this subject and found five
reported a pipeline effect, while six did not. They

49
conducted a study to determine effectiveness of the approach
and effectiveness of different methods of message delivery.
Their data supported the hypothesis that adolescent smokers
are more willing to disclose cigarette use under pipeline
conditions. They concluded it is both prudent and
conservative to employ as credible a pipeline procedure as
possible, and use of this procedure offers the best assurance
of a valid assessment.
Biochemical Tests
A number of biochemical markers can be used to validate
smoking self-reports including measures of thiocyanate,
carbon monoxide, nicotine, and cotinine (Fitzpatrick, 1991;
Jarvis et al., 1987; Sepkovic & Haley, 1985). Levels of
carbon monoxide and thiocyanate (a metabolite of hydrogen
cyanide) are easier and less expensive to determine, but may
be raised through exposures unrelated to smoking, such as
auto emissions and diet (USDHHS, 1988; Jarvis et al., 1987).
Neither can they be used as a marker for smokeless tobacco.
All tobacco products contain substantial amounts of nicotine,
which is absorbed from tobacco smoke in the lungs, and from
smokeless tobacco in the mouth and nose. Nicotine is
metabolized in the liver and lungs, and cleared from the body
by the kidneys (USDHHS, 1988). Measures based on nicotine
have the advantage of being tobacco specific (all forms of
tobacco), but require extensive laboratory instrumentation.

50
Nicotine is a good marker of tobacco use, but its short half-
life in serum (0.5 - 2 hours) makes it a poor choice.
Nicotine is metabolized to cotinine, trans-3-hydroxycotinine,
and nicotine-1-N-oxide; all of which can theoretically be
used as markers (USDHHS, 1988).
Most investigators agree that cotinine is the analyte of
choice because it is tobacco specific and has a relatively
long half-life (Haley, Axelrad, & Tilton, 1983; Jarvis et
al., 1987; Langone, Cook, Bjercke, & Lifschitz, 1988). The
half-life of cotinine is on average 20 hours (Jarvis et al.,
1987; Langone et al., 1988) which makes sample timing in
relation to cigarette smoking less critical. Cotinine
concentrations in blood are generally tenfold greater than
nicotine, and as a result less sensitive analytical
methodology may be acceptable. Cotinine is metabolized, only
17% is excreted unchanged, but levels may persist for up to
seven days after cessation of habitual smoking (USDHHS,
1988).
Cotinine samples from blood, saliva, and urine are
equally applicable to the whole range of issues requiring
estimates of nicotine exposure from tobacco smoking (Jarvis
et al., 1987). Choice of fluid may depend more on practical
considerations (eg. cost, collection availability) than
pharmokinetic considerations. Because concentrations of
cotinine in urine are tenfold to hundredfold greater than
concentrations in plasma or saliva, a variety of analytic
techniques meet sensitivity requirements (USDHHS, 1988).

51
Without use of a 24 hour urine sample though, normalization
using creatine excretion is often used (Haley, Colosimo,
Axelrad, Harris, & Sepkovic, 1989). This normalization
requires additional analysis and thus higher costs. Haley et
al. (1989) concluded the additional analyses may not be
necessary when simple validation of nonsmoking status in a
smoking cessation program is the endpoint.
Several analytical techniques have been used to
determine cotinine concentration in biological fluids. The
most frequent used are radioimmunoassay, liquid
chromatography, and gas chromatography (Skarping, Wiliers, &
Dalene, 1988). The choice depends on the biological fluid to
be assayed; the need for sensitivity, precision, and
accuracy; and economic considerations (USDHHS, 1988).
Immunoassay techniques are simpler, generally require smaller
samples, and may be less expensive. They have been
determined to be best suited for smoking/non-smoking
determinations.
Non-smokers can show low levels of cotinine from
nicotine exposure to environmental tobacco smoke (eg. car,
home, restaurants). Studies have shown passive cotinine
concentrations as high as 32 ng/ml, and active cotinine
concentrations as low as 44 ng/ml (Wall, Johnson, Jacob, &
Benowitz, 1988). Sensitivity for non-smoker analysis is
generally set in the range of 1-25 ng/ml (Thompson et al.,
1990), however cutoff sensitivity and specificity set for
discriminating true has also been set at 50 ng/ml (Jarvis et

52
al., 1987). Other studies have also set non-smoking values
at 50 ng/ml (Fitzpatrick, 1991; Jarvis et al., 1987).
Fitzpatrick sums up nicely the benefits of cotinine
analysis:
The cotinine assay used today can determine either
active or passive exposure to tobacco smoke. It is
specific for exposure to nicotine. It can use urine,
which like saliva, is easy to collect, but it can also
use serum. It has a long half-life of 16 hours so that
a person cannot easily prepare for the test by not
smoking for short periods—ideally, an assay should be
able to detect an individual who has not smoked for 48
hours. It is inexpensive, so that it may be performed
routinely in large screening programs. (Fitzpatrick,
1991, p.ll)
There is no biochemical test which can be expected to
yield perfect separation of non-smokers passive smokers, and
active smokers under field conditions. Wall et al. (1988)
give several reasons for this: intersubject variance in
nicotine metabolism, time of day of sample collection,
underreporting of active smoking, adjustment of cigarette
consumption for nicotine content, and perhaps over or
underreporting of passive smoke exposure. However, the use
of biochemical analyses definitely increase the validity of
smoking self-reports.
Concluding Statement
Because of the impact of health, health care costs, and
readiness, the Navy Surgeon General has set a goal of a
Smoke-Free Navy by the year 2000. Prevention efforts in new

53
accessions, as well as cessation efforts throughout the
ranks, are critical in meeting this goal. Currently the Navy
recruit population shows a higher smoking prevalence than the
general U. S. population. The no-smoking policy in Navy
recruit training provides a perfect opportunity to allow
smokers to stop, but many factors prevent those who quit from
staying quit. Current research reveals many approaches that
show promise in helping these individuals to stay quit, and
non-smokers from ever starting.
Smoking is becoming more and more socially unacceptable,
both in general society, and in the military. However, if
smokers are expected to quit, they must be provided
assistance. Setting policies that provide an environment
conducive to not smoking are beneficial, but alone don't show
high cessation rates. Education programs are an essential
adjunct to no-smoking policies. Quitting smoking is very
difficult and many people cannot do so on their own. Smoking
prevention and smoking relapse prevention programs must be
developed with the characteristics of the Naval population in
mind. They should draw from existing theory and current
research. Programs should provide information designed to
assist individuals in changing behavior intentions to more
health oriented ones. They need to recognize that all
smokers/non-smokers are in different stages of behavior
change and offer varied approaches to reach the entire
audience. This is especially true when groups are to be
addressed and smokers cannot be separated out. Motivation is

54
crucial in any smoking cessation effort; programs must be
designed around providing motivational incentives and
building self-efficacy.
Health behavior change programs should be guided by
social learning theory to encompass environmental, personal,
and behavioral constructs. Participants must decide for
themselves that smoking is potentially detrimental, recognize
the pressures on them to smoke, and develop their own ways to
cope with these pressures. Alternatives must be presented in
order for informed choices to be made. Recruit smoking
education programs should build on what many recruits will
have already had in their formal education. Misconceptions
about tobacco use must be corrected. Long-term consequences
of smoking should be discussed, but short-term effects also
need to be stressed. Current Navy policy, and future policy
direction, should be discussed to give the new Navy member a
picture of what will be expected of them. Recruits who
entered as smokers have to believe they have actually quit
smoking, if they are expected to stay quit after graduation.
Recruit training is a period when a complete lifestyle
transformation is taking place. Recruits are making
wholesale changes in the ways they live, work, and socialize.
They are taking on added responsibilities, receiving personal
and financial independence, and adjusting many health
practices. They should be encouraged at this time to make
decisions, in all areas, that will lead to self-fulfillment
and better health.

CHAPTER 3
METHODS AND MATERIALS
Introduction
This chapter describes the methods employed to conduct
the study. Subjects are described with a discussion of the
sampling methods used. The survey instruments are described
and validity and reliability are discussed. A detailed
description of the study procedures is given including survey
administration, educational interventions, and the booster
program. A discussion of self-report validation techniques
incorporated in the study is then given. Finally, a
description of how data were handled is presented along with
the plan for data analysis.
Subjects
Seven companies of recruits from the Navy Recruit
Training Center (RTC) in Orlando, FL were used in this study.
Five companies were male and two female. Participants were
357 men and 139 women. The mean age of participants was
19.26 years (standard deviation [SD] = 2.27). Over 99% held
a high school degree or equivalent, 22% had some college or
were trade/technical school graduates, and 2% had a four year
college degree. The mean Armed Forces Qualification Test
55

56
(AFQT) score was 65.76 (SD=18.62). The AFQT score provides a
measure of general trainability of recruits. The Navy
requires a minimum AFQT score of 17 with a high school
degree, 31 for other credential holders, and 50 without a
high school diploma (Foley & Rucker, 1989). Seventy-eight
percent of participants were white, 15% were black, 5% were
Hispanic, and 2% were from other ethnic backgrounds.
Recruit training is an intensive 8 week program designed
to indoctrinate the new members as to the ways of Navy life
and prepare them for military duties. The mission of RTC
Orlando is to conduct a training program which will effect a
smooth transition from civilian to Navy life; foster
patriotic behavior; affirm the dignity of the individual;
encourage high standards of personal responsibility, conduct,
manners, and morals; create a desire for self-improvement and
advancement; provide the recruit with knowledge and skills
basic to all naval personnel; develop pride in the unit and
in the Navy and a desire to observe appropriate naval
customs, ceremonies, and traditions; and provide the
Department of the Navy with personnel possessing an effective
level of physical fitness. The mission is carried out
through an intense training and educational program.
The educational program includes health/hygiene classes,
and classes on substance abuse. The current curriculum
however, includes no specific tobacco-use prevention
information (CNTECHTRA, 1991a). There are approximately 75 -
85 recruits in each company and about 5 classes start every

57
week. A recent tobacco use survey showed that about 28% of
entering recruits are smokers (Cronan & Conway, 1988), which
indicates about 23 members of each study company should be
smokers.
The subject sample was drawn from the total recruit
population. Because of time constraints a purely random
sample of all companies was not feasible. One company,
chosen randomly from a weekly starting group, was used as a
pilot group and went through the research program before the
main study group. The other 7 companies were chosen from all
those starting during adjacent weeks in September 1991.
At RTC, companies are sectioned into training groups.
Each training group contains all companies starting during a
given week (usually 6-7 companies). The training group
progresses through recruit training at the same rate and
graduate on Friday of their eighth week. Companies are
filled as recruits arrive at RTC, without segregation except
by gender. This random assignment to companies allowed for a
random recruit sampling using any training group. Training
Group 47 was selected because of projection for 5 male and 2
female companies. This training group started training
during the week of September 9, 1991. However, the second
female company anticipated did not fill until the following
week, thus the second female company used was part of
Training Group 48.
In an effort to determine if the study population was
representative of the entire Navy recruit population

58
demographic data were obtained from Naval Technical Training
Command data bases (CNTECHTRA, 1991b). Table 2 is a
comparison of the study group to 6 months of all recruits
going through RTC Orlando, and all 3 Navy RTC's for several
variables.
Table 2. Study group comparison
Education
level
Average
AFQT*
score
Average
Age
Percent
Minority
All RTCs 6 mo
11.69
61.04
19.51
19.37
RTC Orlando
6 mo
12.07
67.89
19.42
17.8
T-l
12.05
66.07
19.48
19.12
T-2
12.09
68.48
19.41
14.94
T-3
12.02
64.78
19.40
23.48
Sham
11.95
60.57
20.10
26.58
♦Armed Forces Qualification Test
(AFQT) is
required for
enlisted entry
to all services
This table shows the companies chosen for the study were
fairly representative of all companies going through RTC
Orlando, and the rest of Navy Recruit Training Centers.

59
Instruments
Smoking history and relapse information were collected
via pencil and paper survey. Surveys were conducted during
the recruits first week of training (P-4 day), after
graduation (8-3 day), and 3 months after graduation. The
surveys used were modified versions of those by the Naval
Health Research Center for their "new accession tobacco use
survey".
Surveys
The Horn-Waingrow Smoking Motives Questionnaire (Girdano
& Dusek, 1988) was added to the intake survey (see Appendix
A) to examine type of smokers who are best helped by this
program. The Fagerstrom nicotine tolerance questionnaire
(Fagerstrom, 1978) was also added to examine nicotine
addiction. Questions were added to assess knowledge of and
attitudes toward tobacco use.
The graduation survey (see Appendix B) was much shorter
than the intake survey. Most of the questions were repeats
from the first survey with only a few added to assess change
in knowledge and attitudes. The 3 month follow-up survey
(see Appendix C) was a modified version of the Naval Health
Research Center's 12 month follow-up survey with questions
added to measure change in attitude and knowledge.

60
Validity and reliability
A test-retest reliability analysis was accomplished with
the intake survey. An extra company (N=84) was chosen to be
a pilot. This company was administered the intake survey on
their P-4 day. They were encouraged to bring any questions
or concerns to the attention of the researcher. All problems
were noted and incorporated into the briefing for the main
study companies. This group completed the same intake survey
three days later. Key questions to be used in the main study
analysis were analyzed here as part of an instrument
reliability test-retest procedure. The questions were
examined for frequency of non-agreement, then Spearman's and
Pearson's correlations were performed to compute reliability.
Table 3 summarizes the results of the instrument reliability
measurements. Nine of the thirteen items tested showed a
correlation of .80 or better (Spearman) and six of twelve
showed a correlation of .80 or better (Pearson). Questions
that showed poor agreement were explained in the briefing to
the main study companies and the wording was changed on some
for subsequent survey versions. In the study analysis
Questions 10 and 11 were scored as correct if responses below
and above exact percentages were answered. Question 5 showed
a low correlation mainly with non-smokers. For this reason
attitude scores were analyzed for all subjects and for
smokers only.

61
Table 3. Test-retest reliability
Question #
Frequency of
Non-aqreement
Spearman's R
Pearson's R
1
10%
.93
.90
2
12%
.92
.89
3
10%
.90
.95
4
9%
.75
.75
5
17%
.51
.51
6
27%
.79
.76
7
34%
.65
.62
8
14%
.71
.71
9
17%
CM
00
•
.68
10
38%
.80
.79
11
31%
.89
.88
12
17%
.86
.86
13
25%
.92
.93
Question/Variable Key:
1. Smoking status at entry
2. Smokeless tobacco use at entry
3. During the last 30 days prior to entering the Navy how many
cigarettes did you usually smoke on a typical day when you
smoked cigarettes
4. Do you believe cigarette smoking is related to heart disease
5. Are you concerned about the health effects of cigarette
smoking
6. How important is it to you to be a non-user of tobacco
products
7. Over the next year, how likely is it that you'll stop smoking,
if you now smoke
8. In the future, do you see yourself as someone who smokes
9. Would you be in favor of being placed in a smoke-free work
environment
10. What percent of the U.S. population do you believe are current
smokers
11. What percent of all members of the Navy do you believe are
current smokers
12. Should tobacco companies be allowed to target advertising
toward certain groups in order to recruit new customers
13. Fagerstrom nicotine tolerance level

62
This project, including the instruments and consent
statement, was reviewed and approved by the University of
Florida Institutional Review Board (see Appendix D). The
instruments were destroyed after data analysis to satisfy
Institutional Review Board requirements.
Self-Report Validation Techniques
During the instruction period prior to completion of the
intake survey, participants were briefed on possible self-
report cross checks using urine tests. It was explained that
some of their urine samples submitted upon entry would be
screened for a substance which would tell us their smoking
status. They were also told future random drug screen
samples also might be used to validate follow-up self
reports. Subjects were assured the results would in no way
negatively affect them, but that this procedure was a
requirement of an academic research committee. It was
anticipated this bogus pipeline approach would increase
truthfulness of self-reporting for all three surveys.
Cotinine analysis of urine specimens was accomplished
for a random sampling of participants in the intake and
graduation surveys. Urine specimens provided as part of the
Navy drug screening program were used in the study. All
recruits are required to provide a urine sample within hours
of reporting to recruit training. These samples are tested
locally by means of radioimmunoassay and positive samples are

63
sent to Navy drug screening laboratories for gas
chromatography-mass spectrometry screening. The samples
testing negative locally are normally disposed of on site.
Normal RTC procedures require that the day after uncontrolled
liberty (after recruit graduation) one company be randomly
selected for a unit drug screen. The same procedures are
again followed for sample collection and testing. For the
purposes of the present study only drug negative samples
provided the basis for a sampling pool.
Fifty urine samples were selected randomly (20 female
and 30 male) by drug screen lab personnel, from participating
companies upon arrival at Recruit Training Command Orlando.
Approximately 10 ml were transferred to a storage vial and
frozen. The same procedure was followed for the company
chosen for the post-liberty recruit urinalysis. Forty-two
samples were collected at this time. All samples were kept
frozen until analyses could be conducted.
Cotinine analysis was conducted utilizing Florescence
Polarization Immunoassay technology. An Abbott TDX automated
fluorescence analyzer (instrument #2, serial L30179) at the
Shands Toxicology laboratory in Gainesville, Florida was
used. Cotinine reagent was purchased from Abbott
Laboratories and was within freshness parameters. The
analyzer was calibrated by Shands lab personnel, according to
the operations manual. Low, medium, and high controls were
run after calibration and results were within acceptable
limits. Each batch analysis run included at least one

64
control, and all control results were within acceptable
limits.
Results were reported in nanograms per milliliter
(ng/ml). The sensitivity of this analysis, defined as the
lowest measurable concentration which can be distinguished
from zero with 95% confidence, was determined by the
manufacturer to be 50 ng/ml. Indication of smoking was then
set at any result greater than 50 ng/ml. Results were
compared against the self-reported smoking reported on
respective surveys.
Results of cotinine analyses were in 100% agreement with
self-reported tobacco use at pretest, and 96% agreement with
self-reported tobacco use at posttest. This reflects only a
1% misrepresentation of smoking status overall. One subject
indicated no tobacco use but tested high for cotinine; two
others indicated tobacco use but tested low for cotinine.
Self-reported tobacco use and cotinine chemical analyses were
highly correlated (r=.91).
Procedures
After the 7 companies were selected they were randomly
assigned to control or treatment categories. Treatment group
assignment was made before any of the survey data was
processed. One extra company was selected to serve as a
pilot group. This group was used to assist in analysis of
instrument validity and reliability, curriculum

65
effectiveness, and to uncover any unforeseen problems. Table
4 presents an overview of treatment group assignments.
Table 4.
Treatment
qroup assignments
Pilot
Tl
T2 T 3
T 4
Company
C-175 n=84
C-184 n=81
C-181 n=83 C-183 n=82
C-185 n=79
Number
K-079 n=80
C-182 n=88 K-078 n=84
Notes: Tl = Policy only
T2 = Policy + education
T3 = Policy + education + booster
T4 = Policy + sham treatment
Pilot = Policy + education
Intake surveys
All participating companies completed consent forms and
intake surveys on their P-4 day of training (1st week at RTC)
in the same classroom, at the same time of day. Participants
were briefed on what they would be asked to do in the project
and asked to read the consent statement (see Appendix E).
The researcher read the statement aloud to make sure the
subjects knew their participation was voluntary. Information
confidentiality was assured at this point. The intake survey
asked for full name and social security number, but in an
/
effort to assure confidentiality, the follow-up surveys
requested only the last 4 digits of the social security
number as identification. After the explanation, questions
were taken about the project and the consent form.

66
Participants were then asked to sign the consent forms if
they agreed to participate in the study. The signatures were
witnessed, dated, serialized, and retained for a period of 5
years. The statement portions of the consent forms were
collected and given to the company yeomen (recruit in charge
of all company paperwork) for later re-distribution to the
participants. The intake surveys (see Appendix A) were then
completed by the participants. The pilot group participants
were administered the same intake survey approximately 72
hours later.
Education intervention
The education intervention phase was conducted for
participants on their 2-2 day of training. The curriculum
(see Appendix F) consisted of lecture, video-tapes, visual
aids, demonstrations, and group discussions. Participants
were encouraged to ask questions and participation was
solicited during large group discussions.
The main lecture topic areas were:
•Navy tobacco use policies
•myths about tobacco use
•physiological effects of smoking (short and long
term)
•reasons for choosing to use/not use tobacco
•benefits of not starting/resuming tobacco use
after RTC graduation.

67
The videos used were:
•"The Performance Edge", from the U.S. Department
of Health and Human Services. It shows the effect
of tobacco and alcohol on performance. A
motivational pitch for non-use is given
•"The Feminine Mistake", from Pyramid films. Shows
the physiological effects of smoking, benefits of
quitting, and long term hazards of smoking
•"Clearing the Air", from the U.S. Navy. Shows
the effects of smoking, Navy tobacco use policies,
and strategies to quit and stay quit.
The videos used were previewed by 12 recruits 7 weeks before
the education intervention began. Positive feedback was
received for their use in the curriculum.
Posters were displayed throughout the classroom. Poster
placement was the same for each lecture period. Those used
were from the American Cancer Society, and included:
•Animals-"It looks as stupid when you do it"
#F-651/90
•Animals-"Butts are gross" #F-652/90
•"Smoking is very debonair" #2163.03-LE
•"Smoking is very sophisticated" #2163.02-LE
•"Smoking is very glamorous" #2163.01-LE
•"Smoking doesn't work" #2418.04-LE
•"Life, the only race you don't win by finishing
first...Don't smoke" #2122.LE
•"Are you a draggin lady?"

68
•"12 things to do instead of smoking" #2106.LE.
Other visual aids and demonstrations were used during
the lecture periods and the breaks. The following teaching
aids were utilized:
•Consequences of smoking—Display which
graphically depicts detrimental physical effects of
smoking, such as emphysema, lung cancer, and heart
attack
•Second-hand smoke demonstrator—Device which
shows the effect of sitting in a closed room with
smokers, by filtering smoke passively released from
a smoked cigarette
•Mr. Grossmouth—Display which shows the physical
effects of smokeless tobacco to the mouth, tongue,
teeth, and palate
•American Cancer Society pamphlet "50 questions
about smoking".
The education intervention was taught in the same
classroom each time and by the same instructor (the
researcher). Classes started at 7:00 a.m. and ran until
10:00 a.m. Students were told to relax and that the material
was not testable, but they were free to take notes. The
temperature of the room was maintained at 78° F and the
students were allowed to stand, or walk to an in-classroom
drinking fountain, if they got drowsy. Two 15 minute breaks
were given, during which students were asked to discuss
topics for subsequent group discussions. The students were

69
also encouraged to look at the displays and posters during
the breaks. No unusual external events took place during any
of the class periods.
The entire treatment program was designed to motivate
recruits (both smokers and non-smokers) to not initiate
smoking after graduation. A recent personal communication
with Dr T. J. Glynn (September 16, 1991), of the National
Institutes of Health indicated that the primary component of
this program should be motivation to maintain nonsmoking
status, and to want to do so. The benefits of remaining non-
smokers were stressed, and ex-smokers were challenged to make
the decision to not start again. The program was designed to
instill confidence in the recruit's ability to remain smoke
free. It was stressed that the Navy is anti-smoke and not
anti-smoker, and only the individual can make the choice of
being smoke-free. Every effort was made to ensure the
intervention program was not viewed as coercive.
The intervention curriculum was presented to the
supervisory committee, and to several outside experts for
review. The committee was composed of four health educators
and one experimental behavioral psychologist. The outside
reviewers included:
Carlo Diclemente, Ph D
Behavioral Researcher
University of Houston

70
Thomas J. Glynn, Ph D
Chief, Cancer Prevention and Control
Extramural Research Branch
National Institutes of Health
National Cancer Institute
Terry L. Conway, Ph D
Health Psychology Department
Naval Health Research Center
All reviewers stated they believed the program to be a sound
design. Many suggestions were given, and most were
incorporated into the existing plan.
Sham treatment
A sham (placebo) treatment was conducted for one company
to analyze the effect of any intervention on the study
population. The idea was to present an educational
intervention, irrelevant to smoking prevention/cessation, but
prefaced by an explanation that the class is part of an
overall program designed to help recruits remain tobacco-free
after graduation from RTC.
This intervention was accomplished on the company's 2.2
day of training, but only for a 40 minute period. The
curriculum (see Appendix G) consisted of a short lecture
about the Navy's commitment to maintain a healthy, productive
workforce, Navy smoking policy, and goals for tobacco use.

71
Tobacco use was tied in to weight control by the common theme
of heart disease. A 24 minute Navy video entitled "Weight
and fat control/nutrition education" was then shown.
A question and answer period followed the movie. The
class was concluded by a statement about the Navy's
commitment to a healthy workforce and the fact that recruits
should try to make healthy choices in all aspects of their
lives.
Booster
Two companies were given a booster class at the end of
recruit training to reinforce key points of the education
intervention, and to further motivate them not to use tobacco
after graduation. This class was presented on the Friday
before the recruits' departure from RTC. Their formal
graduation ceremony (Pass and Review) was held Friday morning
and the recruits were allowed to go on uncontrolled off-base
liberty starting that evening. The booster class lasted
approximately 45 minutes and was presented mid-afternoon to
both companies in this treatment group.
The booster class incorporated several strategies to
reinforce prior training and increase motivation. Two
pamphlets were distributed to each recruit:
•Smart Move: A Stop Smoking Guide - ACS #2515LE

72
•Clearing the Air: How to Quit Smoking and Quit
for Keeps - National Cancer Institute NIH
Publication No. 89-1647.
These pamphlets are comprehensive guides to quitting smoking.
They cover much of the information which was given in class
and contain many suggestions to help avoid relapse. A wallet
card (see Appendix H) was also given to the recruits. This
card lists 5 reasons to remain tobacco-free and 5 ways to
avoid smoking.
The first part of the class period involved going
through the materials distributed. Those who had never
smoked were asked to pass the materials on to a friend or
relative who does smoke, or save it for a smoking shipmate
they may meet later. The ex-smokers were asked to keep the
material for future reference and to place the card in their
purse of wallet for reference as necessary after graduation.
A nineteen minute video (Hazards of Tobacco) was then
shown. This video was made by Captain David Moyer, a Navy
physician who has taught the material in the video to over
50,000 Navy and Marine Corps recruits at training centers in
San Diego, California. This video also covered many of the
same points the education intervention covered, as well as
some different reasons for the recruit to not start/resume
tobacco use.
The recruits were then asked to sign a pledge to assist
the Navy in reaching its goal of being smoke-free by the year
2000. Each recruit received a certificate of participation

73
in the tobacco prevention program (see Appendix I), but
signing the pledge was voluntary. It was stressed that
signing was not necessarily a promise never to use tobacco,
but rather a promise to do whatever they can to help reach
the goal. The recruits were told the Navy hoped part of this
assistance would be a choice to remain tobacco-free. The
certificate was signed by the researcher, as the program
director, and the Commanding Officer of Recruit Training
Center, Orlando.
All recruits in the booster companies received a T-shirt
courtesy of the American Cancer Society. The T-shirts were
yellow and carried the logo of "Smoke-free class of 2000".
These shirts are being used in the national "Smoke-free class
of 2000" campaign. The recruits were told they are part of
the Navy's smoke-free class of 2000. The recruits were
thanked for their participation, congratulated on graduation,
and reminded of the upcoming follow-up surveys.
Follow-up surveys
Follow-up surveys were administered just before the
participants left RTC, then again 3 months after graduation.
These surveys were designed to measure current tobacco use
habits, knowledge, and attitudes.
The graduation survey (see Appendix B) was administered
by the company commanders after the uncontrolled liberty
weekend. Because some of the questions dealt with possible

74
rules infractions, the company commanders were asked to leave
the room while the surveys were completed. The company
yeoman collected the completed surveys, sealed them in an
envelope, and returned them to the RTC scheduling office
where the researcher collected them. The female control
company had their graduation surveys mailed to them 3 weeks
after graduation due to confusion in who was to administer.
The 3 month follow-up surveys (see Appendix C) were
mailed to participants at their current command. Those
attending schools located at Naval Training Center, Orlando
were administered the survey during one of their class
periods by a command representative. These surveys were
collected by the command Drug and Alcohol Program Advisor and
mailed to the researcher. The majority of the surveys were
mailed to the participants' Commanding Officer. The
Commanding Officers' representatives were instructed to
distribute the surveys to listed participants, collect the
completed forms, and mail them back to the researcher. One
reminder was sent to the commands which had not responded
within one month of the original mailing. Several commands
not responding to the reminder letter were phoned and
questioned concerning survey status. A number of surveys
(31) had to be re-sent to individuals that had already moved
from their second command. Some surveys (in addition to
those readdressed) were mailed, to individuals (80), with a
self-addressed government envelope and instructions for
return. Participants were not required to pay any postage.

75
Data Preparation
Once the surveys were completed the answers were
transferred to a 240 item general purpose answer sheet
formatted for optical mark reading. The number of questions
asked on the three surveys totalled 279. Many of the answers
were eliminated or combined so that only 168 data points were
actually coded. The answer sheets had only five response
circles per answer. Some survey questions that had more than
five responses had to be collapsed to fit this requirement.
This was done consistently for questions which were repeated
in surveys. All answers were coded by numbers one through
five (eg. No=l; Yes=2) for data entry, and a survey layout
(codebook) was composed to avoid confusion during analysis.
This layout was used during the coding process to ensure
answers were coded consistently and transferred to the
appropriate circles on the answer sheets. This process was
completed by two individuals who were versed on the
procedure. This process was chosen for a number of reasons
including:
-multiple surveys were involved
-illogical answering could be identified before entry
-the answer sheets could be re-scanned in the event of
data file loss on the computer
-computer entry errors, due to the large data set, could
be minimized.

76
The completed answer sheets were scanned by a mark reader
which then compiled the data and stored a data file on a
floppysdisk and in a university computer account.
Once the data were in the computer file variables were
range checked for accuracy and improper codes were either
corrected or changed to missing data points. No attempt was
made to impute missing data points.
Data analyses were accomplished using:
-the Statistical Analysis System (SAS) on the University
of Florida VAX cluster
-SAS on the Northeast Regional Data Center computer
Virtual Telecommunications Access Method, and
-Stat View SE + Graphics statistical analysis program on
a Macintosh SE personal computer.
Analysis Plan
This study was set up on a split plot with repeated
measures design. Table 5 is a presentation of the design
setup. Because tests of the null hypotheses consisted of
both continuous and categorical variables, different testing
procedures were used. Smoking attitudes and smoking
knowledge were examined using a general linear model (GLM)
for repeated measures analysis of variance (ANOVA). Null
hypotheses with categorical variables (relapse rate, smoking
initiation, cigarette consumption, and smoking intentions)
were examined by using frequency tables with the Pearson's

77
chi-square statistic. This test statistic looks at the
goodness of fit between the distribution observed and the
distribution expected (Aday, 1989).
Table 5. Repeated measures design
Pre-test
Post-test
3 Month f/u
0
Tl
0
0
0
T2
0
0
0
T3
0
0
0
T4
0
0
Notes: Tl = Policy only
T2 = Policy + education
T3 = Policy + education + booster
T4 = Policy + sham treatment
Smoking relapse and smoking initiation were examined
according to Table 6, using differences between pretest and
follow-up.
Tl
T2
T3
T4
Notes:Dl=current smoking at pretest and at follow-up (RELAPSE)
D2=current smoking at pretest but not at follow-up (NON-RELAPSE)
D3=no smoking at pretest or follow-up (NON-INITIATION)
D4=no smoking pretest but current smoking follow-up (INITIATION)
Table 6. Chi-square frequency table
Dl
D2
D3
D4

78
Smoking intentions were examined using differences between
pretest and posttest, observe effect of policy and education.
Cigarette consumption was examined using differences between
pretest and follow-up.
A number of univariate analyses procedures were used to
help describe population variables and draw conclusions about
possible future benefits in research designs with this
population. The significance level for all the tests was set
at p=.10, as the consequences of a Type I error did not
outweigh acceptance of a high probability of making a Type II
error. As this was the first study of its kind with Navy
recruits, the exploratory nature of the educational design
was considered in determining the alpha level.

CHAPTER 4
RESULTS AND DISCUSSION
Introduction
The purpose of this chapter is to present the results of
data analysis and an explanation of how these results support
or do not support the hypotheses. The data presentation and
discussion are organized around individual hypotheses.
The chapter begins with a precise description of the
study population as it evolved through the study period.
Next, the actual results as they apply to each hypothesis are
presented. The last section is an interpretation of the
findings, a discussion of the implications of additional
knowledge in the smoking field, and a discussion of potential
applications of the findings.
Population Description
The study began with a total of 557 subjects in 7
recruit companies. Fourteen percent of these subjects were
lost due to normal attrition from their original recruit
company. This attrition was equally distributed across
subject companies. Therefore, the total number of subjects
who completed a pretest and graduated with their original
company was 496 (only two subjects refused to complete the
79

80
pretest survey). Seventy-four percent of this total
completed surveys at graduation (only 50% were completed in
treatment Group 1 due to an administering error in one
company).
Follow-up surveys were mailed to 516 individuals. Of
these surveys 320 were returned completed for a response rate
of 62%. Table 7 summarizes survey completion at each
occasion.
Table 7. Percent survey completion at each measurement
period
Treatment qroup
1
2
3
4
Total
Pre
(140)
(151)
(136)
(69)
(496)
Post
50% (70)
85% (128)
82% (112)
81% (56)
74% (366)
F/U
57% (80)
64% (97)
60% (82)
29% (20)
56% (279)
♦Notes:Actual numbers are in parentheses.
Treatment: 1 = Policy only
2 = Policy + education
3 = Policy + education + booster
4 = Policy + sham treatment
Treatment Group 4 consisted of only one recruit company and a
poor follow-up return rate of 20 should be noted.
Ten percent of the surveys were reported lost or
undeliverable to participants, and 28% were not returned (not
accounted for) at all. Forty-two of the surveys not returned
had been sent to 13 commands who did not respond to the
initial letter or the reminder, and could not be reached by

81
phone. The rest of the non-returned surveys had been mailed
directly to individuals. Only a 22% response rate was
obtained when participants' Commanding Officers were not
involved in administering the follow-ups. The increase in
overall follow-up response shows the utility of mailing
surveys via Commanding Officers.
Of the completed surveys at follow-up, 279 were usable
for the main study population. This represented 56% of the
original pretested population The rest were unidentifiable
as study participants. An analysis was performed to
determine if the group of non-respondents was representative
of the whole population with respect to initial smoking
status; Table 8 summarizes the findings.
Table 8. Percentage of smokers in non-respondent group and
original study population
Treatment qroup
1
2
3
4
Total
Non-
51.7%
46.3%
53.7%
42.9%
48.8%
Respondents
(31)
(25)
(29)
(21)
(106)
At pretest
50.7%
35.8%
46.3%
39.1%
43.3%
mj
(ID
L63J
L1ZJ
(215)
♦Note: Actual numbers in parentheses.
Non-respondents of each treatment group had a higher
percentage of smokers, but the differences from the pretest
results were not significant (x2 = 4.65, p>.1)-

82
Results
Smoking relapse
Participants were asked to respond to questions
regarding current smoking status, as part of each of the
three surveys. Current smoking status for the pretest
reflected status just before entering recruit training. A
summary of current smoking by treatment group, at each
measurement period, is presented in Table 9. This table also
shows the smoking relapse rate for each treatment group.
Table 9. Percent of current smokers at each measurement
period
Treatment
group
1
2
3
4
Total
n=161
n=171
n=166
n=69
N=496
Pre
50.7%
35.8%
46.3%
39.1%
43.3%
(71)
(54)
(63)
(27)
(215)
Post
27.1%
3.8%
2.6%
18.9%
10.2%
(19)
(5)
(3)
(11)
(38)
F/U
42.5%
25.5%
33.7%
25.0%
32.7%
(34)
(25)
(28)
(5)
(92)
Relapse
Rate
82.5%
66.6%
76.5%
66.6%
75.5%
♦Note: Actual
numbers
in parentheses
While relapse
rates (at follow-up)
are lower
among
participants in the treatment groups, results of chi-square
statistics calculated for these differences showed they were
not significantly different than the control (x2 = 1.68,
p>.l). Since the RTC smoking policy still applied to

83
participants at time of posttest, indications of current
smoking were considered violations of rules (smoking on
liberty) rather than relapse. The education treatment groups
(Groups 2 & 3) showed lower violation of smoking rules and
results of chi-square analysis showed these differences to be
significant (x2 = 22.08, p<.001).
Several variables were examined that may have confounded
the relapse results: participant gender, AFQT scores,
Fagerstrom nicotine tolerance scores, age started smoking,
and cigarette consumption prior to entry. Covariance of the
continuous variables (AFQT and Fagerstrom scores) was
initially examined by a general linear means procedure (SAS
PROC GLM) to determine if further analysis was warranted.
Categorical modeling procedures were then run
controlling for the variables of possible significance.
Table 10 summarizes the smoking status at entry and relapse
rate by gender, for the study population.
Table 10. Percent of current smokers by gender and
corresponding relapse rates
Male
Female
Current
entry
smokers
at 40.9%
49.6%
Relapse
rate
72.6%
79.2%
The differences seen in relapse rate by gender were found not
to be significant (x2 = .634, p>.l).

84
The Fagerstrom scores were transformed to categorical
form by creating two levels:
- low tolerance (Fagerstrom scores 1-6)
corresponding to low nicotine addiction
- high tolerance (Fagerstrom scores 7-11)
corresponding to high nicotine addiction.
Table 11 summarizes nicotine tolerance level reported at
entry and corresponding relapse rates.
Table 11. Nicotine tolerance levels reported with
corresponding relapse rates
Nicotine Tolerance
Level
Low
High
Reported at entry
74.7%
25.3%
Relapse Rate
76.1%
96.8%
The data seen in Table 11 seems to indicate that smokers
reporting a high nicotine tolerance relapsed to smoking at a
higher rate. The differences seen in relapse rate by
nicotine tolerance level were found to be significant (x2 =
3.58, pc.l).
Another category that seems to affect smoking relapse is
the number of cigarettes smoked prior to entry in recruit
training. Figure 1 summarizes the relapse rates for given
categories on smoking at entry.

85
100
80-
a>
-p
u 60-
0)
w
p.
A 40-
<8
20-
oJ—
1 2 3 4 5
Cigarettes smoked
*Note: 1 = no smoking
2 = <1 per day
3 = 1-5 per day
4 = 6-20 per day
5 = >20 per day
Figure 1. Percent relapse for corresponding entry smoking
levels
â–¡ Relapse
rate
Some relapses are found in cigarette consumption
category "none" because those indicating they quit within two
months prior to recruit entry were considered current
smokers. An obvious trend is seen in that relapse increases
with an increase in cigarette consumption. The differences
seen in relapse rate by prior cigarette consumption were
found to be significant (x2 = 35.85, pc.001). Analysis of
age smokers started and their AFQT scores did not reveal any
significant results.
To determine if relapse was affected by increased
knowledge scores an analysis of variance (ANOVA) was
conducted modeling relapse with knowledge gain. Possible

86
knowledge score range was zero to six. The mean knowledge
gain for non-relapsers was 0.95 (16%) and for relapsers was
0.34 (6%). This difference was significant (F = 5.09, df =
11 77, p<.1).
In an effort to understand why recruits start smoking
again after boot camp, participants were asked to list
reasons they began smoking again. The top five reasons
relapsers listed for starting smoking after boot camp were:
- "It calmed me" 81%
- "I liked the taste" 56%
- "Parents or friends back home smoke" 53%
- "Friends smoked" 49%
- "I had no desire to quit" 44%.
Smoking initiation
The other side of the smoking status analysis concerned
non/former smokers who began smoking during the three month
follow-up period. Table 12 is a summary of smoking
initiation by treatment group.
Table 12. Percentage smoking initiation
Treatment
qroup
1
2
3
4
Total
Smoking
2.5%
7.3%
4.1%
7.1%
5.3%
started
UJ
(5)
(2)
— (1J
(9)
*Note: Actual numbers in parentheses

87
A chi-square procedure was used to analyze differences
between groups. The differences observed were found to be
not significant (x2 = 1.44, p>.1)-
Smoking attitudes
The attitude score was obtained by summing adjusted
values for the following variables: concern about cigarettes,
concern about pipe smoking, concern about chewing tobacco,
concern about snuff use, the importance of being a non-
smoker, feeling about working in a smoke-free environment,
and attitude toward targeted cigarette advertising. The
range of possible scores was zero to ten (ten being the most
positive attitude toward not smoking).
Two sets of analyses were conducted for attitude
changes. Smoking attitude scores for all participants were
examined, then scores were examined for those participants
who were current smokers at entry to the Navy. Table 13
presents the attitude score means and standard deviations
observed (for all participants) at each measurement period by
treatment group.

88
Table 13. Attitude scores at each measurement period and
differences pre to post for all subjects
Treatment
qroup
Total
1
2
3
4
6.31
6.37
6.33
6.23
6.32
Pre
(2.88)
(2.80)
(2.99)
(2.99)
(2.89)
6.46
7.41
7.36
6.87
7.12
Post
(2.93)
(2.58)
(2.65)
(2.73)
(2.71)
6.66
6.49
7.05
6.65
6.71
F/U
(3.09)
(2.94)
(2.77)
(2.89)
(2.92)
Diff.**
0.25
1.05
0.91
0.89
0.83
post-pre
(2.33)
(2.36)
(2.69)
(2.87)
(2-55)
*Note: -Standard deviations in parentheses
**Differences reflect only subjects completing both pre and post
tests.
Repeated measures ANOVA were performed to determine if
time, treatment group, or interaction effects were present.
A significant time effect was observed for all groups (F =
4.38, df = 6, 394, p<.1)- Treatment effect differences were
not significant (F = 0.5, df = 3, 197, p>.l), but interaction
effects were significant (F = 1.89, df = 6, 394, pc.l). This
indicates the changes seen through time on the smoking
attitude scores of all subjects were different depending on
which treatment group the subject was in. Separate critical
F values were then calculated for paired attitude scores
based on the significant interaction analysis. Pretest
scores were not significantly different for any two treatment
groups, which was also the case for follow-up scores. For
this reason, only attitude differences pre to post are
reported. The only significant treatment differences seen
occurred on the posttest and are summarized below.

89
TRT 1 - TRT
2
F = 13.36
, P
<
.10
Posttest
TRT 1 - TRT
3
F = 11.37
/ P
<
.10
scores
TRT 4 - TRT
2
F = 3.96,
P
<
.10
TRT 4 - TRT
3
F = 2.92,
P
<
.10
Table
14 presents the
attitude score
means
and standard
deviations
observed (for smokers
at entry)
at
each
measurement
period by treatment
group.
Table 14.
Attitude scores
differences pre
at each measurement
to post for smokers
period and
Treatment cjroup
1
2
3
4
Total
4.63
4.41
4.17
4.33
4.40
Pre
(2.52)
(2.44)
(2.51)
(3.10)
(2.57)
4.95
5.89
5.84
5.75
5.63
Post
(2.72)
(2.47)
(2.77)
(2.64)
(2.66)
4.77
4.23
5.02
6.0
4.77
F/U
(2.83)
(2.42)
(2.47)
(2.90)
(2.61)
Diff.**
0.18
1.51
1.50
1.50
1.19
post-pre
(2.36)
(2.47)
(3.26)
(2.527)
(2.76)
*Note: Standard deviations in parentheses
*‘Differences reflect only subjects completing both pre and post
tests.
Repeated measures ANOVA were performed to determine if
time, treatment group, or interaction effects were present.
A significant time effect was observed for all groups (F =
5.74, df = 6, 148, pc.l). Treatment effect differences were
not significant (F = 0.61, df = 3, 74, p>.l). Interaction
effects were also not significant (F = 1.38, df = 6, 148,
p>.l). Separate critical F values were calculated for paired
attitude scores. Pretest scores were not significantly

90
different for any two treatment groups. The only significant
differences seen for posttest and follow-up scores are
summarized below:
TRT
1
- TRT
2
F =
5.59,
P
< .10
Posttest
TRT
1
- TRT
3
F =
5.13,
P
< .10
scores
TRT
1
- TRT
4
F =
6.19,
P
< .10
Follow-up
TRT
2
- TRT
3
F =
3.07,
P
< .10
scores
TRT
2
- TRT
4
F =
4.57,
P
< .10
Smoking Knowledge
Knowledge on certain aspects of tobacco use were
examined for all treatment groups. The knowledge score was
obtained by summing adjusted values for the following
variables: smoking effect on heart disease, smoking effect
on cancer, smoking effect on emphysema, smoking
addictiveness, smoking prevalence in U.S. population, and
smoking prevalence in Navy population. The possible range
for scores was zero to six. A score of six indicated a high
level of smoking knowledge and a score of zero indicated a
low knowledge.
Table 15 presents the mean scores and standard
deviations observed at each occasion by treatment group along
with the differences observed between occasions.

91
Table 15. Knowledge scores at each measurement period and
differences observed
Treatment
qroup
Total
1
2
3
4
4.01
4.06
4.07
3.93
4.03
Pre
(1.08)
(1.17)
(1.02)
(1-13)
(1.10)
4.29
4.59
4.57
4.25
4.48
Post
(0.83)
(0.85)
(0.85)
(1.00)
(0.89)
4.14
4.39
4.56
4.05
4.35
F/U
(1.02)
(1.00)
(0.93)
(0.39)
(0.98)
Diff.**
0.19
0.54
0.45
0.29
0.41
post-pre
d-21)
(1.09)
(1-H)
(1.12)
(1.13)
Diff.***
CN
Csl
«
O
-0.25
r^
o
•
o
-0.35
-0.19
f/u-post
(1-24)
(1-04)
(1-10)
(0.70)
(1-07)
♦Note: Standard deviations are in parentheses.
**Differences reflect only subjects completing both pre and post
tests
***Differences reflect only subjects completing both pre and
follow-up.
Repeated measures ANOVA were performed to determine if
time, treatment group, or interaction effects were present.
A significant time effect was seen for the entire population
(F = 8.46, df = 6, 398, pc.l). Treatment effect was also
significant (F = 2.27, df = 3, 199, p<.1) but interaction
effect was not significant (F = 1.31, df = 6, 398, p>.l). A
knowledge difference variable (knowledge gain) was produced
by subtracting the pretest knowledge score from the posttest
knowledge score. An ANOVA (SAS PROC GLM) was conducted
modeling knowledge gain with treatment level. Post-hoc tests
revealed a significant difference only between treatment
Groups 1 and 2. A knowledge difference variable (knowledge
retention) was produced by subtracting pretest scores from
follow-up. Results of knowledge retention show the booster

92
group exhibited the best retention but post-hoc tests (PROC
GLM) revealed the group differences were not significant.
Smoking Intentions
Changes in smoking intentions were measured by analyzing
responses to the question "In the future, do you see yourself
as someone who smokes?" on all three surveys. Table 16
summarizes the percent of respondents indicating a future
intention not to smoke, by treatment group.
Table 16. Percent of respondents indicating intention not to
smoke in the future
Treatment
group
Total
1
2
3
4
Pre
74.6%
88.6%
70.9%
80.9%
79.5%
Post
68.6%
83.1%
73.9%
72.4%
77.7%
F/U
65.4%
86.6%
77.8%
90.0%
79.0%
A categorical data modeling procedure was conducted
using responses given on the pretest and the follow-up. A
significant treatment effect was seen between treatment
levels (x2 = 11.12, p<.l), but no significant time effect was
observed over the entire population (x2 = 0.9, p>.l). Only
treatment Group 3 showed a continual increase in the percent
indicating an intention not to smoke but the difference
observed was not significant (x2 = 0.681, p>.l).

93
In an effort to explain relapse differences, smoking
intention by gender were examined. On the pretest survey 68%
of women and 83% of men indicated intention not to smoke in
the future. The difference observed was found to be
significant (x2 = 11.23, pc.001).
Cigarette consumption
Cigarette consumption was measured for smokers on each
survey occasion. The responses were partitioned into three
groups for analysis: no smoking/very light (< 1 per day),
moderate smoking (1-20 per day), and heavy smoking (> 20
per day). Table 17 summarizes the percent of respondents in
each category, by treatment group, on both the pretest and
follow-up. Since smoking was not authorized at time of
posttest, cigarette consumption at posttest is not reported.
Table 17
Cigarette consumption
Treatment group
1
2
3 4
Total
Cigarette
usage
pre f/u
pre f/u
I
pre f/u pre f/u
pre f/u
No/light
54.7 57.5
68.9 75.2
60.0 64.6 1 65.7 80.0
65 68
Moderate
35.3 37.5
22.3 22.7
31.9 30.5 | 26.9 15.0
26 28
Heavy
10.1 5.0
8.8 2.1
8.1 4.9 1 7.5 5.0
9 4
♦Note: Results reported in percentage

94
The observed trend overall was a reduction of heavy
smoking with respondents moving gradually to Categories 1 and
2. This overall change in cigarette consumption was found to
be significant (x2 = 8.94, pc.l). Individual chi-square
statistics were calculated, using observed and expected
consumption responses at follow-up, for treatment groups.
Though all groups showed a decrease in percentage of heavy
smokers, the only individual group differences proving to be
significant were in treatment Group 2 (x2 = 5.584, pc.l).
Smoking Habits
In order to provide insight to characteristic difference
between smokers in this study and in the general population,
several survey results regarding tobacco use are presented
here.
-Forty-three percent of the study population (41% of men
and 50% of women) indicated they were current smokers
upon entry to recruit training. Another 7% indicated
they were former smokers.
-A breakdown of current smoking by race showed the
following:
- Caucasian
45%
(202)
- Hispanic
39%
(11)
- Filipino
20%
(1)
- Black
21%
(18)
- Asian
20%
(1).

95
-A breakdown of current smoking by educational level
showed the following:
- GED
78%
(11)
- High School
40%
(171)
- Trade School/ some college
41%
(52)
- College Graduate
33%
(4).
-For all participants who indicated they ever smoked,
84% indicated they began smoking before the age of 18,
39% before the age of 14.
Discussion *â– 
The potential to affect tobacco use behavior during
recruit training is tremendous. Smoking prevalence in the
Navy can be drastically reduced if fewer personnel entering
the service smoke. This study sought to find ways of
decreasing prevalence through increasing maintenance of
tobacco abstinence after recruit training. The study
examined an education program designed to decrease smoking
relapse through increasing smoking knowledge, increasing
motivation to remain tobacco free, and furthering smokers in
their behavior change process of becoming ex-smokers.
Smoking relapse
Smoking relapse rates for most smoking cessation
programs average 70% at 3 months and increase another 10 -
15% between 3 and 12 months (Schwartz, 1987; Shiftman et al.,

96
1985). The cessation programs normally studied are voluntary
cessation programs. The overall relapse rate in this study
of 76% is in agreement with previous research even though
this study was a non-voluntary program. Though the results
indicate no significant differences in relapse rates between
treatment groups, several confounding variables seemed to
influence the significance.
Unlike the results of Blake et al. (1989) this study did
not find significant relapse differences due to gender
(though relapse rate for women was higher). Results of
smoking intention by gender, though, were similar to the
finding of Blake et al. They found women more tentative and
less committed to quitting completely; the present study
found that while 83% of men initially reported an intention
not to smoke only 68% of women indicated the same intention.
This difference in future smoking intentions cannot be
explained by the difference in smoking status alone.
Nicotine tolerance and cigarette consumption at entry
proved to be the best indicators of relapse in this study.
These results are in agreement with the study by Gritz et al.
(1991) and the meta-analysis of behaviorally based smoking
cessation studies by Glasgow and Lichtenstein (1987). The
results of the present study support what many retrospective
studies have alluded to previously (Hughes & Hatsukami,
1986), that withdrawal symptoms affect short and long term
quitting. The results are not the same as seen in the study
by Cronan et al. (1989) who found entry cigarette consumption

97
did not affect cessation during recruit training. Findings
in the present study indicate light smokers (< 6 cigarettes
per day) were affected more by the intervention. Since
almost all heavier, addicted smokers relapsed in this study,
additional research is needed to find effective ways of
reaching them.
Uncontrolled confounding variables may have had an
effect on relapse rates. The company showing the highest
relapse rate also showed the highest response that recruits
sneaked tobacco products during training. Many factors could
have contributed to why more recruits violated the rules (or
reported doing so) in this company. One possible factor is
the attitude of the company commanders concerning RTC smoking
policy, though the present study cannot support this
assumption. Future studies are needed to examine confounding
variables such as these.
Important to recognize here is, though most of the
subjects relapsed to smoking, for many this was their first
attempt at cessation. Since most smokers require several
cycles through the change process before quitting for good
(Prochaska & DiClemente, 1984) the recruit quitting attempt
will bring the smokers closer to final quitting. Entering
the change cycle is important and if the recruits relapsed,
it is equally important they move back to the action stage as
soon as possible. The present intervention may not have
succeeded in full behavior change but hopefully it moved

98
individuals to a higher stage of change, which is just as
important.
Differences in knowledge gain score were found to be
significantly related to relapse. Though knowledge gain
group differences were not significant, a trend was observed
with the education groups exhibiting a greater change than
the control and sham groups. Comparing the education only
(Treatment 2) to the control (Treatment 1), both show similar
scores on the two main relapse predictors; nicotine tolerance
level and prior cigarette consumption. Yet the control group
shows a higher relapse rate. This may be explained in that
the education group had the higher knowledge gain score.
The relapse trend between education and control indicate
the education intervention could affect relapse. The theory
of reasoned action (Ajzen & Fishbein, 1980) states a change
in behavioral beliefs leads to behavior change. In the
present study, knowledge gain measured positive changes in
beliefs that smoking is detrimental to health. Though an
educational effect on relapse could not be confirmed in the
present study, the trend observed is encouraging.
Smoking initiation
Perhaps the most encouraging result of the present study
involves the low reported initiation of smoking by non/former
smokers. Only 5% (9 of 171) of the entry non-smokers
reported being current smokers at follow-up.

99
Glynn (personal communication, September 16, 1991)
reported a possible second uptake period for smoking; during
employment transition. A recent study by Cronan et al.(1989)
reflected this uptake period for Navy recruits. They found
14% smoking initiation in a control group and 10% initiation
in all their study groups during boot camp. Their study was
conducted before a non-smoking policy had been instituted in
recruit training. They also found a reduction of initiation
for a no-smoking and an education treatment group. It's
possible that since smoking initiation cannot occur now
during boot camp, any smoking uptake due to employment
transition in the Navy will occur immediately after training.
The present study shows this is indeed the case but to a
lower extent than indicated by Cronan et al. (1989). Since
the present study shows no significant treatment group
difference for smoking initiation it must be assumed that the
effect of the recruit smoking policy on smoking perceptions
is responsible for the lower numbers seen. These results
show promise that the recruit no-smoking policy is having a
positive effect on preventing non-smokers from starting the
habit. Policy alone may affect smoking cessation slightly
(eg. early adopters in diffusion of innovation) but for
prevention of relapse, additional structured education
programs may be needed.

100
Smoking knowledge, attitudes, and intentions
The present study showed significant changes in smoking
knowledge between pre and post testing. Significant
treatment group differences were present only between the
education only (Group 2) and the control (Group 1). The
booster group showed the best knowledge retention, but the
differences observed were not significant. The increases in
knowledge seen in both the control and sham groups may be
explained by the attitude increases also seen in both groups.
Attitude change resulting from smoking policy and the
emphasis on smoking and health portrayed in the sham
treatment may have caused some survey respondents to answer
"yes" to all questions relating diseases to smoking. Since
all correct answers were "yes", this may have inflated all
knowledge scores enough to nullify any significant
differences.
Attitude changes were clearly evident and moved toward
more positive attitudes about non-smoking. At graduation the
attitude changes for smokers were even more obvious, though
the sham treatment group changed exactly the same as both
education groups. The booster group did not seem to have any
additional effect on maintaining attitude change as suggested
by Brownell et al. (1986). Possible explanations for the
attitude change seen in the sham group are differing
perception of importance of no smoking by the Navy because of

101
attention paid by the sham education session or confounding
variables such as company commander influence.
Intention not to smoke in the future is one of the
variables that did seem to be affected by the booster
program. Though time effect in treatment Group 3 was not
significant, this group was the only one which showed a
continual rise with time. All the other treatment groups
showed inconsistent intention changes across time. No
variables examined, other than the booster program, seem to
explain the intention change seen in the booster group. The
role of boosters session in changing intention is in
agreement with the suggestions given by Glynn et al. (1991)
for smoking cessation. As mentioned previously, females in
the study showed lower intentions not to smoke. The fact
that the booster group contained a female company, and still
showed a continual increase provides further evidence of a
booster effect.
Intention not to smoke in the future is very important.
Ajzen and Fishbein's (1980) theory of reasoned action views a
person's intention to perform, or not perform, a behavior as
the immediate determinant of the action. Therefore, the next
cessation attempt for smokers in the booster group may come
sooner than for smokers in other groups.
A clear example of how intention predicts behavior in
this population was seen with the pretest question "Do you
intend to resume smoking after graduation?" Relapse for
those who answered probably not was 64%, for those answering

102
probably will relapse was 78%, and for those answering
definitely will relapse was 100%. A firm intention to engage
in behavior is not easily influenced by external factors.
The key to changing smoking behavior is changing intentions.
The results of the present study agree with intention results
reported by Ajzen and Fishbein (1980).
Cigarette Consumption
The results of the present study display a significant
reduction in cigarettes smoked by those who relapsed. This
reduction was demonstrated by examining a drop in category
(no/light, moderate, heavy) rather than actual numbers of
cigarettes. Most studies report an overall percent reduction
in baseline smoking which confounds results due to subjects
who guit completely versus those who only show reduction
(Glasgow & Lichtenstein, 1987). The way results were reported
for the present study reflect an actual decrease in smoking
for relapsers. Since all heavy smokers relapsed after boot
camp, the changes observed from the heavy category to light
or moderate can only reflect an actual cigarette consumption
drop.
The results of a cigarette consumption reduction are in
agreement with an Army study by Carroll et al. (1989) who
found a majority of smokers had decreased consumption after
institution of major smoking policies. The only individual
treatment group difference that was significant in the

103
present study, was seen in the education only treatment group
(Treatment 2). This group also showed the highest smoking
knowledge gain and highest smoking attitudes increase. These
results suggest the education intervention, though not
significantly affecting relapse, may have affected the number
of cigarettes smoked by relapsers. Results of the present
study and others clearly show cigarette consumption affects
successful cessation. The reduction seen with relapsers
should then positively affect cessation success in subsequent
quit attempts by study participants.
Smoking habits
The no-smoking policy currently in effect at RTC,
Orlando seems to be effective, not only in reducing smoking
in boot camp, but also in preventing smoking initiation
immediately after graduation. The present study shows the
utility of combining a smoking education program with the
policy.
Forty-three percent of recruits reported current smoking
status upon entry. This number is not in agreement with the
study of Cronan and Conway (1988) of 28% or the study by
Cronan et al. (1989) of 24%. The discrepancies may be partly
found in that the present study considered former smoker of
less than two months to be current smokers. Further
differences obviously lie in the fact that the present study
included female recruits. The present results did agree with

104
the findings of the Grochmal (1990) study of 40% current
smoking at entry. Most disturbing is the fact that the
overall rate of 43% is in sharp contrast to the 29% thirty
day prevalence reported for high school seniors by Johnston
et al. (1991). Clearly the recruit population taken in by
the Navy have a much higher smoking prevalence than their
peers, and this serves only to perpetuate the Navy smoking
problem.
The present study finding of smoking by gender (41% male
and 50% female) were also similar to the Grochmal (1990)
study. These findings are in contrast to Johnston et al.
(1991) who report males and females are equally likely to
smoke and Bray et al. (1988) who found smoking was not
predicted by gender.
The 1989 Surgeon General report on smoking (USDHHS,
1989) placed smoking prevalence for whites at 29%, blacks at
34%, and Hispanics somewhere around 40%. The present finding
of 45% white, 21% black, and 39% Hispanic are in contrast to
the general population findings. The Surgeon General
(USDHHS, 1989) reported a decline in smoking prevalence as
education level increases; from 36% with less than high
school education to 16% for college graduates. The present
study found a decrease as well but college graduates still
reported a 41% smoking prevalence which was the same
prevalence reported by high school graduates (the small
number of college graduates included in the present study may
have affected the observed percentage).

105
The results of this study can be used to design a
comprehensive smoking prevention/smoking cessation program to
be used at all Recruit Training Centers. Knowledge of why
recruits use tobacco and why smokers relapse after graduation
will allow interventions to be better tailored to this group.
Retaining methods that seem to reach light smokers while
adding methods to affect heavier smokers better would be
prudent. For example: knowing 81% of smokers indicated they
started smoking again after boot camp because "it calmed me",
suggests a stronger stress coping skills section must be
incorporated in programs.
Findings concerning the type of smokers entering the
Navy can be used to better target cessation efforts for the
general Navy population. If most of the smokers relapsing
after boot camp are the heavier more addicted ones, then
cessation efforts need to address them. The reasons given by
these smokers (eg. stress relief, peer pressure, boredom) can
be used to help these individuals cope with relapse. Navy
cessation programs need to be adapted to specifically help
the Navy smoker.
Cautions
As with any study, the reader should be cautious to not
assume too much from the results of the present study.
Significant differences found have been combined with trends
observed in an effort to explain the results. The reader

106
should keep in mind the limitations of the study and the
assumptions which were presented in chapter 1. Several other
factors should also be kept in mind when interpreting the
results:
-the sham treatment group had fewer subjects than the
other groups and a 25% response rate on the follow-up
survey further reduced the sample size used in some
analyses
-the control group only had a 50% completion of post¬
test surveys which decreased sample size in some
analyses
-the overall follow-up response rate and other
attrition factors made the final smoker population less
than was originally anticipated; this reduction in
sample size had an effect on analyses power
-more surveys were returned completed from participants
who went on to longer training programs after boot
camp, as opposed to those who had finished all their
training before follow-up
-follow-up was difficult due to tracking problems in the
Navy system.

CHAPTER 5
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
"The reason I don't smoke is because I don't want my
younger brothers and sisters to smoke, and they look up
to me"
-A Navy recruit, Sept 1991
Summary
This study examined the impact of an education program
on smoking knowledge, attitudes, and intentions of Navy
recruits undergoing 8 weeks of training in a normal no¬
smoking environment. The study also examined smoking relapse
and cigarette consumption subseguent to recruit graduation.
Specifically the study was designed to: (1) add to the
literature information on effective prevention and cessation
of smoking using education techniques; (2) measure effect of
current no-smoking policy at Recruit Training Center,
Orlando, FL; (3) examine differences in observed levels of
the above listed variables, for various treatment conditions;
(4) examine smoking initiation rate differences (for non-
smokers prior to recruit training) for various treatment
conditions; and (5) examine variables affecting smoking
relapse.
107

108
Participants in the study numbered 496 (357 men and 139
women), in seven recruit companies. The companies were
randomly assigned to 4 treatment conditions: (1) policy only
comparison (n = 140); (2) policy plus education (n = 151);
(3) policy plus education with a booster (n = 136); and (4)
policy plus sham treatment (n = 69). Tobacco use knowledge
and behavior surveys were administered to all subjects at the
beginning of recruit training, at graduation, and three
months after graduation. The subjects in both education
groups received a three hour education intervention during
recruit training. The booster group received an hour long
booster program at the end of their training cycle, which
included signing a pledge to assist Navy smoking cessation
efforts. Subjects in the sham treatment group received an
hour long education program, unrelated to smoking, to measure
the effect of any intervention on the study population. A
random selection of urine samples was analyzed for cotinine
levels to validate self-reported tobacco use. Cotinine
analyses were concurrently accomplished with pre- and
postsurvey completion.
Treatment group differences for smoking attitude and
knowledge change were analyzed with one-way and repeated
measures (3) analysis of variance (ANOVA). Treatment group
differences for smoking relapse, smoking initiation,
cigarette consumption change, and smoking intentions were
analyzed by using frequency tables with the Pearson's

109
chi-square statistic, and a categorical modeling procedure
(SAS PROC CATMOD).
The results indicated subjects in the education only
treatment relapsed to smoking less frequently than the
control or education plus booster groups, but these group
differences were not statistically significant. No signifi¬
cant group differences were observed for smoking initiation,
though the overall smoking initiation rate observed was less
than anticipated. A knowledge gain was observed for all
subjects, but the only significant treatment group difference
occurred between the education only and control groups.
Positive changes in smoking attitudes were observed for all
subjects and differences were significant between the
education groups and the control and sham groups. No added
booster effect was observed for smoking attitudes or
knowledge. The booster treatment subjects showed the only
consistent improvement in positive future smoking intentions,
but the effect was not significant. A significant education
effect was seen in reducing the number of recruits violating
the no-smoking policy during the uncontrolled liberty
weekend. An overall decrease in cigarette consumption was
observed for smoking relapsers in all categories, but the
only significant changes occurred in the education only
group.

110
Conclusions
Analysis of data collected in this study justify the
following conclusions.
(1) The current Recruit Training Command no-smoking
policy has been effective in reducing smoking
initiation, after graduation.
(2) Smoking education significantly affects attitudes
toward smoking for Navy recruits.
(3) Smoking education and placebo education
significantly affect attitudes toward smoking for Navy
recruits who were current smokers upon entering recruit
training.
(4) Smoking education significantly affects smoking
knowledge among Navy recruits.
(5) Smoking education significantly affects cigarette
consumption for Navy recruits who relapse to smoking.
(6) Nicotine addiction and prior cigarette consumption
were the best indicators of relapse for Navy recruits.
In this study sufficient evidence for a conclusion was
not observed for the following:
(1) effect of smoking education on smoking relapse rates
of Navy recruits
(2) effect of smoking education on future smoking
intentions of Navy recruits

Ill
(3) effect of smoking education on smoking initiation
after boot camp for recruits who did not smoke at Navy
entry
(4) booster effect on education consequences on smoking
knowledge and smoking attitudes.
It is clear that while the study population resembled
civilian counterparts in some respects, they certainly were
different in most areas of tobacco use. Selection of higher
prevalence smokers into the Navy does not improve the outlook
for decreasing overall Navy smoking prevalence in the near
future. It was encouraging to see at least some recruits not
relapsing to smoking after boot camp, but it is clear that
policy alone will not significantly reduce the number of
smokers entering the general Navy population. The relapse
rate for recruits seems to reflect relapse rates for most
smoking cessation programs, which is encouraging considering
the non-voluntary status of entry to cessation.
Though nicotine addiction and prior cigarette
consumption best predicted smoking relapse for Navy recruits,
a firm intention to resume smoking always predicted relapse.
This agrees with the theory of reasoned action which believes
intention to perform a behavior is the best predictor (Ajzen
& Fishbein, 1980). Smoking behavior change must be brought
about by producing changes in beliefs. Beliefs are affected
by the attitude toward behavior and perceived social

112
pressures (subjective norm). Attitude is a function of an
individual's belief that the outcome of performing a given
behavior will be positive or negative. Knowledge of
smoking's adverse effects play a key role in changing
attitudes.
The present study results show smoking education
affected smoking knowledge and attitudes. The booster group
showed a trend toward increased intention to not smoke in the
future. Changing beliefs during recruit training by changing
smoking knowledge, attitudes, and intentions can assist
smokers in changing perception that smoking leads to more
negative than positive outcomes. The current Recruit
Training Command no-smoking policy, especially when fully
supported by recruit company commanders, increases social
pressure on the recruits not to engage in smoking behavior
after recruit training. The recruit experience, combined
with continued smoking education, stricter smoking policies,
and increased negative social acceptance of tobacco use, can
accelerate the cycle of smoking behavior change. This may
make new Naval personnel who remain smokers more receptive to
smoking cessation efforts encountered through their Naval
career. A recruit smoking education program can accelerate
the drop in Navy smoking prevalence and assist the Navy of
reaching its goal of being smoke free by the year 2000.

113
Recommendations
Evident in the present study is that no factor by itself
affects relapse. Many things predict and affect relapse.
The present study has highlighted numerous variables which
together can decrease smoking relapse in recruits after
graduation. These factors need now to be used in a
comprehensive smoking program for all recruits. Further
studies should be performed to determine additional elements
which will better reach heavier, addicted smokers who were
not affected by the present interventions. The following
recommendations are made.
(1) Further studies should be conducted using
interventions addressing the top reasons given for
returning to smoking (eg. stress, peer/family pressure,
boredom).
(2) A 12 month and 36 month follow-up should be
conducted with the present study population to examine
long term effects.
(3) Further studies should be conducted varying the
education dosage (eg. 1 hr, 3 hr, 6 hr) to determine if
"more is better".
(4) Improve present research design by:
-balancing treatment group cell size by total
number and gender

114
-conducting education sessions later in training
cycle when recruits have abstained from smoking
longer
-breaking education classes into one hour sessions
to allow time to process smaller portions of
information and formulate questions for later
sessions
-incorporating refusal skills training and role
playing into curriculum
-incorporating some correct "no" answers into
knowledge questions.

APPENDIX A
INTAKE SURVEY
Reprinted with permission of Dr. Terry L. Conway, Naval
Health Research Center, San Diego, CA

TOBACCO USE SURVEY
Dear Participant:
You and several hundred other new members of the U.S. Navy have been selected to participate in this
survey. Your answers will assist researcners at the Naval Health Research Center study tobacco use among
new Navy members and evaluate current tobacco use policies. Your participation is very important because
the information you provide will help guide future program policy regarding tobacco use
Please answer all the questions honestly and to the best of your ability. Your responses are for
research use only and will be kept strictly confidential. Data will be reported so that no individual
participant can oe identified. If you have any questions about this survey, please contact Dr. Terry L
Conway, Naval Health Research Center. San Diego, CA 92186-5122/Autovon: 553-8465: Commercial: (619)
553-8466.
Thank you very much for your cooperation in this project!
DEPARTMENT OF THE NAVY
NAVAL HEALTH RESEARCH CENTER
P.O. BOX 85122
SAN DIEGO, CA 92186-5122
PRIVACY ACT STATEMENT
CONSENT STATEMENT
1. AalKottr. 5 USC XI
2. Parpoee. Medical research information will be
collected to enhance basic medical Knowledge,
or to develop testa, procedures, and equipment
to improve the diagnosis, treatment, or
prevention of illneaa. injury, or performance
impairment.
3. Use. Medical research information will be used
for statistical analysts and reporta by the
depart men is of Navy. Defense, and other U.S.
Government agencies, provided this use is
compatible with the purpose for which the in¬
formation was collected. Use of the informa¬
tion may be granted to non-Government agen¬
cies for individuals by the Chief. Bureau of
Medicine and Surgery, in accordance with the
provisions of the Freedom of Information Act.
4. Disclosure. i understand that ail information
contained in the Consent Statement or derived
from the study described therein will be
retained at the Naval Health Research ('enter.
San Diego, and that my anonymity will be
maintained. I voluntarily agree to its disclosure
to agencies or individuáis identified in ihe
preceding paragraph, and I have been inlormed
ihat failure ui agree to such disclosure mav
negate the purposes for which the *tu«iv is
being conducted.
uuüivy
This research is part of an evaluation of the tobacco use prevention and cessation component of the Navy's
Health and Physical Readiness Program. Your participation in this study involves completing the followup â– 
survey. which should lake aoout 15 minutes and asks about your tobacco use. in addition we will be ,
administering two similar follow-up surveys: one at the end of your current training and one in approximately
one year. 1
Your paniapaiior is strictly voluntary. Refusal to participate will involve no penalty or toas of any benefits
to which you are otherwise entitled. All data from this research will be kept at the Naval Health Research
Center and used for research purposes only. Primarily, the data will be summarised in reporta far I
professional audiences interested trr health and nutrition, la all case*, the data will be reported so that .
no ladivtdaal respondent can be identified. The Information gathered will not become part of year
service record or medical record. 1
VMr hope that you will consent to participate, because your input is needed for program evaluation. By
signing this consent form, you state that your participation is voluntary, without force or duress of any
kind. You also acknowledge that vou understand the purpose of this study and that you are free to withdraw
your consent at any time without prejudice to yourself or your military or civilian career.
Should questions arise, feel free to contact Terry L Conway. Naval Health Research Center. San Diego. CA
92186-5122.Autuvon: .'i5.'WHW: Commercial: (619) 553-&46JS.
7
• Use a NO. 2 PENCIL only.
• Do not use ink or ballpoint pen.
• Pill in the circle completely.
• Cleanly erase any marks you wish to change.
• Do not make any stray marks on this form.
Ooi
0ccmntcT MASK
O'® © QwCOMtfCT MARKS ™
IOOOOOOOOOOOO
116
rrfi 11111111 i i 111

117
txi»fft>«cnb
IS: Ptoasa darken in t
use A DARK LEAD PENCIL
ha onto corresponding to tto answrr which toaCTfescntos yore
-DO NOT USE INK—and be sure to fill tto cvcto comptetsiy.
T
—
NAME
I
T
™i®©©©©® @® ®® ® ®® ® ®l
™i®®®®®®®®®®®®®®®
“©©©©©©©©©©©©©©©I
■■I® © ® © ® © © ® ® ® ® ® © © ©
©©©©©©©©© ©©©©©I
■■©©©©©©©©©O®®®®©
«■ ™@®®®©©®©©®®®®®©
—©0©©©0©0©00©00©j
—<2>©©©©©Q©©©©©©©©!
™©©®®®®®®®®©®©©©
“©©©©©©©©©©©©©©©
™®®®®®®®@®®®®®®®l
■i®®®®®®®®®®®®®®®
•»©©@®® @®@ ®® ©©©©©(
«®®®®®®®®®®®®®®©
—©®©©®©®©®®®©©©©
—©©©©©©©©©©©©©©©I
™<5)©©©©©© ©©©©©©©©
«©0©®©©©©©©©®®©©
I First (1st 7 letters)
I®©©®®©®)
®®®®®®®(
©©©©©©©I
|®@ ® ® ®@®l
©©©©©©©
¡©©©©©©©I
(©©©©©©©
©®@®® ®®|
®©OGO©OI
©©©000©
©®®®®®0
©©©©©©©
®®@®®®®l
©®®®®®®l
!®@©©@®®l
I®©®©©©©
®®®@®®®i
■o©©©©©©©©©©©©©©
_■©©©©©©(
©®®©©® ©(
©©©©©©©(
i@®®@®®(
©®® ©©©©
©©©©©©©
©©©©©©©i
)®
|®®®
©©©l
©@©
©©©
©©©)
®®®i
©o©
©o©
©®©
©o©
®®®l
©®©
®@©
©®©
®@©
®®®
©©©
©©©j
©0©
®®0
j®®©
©0©
©©©
| OFFICER I
(DESIGNATOR!
©®@©
©©©©
©@©0
©©©©
0®®©
©©©©
®®®©
0©0©
®®®0
0®®©
5. TOOAY'S
| DATE 1
©Jan i OAY I YEAR I
©Feb | I III
©Mar ©©
£>Aor !©©
BMav I©©
Jun ©®
©Jul | ®
BAug ®
Sep I ®
© Oct I ©
©Nov ¡ ®
©Dec i ©
"SI
©
©
m
SOCIAL SECURITY
NUM8ER
© ® © © ® © © ® @|
©©©©©©©©©
©®©©®©®®©
©®®®00®®0j
®©©®®®®®®l
®®®®®®©®s
®®®®®®®®®
©©©©©©©©
©®®®®®®®®
©®®Q©©©®©
CURRENT COMMAND
ORecnjlt Naming Center. San Diego
O Recruit Training Center. Great Lakes
O Recruit Training Center. Orlando
O Officer Candidate School
O Officer indoctrination School
O Naval Academy
!
RACE
0 Caucasian
0 Hispanic
0 Pilono
O Black
O Asian
O Other
L HIGHEST LEVEL OF EDUCATION
O 11 vears or less
OGED or certificate
OHigh school graduate
O^raae or technical school graduate
O Some college
O4 year college degree
O Graduate or professional study But no degree
Q Graduate or professional degree
â–º
I 10.
SEX
mm
0 Male
O Female
n MARITAL STATUS
O Never married
O Mamed or living as married
O Separated/divorced/widowed
â–¡ TOBACCO USE
'-jlLÍIl
¿■■i- «f
13. Have you smoked 100 cigarettes in your life?
O Yes
Ono
14. At what age did you first start using tobacco
products fairly regularly?
ONA never have used tobacco O - 17
O Under 12 years old Q 18 - 20
012-14 O 21 or older
15. For how many years have vou used (or did you use!
tobacco on a regular basis (do not include the time
when you quit using tobacco)?
QNA. never have useo tobacco
Qless than one year
Q(D(D©Q® Q® (?) @ © © ® © @l
YEARS
Peg* 2

118
Please indicate tobacco use at entry into the Navy by
marking one answer for each tobacco product.
«VIA I »0AMEA t
JSEO I USEA
16. Cigarettes
17. Cigars
18. Pipe Tobacco
19. Chewing Tobacco
20. Snuff/Dip
o
o
o
o
3
o
c
o
o
LIGHT
USER
o
o
o
o
Q
V00EAATE
-SEA
o
o
o
o
HEAVY I
üSEA |
O !
O !
O I
OF TOBACCO
USED
21. When was the most recent time you smoneo a cigarette?
O Never smoked a ciqdrette
O 10 or more vears ago
06-9 vears
03-5 vears
O 1 - 2 /ears
07-11 months ago
04-6 months ago
02-3 months ago
05-7 weeks ago
O Ourmq tne oast 30 davs
O Today
22. During the last 30 days fust prior to entering the Navy,
how many cigarettes did you usually smoke on a
typtcal day when you smoked cigarettes?
OOd not smoke any cigarettes O 21 - 25 cigarettes
m the last 30 davs
O Fewer than 1 cigarette.
on the average
O 1 - 5 cigarettes
06-10 cigarettes
Oil - 15 cigarettes
O 16 - 20 oaarettes
O 26 - 30 cigarettes
031 - 35 cigarettes
O 36 - 40 cigarettes
041 - 45 cigarettes
046-55 cigarettes
O 56 or more cigarettes
DURING THE MONTH BEFORE ENTERING THE NAVY...
23. On the average, how many days per month did you
use chewing tobacco?
O Never m the oast 12 months/ G 2-3 davs a month
Don t use chewmg tobacco O 1 *2 davs a week
OOnce or twice m the oast 12 months 03-4 davs a week
O 3-6 davs m the Dast 12 months O 5-6 davs a week
07-11 davs m the oast 12 months O About every dav
26. On the davs you used snutf/dip. how many times per â– 
day did you use it? i
Ona 02 04 06 08 I
C i 03 C= 03 09* <
)
27. On the average, how many davs per month did you â– 
smoke a pipe? i
O Never m me oast ! 2 months/ 02-3 davs a month «
Don t smoKe a oipe Q 1-2 uavs a week •
O Once or twice m the oast 12 months 03-4 davs a week â– 
03-6 davs m the oast 12 months 05-6 days a ween â– 
07-11 aavs m the past :2 montns O About every dav â– 
O About once a month â– 
28. On the davs you smoked a pipe, how many pipefuls of â– 
tobacco did you smoke? a
Ona 02 O4 06 08 a
O' 03 0= 03 09- «
29. On the average, how many days per month did you â– 
smoke cigars? a
O Never m the oast 12 months/ 02-3 davs a montn â– 
Don t smoke cigars 01 *2 devs a week â– 
OOnce or twice in the past 12 months 03-4 davs a week â– 
03-6 davs m tne oast 12 months 05-6 davs a week â– 
07-11 davs m the past 12 months O About every oav â– 
O About once a month â– 
30. On the days you smoked cigars, how many did you â– 
smoke? â– 
CNA 02 O'* 06 Q8 â– 
O' 03 05 07 09* â– 
IF YOU HAVE NEVER USED CIGARETTES. m
CIGARS. OR PIPES. PLEASE MARK HERE C AND a
GO TO *32. m
31 Below is a list of reasons people give for START- si
ING to use CIGARETTES. CIGARS, and/or â– 
PIPES. For each possible reason, mark NO or â– 
VES to indicate whether it was a reason why you â– 
started to use any of these tobacco products. â– 
0 About once a month
NO
YES
a) 1 was bored
O
o
On the days you used chewing tobacco, how many
b) Most of my friends did.
0
0
times per day did you use it?
c) 1 wanted to be "coot"
o
o
Ona 02 O'* 06 08
d) 1 liked the image.
o
0
*
cn
o
O
m
o
ro
o
6
e) 1 liked the taste
o
o
f) It gave me a kick.
c
o
On the average, how many days per month did you
gj 1 wanted to show that 1 was tough.
0
o
use snuff/dip?
hi 1 wanted to take a oare.
0
o
0 Never m the past 12 montns/ 02-3 days a montn
it It calmed me.
o
O 1
Don t use snutt die 0 '*2 davs a week
j) 1 wanted to lose weight.
0
c
0 Once ".vice -n me oast 2 months O 3-4 davs j wee*
k) 1 wanted to look and feel like an adult.
/“V
v-'
o,
0 3-6 davs m me pas: 12 months C 5-6 davs a week
i) 1 wanted to oe masculine.
0
o:
07-11 jjvs n me dast ’2 months 0 4oout everv uav
mi 1 didn't want to feel left out of a group.
o
0 1
0 About once a mprtn
1 wanted to show 1 vvasn t afraid.
O 1
oi Mv parents smoned.
o
c :
p) 1 was curious.
Q
J2J
Page 3

119
IF YOU HAVE NEVER USED CHEWING TOBACCO.
SNUFF OR DIP PLEASE MARK HERE C AND
GO TO »33
32. Below ts a list of reasons oeopie give for START¬
ING to use CHEWING TOBACCO. SNUFF, ana/
or DIP. For each possible reason, mark NO or
YES to indicate whether it was a reason why you
started to use any of these tobacco products
NO
VES
$
al I was bored.
bi Most of my friends did
c) I wanted to be cool."
d) I liked the image.
e) I liked the taste.
f) It gave me a kick.
g) I wanted to show that I was tough.
h) I wanted to take a dare.
i) It calmed me
j) I wanted to lose wetght.
k) I wanted to look and feel like an adult.
I) I wanted to be masculine.
m) I didn't want to feel left out of a group.
n) I wanted to show I wasn t afraid,
oi My parents smoked.
p) I was curious.
q) Smokeless tobacco was less noticeable to
use m "restricted" areas than cigarettes.
r) Smokeless tobacco was less offensive
to nonsmokers.
â–¡knowledge on
SMOKING POLICY
o : o
o o
O Í o
C ' o
O ! O
G O
o
o
O I o
o o
o : Q
0 â–  o
o : o
O : 0
o ; o
o; o
o i o :
0 : O :
33. Has anyone in authority informed you about this
command's policy on smoking/tobacco use?
O No O Yes
34. Do you know what the specific rules are for smoking or
using other tobacco products while you are at this
command?
O No O Yes
—W □ORIENTATION AND INTENTIONS
$
35. Does it bother you when someone is smoking
around you?
O No O Yes
36. When you are inside public areas that have no rules
about smoking and someone lights up a cigarette, what
are you most likely to do?
O Just do nothina
OVIove r.rav »rom me person
O 4sk top cersun not to smokei
O Somethin • • •••• specif.: —►
| 37 Do vou neiieve cigarette smoking
ii is related to heart disease?
oi is related to cancer?
ci is related to emphysema?
d) is addictive? '
38 Are you concerned about the health effects of
NO
o
o
r\
b) Cigars/pipes?
cl Chewing tobacco?
d) Snuff/dip?
NO
o
0
o
o
rfS
o
c
c
YfS
o
o
o
o
39 How important is it to you to be a non user of tobacco
products?
_ Not at ail important O Very important
Sumewnat important OExtremely important
_ Vooer.neiv important
-'.v'v VV\
oioppioia
Over the next year . .
40. If you currently smoke cigar¬
ettes. cigars, or a pipe, how
likely is it that you will stop
smoking?
41. If you currently use chewing to¬
bacco. snuff, or dip. how likely is
â– t that vou will stop using these
smokeless tobacco products. OiOIOOlO
42. If you currently do not smoke
cigarettes, cigars, or a pipe, how t
likely is it that you will reman a
non smoker?
43. If vou currently do not use
chewing tobacco, snuff, or dip.
how likely is it that you will
remain a non user? OlOlOlQlOiQl
obo
do
G
O
In the future, do you see yourself as . .
44 Someone who smokes?
45. Someone who uses smokeless tobacco?
In the future, are you likely to be a
NON-USER of tobacco . . .
46 Out of concern for your health?
47 Because a medical orofessional has told
vou to quit?
48 Because of the cost of tobacco products?
49. Because of the social oressure not to use
tobacco?
50. Because of the hassles related to
smoking-restricted areas?
51 Because few of vour peers/friends use
tobacco?
Thank you for Completing This
NO
YES
0
0
o
o
o
j
o 1
0
O 1
o
O !
0
o!
0
oj
•0
O !
SURVEY!
ici
OOnh r\
— V-/1 -W/1
Page 4

120
Please indicate in the above boxea the
last 4 digits of your social security
number.
52. Do you intend to use cigarettes after
graduation from training, when the smoking
policy allows you the choice to do so?
O No O Yes
53. Would you be in favor of being placed
in a smoke-free work environment after
leaving training?
O No O Yes
54. What percent of the U. S. population
do you think are current smokers?
020% 030% O40%
050% O60% 075%
55. What percent of all members of the
Navy do you believe are current smokers?
0 201 O30% O40%
O50% O60% O70%
56. Should tobacco companies be allowed
to target advertising toward certain
groups in order to recruit new customers?
O No O Yes
57. Do you expect to complete a college
degree sometime in the future?
O No O Yes
58. Do you plan to make the Navy a
career?
O No O Yes
60. On average, how many cigarettes did
you smoke per day before entering the
Navy?
cigarettes per day
61. What brand of cigarettes did you
smoke?
62. Did you inhale?
O always
O sometimes
O never
63. Did you smoke more in the morning
than during the rest of the day?
O No OYes
64. How soon after waking up did you
smoke your first cigarette?
O within 5 minutes
O within 30 minutes
O not until after breakfast
65. Which cigarette will be the hardest
for you to give up?
O first one in the morning
Othe one after meals
O the one while on the phone
O other
66. Did you find it difficult to refrain
from smoking in places where it was
forbidden (example: church, library, work,
plane) ?
O No O Yes
67. Did you smoke if you were so ill that
you were in bed most of the day?
O No OYes
If you indicated that you have never
smoked cigarettes STOP here. If you
indicated you have EVER regularly smoked Continue on reverse
please answer the rest of the questions
based on prior smoking habits.
59.How do you think the smoke-free
policy at this training command will
influence your tobacco use after you
leave?
OWill help me STOP using tobacco
O Will help me REDUCE my tobacco use
Owill NOT CHANGE my tobacco use
Owill PROBABLY INCREASE my tobacco
use when I leave
UUÃœIV3

121
Please circle the appropriate
response
Always Never
68. I smoke cigarettes in 54321
order to keep myself from
slowing down.
69. Handling a cigarette is 54321
part of the enjoyment of
smoking it.
70. Smoking cigarette is 54321
pleasant and relaxing.
71. I light up a cigarette 5 ' 3 2 1
when I feel angry about
something.
72.When I have run out of 54321
cigarettes 1 find it almost
unbearable until I can get
them.
73. I smoke cigarettes 54321
automatically without even
being aware of it.
74. I smoke cigarettes to 54321
stimulate me, to perk myself
up.
75. Part of the enjoyment 54321
of smoking a cigarette comes
from the steps I take to
light up.
76. I find cigarettes 54321
pleasurable.
77. When I feel 54321
uncomfortable or upset about
something, I light up a
cigarette.
78. I am very much aware of 54321
the fact when I am not
smoking a cigarette.
79. I light up a cigarette 54321
without realizing I still
have one burning in the
ashtray.
80. I smoke cigarettes to 54321
give me a "lift".
81.When I smoke a
cigarette, part of the
enjoyment is watching the
smoke as I exhale it.
82. I want a cigarette most 54321
when I am comfortable and
relaxed.
83. When Z feel "blue" or 54321
want to take my mind off
cares and worries, I smoke
cigarettes.
84. I get a real gnawing 54321
hunger for a cigarette when
I haven't smoked for a
while.
85.I've found a cigarette 54321
in my mouth and didn't
remember putting it there.
86.Do you intend to resume smoking after
graduation?
0 probably not
Oprobably will
Odefinitely will
Thank you for
your Cooperation
5 4 3 2 1

APPENDIX B
GRADUATION SURVEY

TOBACCO USE SURVEY
tí 0 0 4 ¿ 5
Dear Participant:
As you may recall, we are conducting an ongoing study of tobacco use among new Navy members.
You completed a survey at the beginning of recruit training and we ask for your cooperation
again. This survey is designed to measure your tobacco usage, and attitudes toward tobacco
use and Navy smoking policies at this point in time. This project is providing valuable
information to Navy policy makers and we hope you will continue to participate by taking 15
minutes to complete it.
Please answer the questions honestly and to the best of your ability. Answers will be kept
strictly confidential and the only identifying information we ask for is the last 4 digits of
your social security number. Your command will not have access to any of the individual data.
Participation is still voluntary and you do not have to answer any question you do not wish to
answer.
Thank you very much for your continued cooperation in this project 1
Directionsi
â– Use a NO. 2 pencil
‘Fill in circles completely or enter information in blocks provided
•Do not make any stray marks on this form
•Make sure you have entered the last 4 digits of your social security number where
indicated
1.Enter the last 4 digits of your
social ..curity nuab.r. 1 AMOUNT OF TOBACCO PRODUCTS USED
2.Enter your recruit conpany nuaber
3.Today's Date:
month / day / year
/ /
Itobacco use 1
Please indicate past and current tobacco use
by marking NO or YES for each tobacco product
4.Before entering the Navy were you a
regular user of ...7
a) Cigarettes
b) Cigars
c) Pipe tobacco
d) Chewing Tobacco
e) Snuff/Dip
5.During recruit training did you use?
NO
YES
a) Cigarettes
o
0
b) Cigars
0
0
c) Pipe tobacco
0
0
d) Chewing Tobacco
0
0
e) Snu££/Dip
0
0
6.Has your company had your
"uncontrolled liberty weekend"?
0 No O Yes
a) If YES, did you use tobacco products
when allowed off base?
0 No o Yes
NO
YES
0
0
0
0
0
0
0
0
0
0
7.When was the soft
snoked a cigarette?
0 Never smoked a
cigarette
0 2 or more years
ago
0 1-2 years ago
0 7-11 months ago
recent tine you
0 4-6 months ago
0 8-9 weeks ago
0 1-8 weeks ago
0 [hiring the past
7 days
0 Today
8.During the last 30 days, how nany
cigarettes did you usually smoke on
typical day when you smoked
cigarettes ?
0 Did not smoke any
cigarettes
O Fewer than 1, on
the average
O 1-5 cigarettes
0 6-10 cigarettes
O 11-15
0 16-20
O 20-25
O 26 or more
cigarettes
9.When was the most
smoked a cigar?
0 Never smoked a
cigar
O 2 or more years
ago
O 1-2 years ago
0 7-11 months ago
10. When was the
used smokeless
0 Never used
smokeless tobacco
0 2 or more years
ago
0 1-2 years ago
0 7-11 months ago
recent time you
O 4-6 months ago
O 8-9 weeks ago
O 1-8 weeks ago
O During the past
7 days
O Today
most recent time you
tobacco?
O 4-6 months ago
0 8-9 weeks ago
O 1-8 weeks ago
O During the past
7 days
O Today
...Continue on back
123

124
¡KNOWLEDGE O T SMOKING POLICY
11.Oo you know what the «pacific
rules are for saoking or using other
tobacco products while at this
coaaand ?
0 No 0 Yes
12.How often were the coaaand saoking
rules enforced during recruit
training? HALF OF
THE TIME
0%10%20%30%40%50I60%70%80%90%100%
0000000000 0
NEVER ALWAYS
13.Were these saoking rules enforced
for everybody?
0 No 0 Yes
20.How iaportant is it to you to not usi
tobacco products?
0 i!ot at all important 0 Very important
0 Somewhat important 0 Extremely
0 Moderately important important
21.What percent of the U. 8. population
do you think are current saokers?
0 20% 0 30% 0 40%
0 50% 0 60% 0 75%
22.What percent of all newborn of the
Wavy do you believe are current
saokers ?
0.20% 0 30% 0 40%
0 50% O 60% O 75%
14.How often did people sneak a
cigarette even though they were in a
saoking restrictive area?
0 Never 0 Sometimes 0 Always
0 Rarely 0 Usually
23.Should tobacco coapanies be allowed
to target advertising toward certain
groups in order to recruit new
custoaers ?
O No 0 Yes
15.Would you be in favor of being
placed in a saoke-free work environnent
after leaving RTC?
O No O Yes
16.How do you think that the saoke-
free policy at your recruit training
coaaand will influence your tobacco
use after leaving that coaaand?
0 NA-I was not a tobacco user
0 Will help me STOP using tobacco
0 Will help me REDUCE my tobacco use
O Will NOT CHANGE my tobacco use
0 PROBABLY WILL INCREASE my use
17.How do you think the saoking
education classes offered at recruit
training command will influence your
tobacco use after leaving the
coaaand?
0 NA-I was not a tobacco user
0 Will help me STOP using tobacco
0 Will help me REDUCE my tobacco use
0 Will NOT CHANGE my tobacco use
0 PROBABLY WILL INCREASE my use
¡ORIENTATIONS I
18.Do you believe saoking..
a) is related to heart
disease?
b) is related to cancer?
c) is related to emphysema?
d) is addictive?
19.Are you concerned about
the health effects of...
a) Cigarettes?
b) Cigars/Pipes?
c) Chewing Tobacco?
d) Snuff/Dip?
NO
Yes
0
0
0
0
0
0
0
0
NO
Yes
0
0
0
0
0
0
0
0
¡INTENTIONS
24.On a scale of 1 - 5, how likely
are you to start saoking cigarettes
after graduation froa recruit
training?
1 2 3 4 5
not very likely definitely will
25.On a scale of 1 - 5, how likely
are you to start using saokeless
tobacco products after graduation
froa recruit training?
1 2 3 4 5
not very likely definitely will
In the future, do you see
yourself as . • •
No
Yes
26.Someone who smokes?
0
0
27.Someone who uses
saokeless tobacco?
In the future are you
likely to be a non-user
of tobacco.••
0
o
28. Out of concern for
your health?
0
0
29. Because a medical
professional has told you
to quit?
0
0
30. Because of the cost of
tobacco products?
0
0
31. Because of social
pressures not to use
tobacco ?
0
0
32. Because of hassles
related to smoking
restrictive areas?
0
0
33. Because few of your
peers/friends use
tobacco ?
0
0

APPENDIX C
THREE MONTH FOLLOW-UP SURVEY

TOBACCO USE SURVEY
Dear Participant:
As you may recall, we are conducting an ongoing study of tobacco use among new Navy
members. You completed surveys at the beginning of recruit training and at graduation. This
survey is designed to measure your tobacco usage, and attitudes toward tobacco use and Navy
smoking policies at this point in time. This project is providing valuable information to
Navy policy makers and we hope you will continue to participate by taking 15 minutes to
complete this survey and returning it , either in the envelope provided or to the class
coordinator you received it from.
Please answer questions honestly and to the best of your ability. As mentioned
previously, your answers are for research purposes only and will be kept strictly
confidential. For this reason the only indent if ying information we ask you to list is the
last 4 digits of your social security number, in the blocks designated. Data will be reported
so that no individual participant can be identified. Participation is voluntary and you do
not have to answer any question you do not wish to answer. We do ask that all surveys be
returned, completed or not, so that all can be accounted for. If you have any questions about
this survey, please contact LCDR T.L.Pokorski, University of Florida, Department of Health
Science Education, #4 FLG, Gainesville, FL 32611/(904)372-7574.
Thank you very much for your continued cooperation in this projectl
UNIVERSITY OP FLORIDA
DEPARTMENT OP HEALTH SCIENCE EDUCATION
#4 PLG (CODE P)
GAINESVILLE, FL 32611
OPNAV Approval: Reports Control Symbol 6100-6
Directions:
•Use a NO. 2 pencil
•Fill in circles completely or enter information in blocks provided
• Do not make any stray marks on this form
•Return survey as soon as possible in envelope provided, or seal it in the envelope and
return it to the class coordinator from whom you received it
•Make sure you have entered the last 4 digits of your social security number where
indicated
1.Enter the last 4 digits of your 4. Today's Date:
social security number.
month / day / year
5. Enter your recruit company number
2.Enter your enlisted rating.
(esamplei SI, HA, ET3 , etc) I—.—.—j—i
3.Pay Grade
0 E-l O E-2 0 E-3
0 E-4 0 E-5
126

127
For each time period, pleaae mark the type o f duty station you were assigned and indicate
your tobacco use during that time period.
TIN!
F1 AMI
TIP* OP DUTY STATIO*
TOBACCO U8K
Never
Used
Former
User
Current
User
(. JUST
NOT APPLICABLE
a) Cigarettes
0
0
0
PRIOR TO
b) Cigars
0
0
0
ENTERING
c) Pipe Tobacco
0
0
0
NAVY
d) Chewing Tobacco
0
0
0
e) Snuff/Dip
0
0
0
7. 1-2
RECRUIT TRAINING
a) Cigarettes
0
0
0
MONTHS
b) Cigars
0
o
0
AFTER
c) Pipe Tobacco
0
0
0
ENTERING
d) Chewing Tobacco
0
0
0
(during
e) Snuff/Dip
0
0
0
training)
8. 3-4
0 Ship 0 Submarine
a) Cigarettes
0
0
0
MONTHS
0 Air Squadron 0 Shore
b) Cigars
0
0
0
AFTER
0 "A" School CONUS
c) Pipe Tobacco
0
0
0
ENTERING
0 Other School
d) Chewing Tobacco
0
0
0
NAVY
0 Shore-Overseas
e) Snuff/Dip
0
0
0
9. AT THE
0 Ship 0 Submarine
a) Cigarettes
0
0
o
PRESENT
0 Air Squadron 0 Shore
b) Cigars
o
o
0
TIME (5-6
O "A- School CONUS
c) Pipe Tobacco
0
0
0
months
0 Other School
d) Chewing Tobacco
0
0
0
after)
0 Shore-Overseas
e) Snuff/Dip
0
0
0
Iamoumt of tobacco products used I
10.When vai the moat recent time you
smoked a cigarette?
0 Never smoked a
cigarette
0 10 or more years
ago
0 6-9 years ago
0 3-5 years ago
0 1-2 years ago
0 7-11 months ago
0 4-6 months ago
0 2-3 months ago
0 During the past
30 days
0 Today
11.During the last 30 days, how many
cigarettes did you usually smoke on a
typical day when you smoked cigarettes?
0 Did not smoke any
cigarettes
0 Fewer than 1, on
the average
0 1-5 cigarettes
0 6-10 cigarettes
DURING THE LAST 5
O 11-15 cigarettes
0 16-20
O 20-25
0 26 or more
cigarettes
MONTHS...
12.On the average, how often did you use
chewing tobacco?
0 Never/Don't use it O Appx once/month
O Once or twice in the 0 2-3 days/month
last 5 months 0 1-2 days/ week
0 3-6 days in the 0 3-4 days a week
last 5 months 0 5-6 days a week
0 7-11 days in the O About every day
last 5 months
13.On the days you used chewing tobacco,
how many times per day did you use it?
ONA 0 2 04 06 08
01 03 05 07 0 9+
14.On the average,
snuff/dip?
O Never/Don’t use it
0 Once or twice in the
last 5 months
0 3-6 days in the
last 5 months
0 7-11 days in the
last 5 months
how often did you use
0 Appx once/month
O 2-3 days/month
01-2 days/week
0 3-4 days a week
0 5-6 days a week
0 About every day
15.On the days you used snuff/dip, how
many times per day did you use it?
0 NA O 2 04 06 08
01 03 05 07 0 9+
16.On the average, how often did you smoke
a pipe?
0 Never/Don't use them 0
0 Once or twice in the 0
last 5 months 0
0 3-6 days in the 0
last 5 months 0
0 7-11 days in the 0
last 5 months
Appx once/month
2-3 days/month
1-2 days/week
3-4 days a week
5-6 days a week
About every day
17.On the days you smoked a pipe, how
many pipefuls of tobacco did you smoke?
ONA 0 2 04 06 0 8
01 03 05 07 0 9+

128
18.On the average, how often did you
smoke cigare?
O Never/Don't use them O Appx once/month
0 Once or twice in the O 2-3 daye/month
last 5 months
0 3-6 days in the
last 5 months
0 7-11 days in the
last 5 months
19.On the days you
many did you smoke?
0 NA 0 2 0 4 O
0 1 0 3 0 5 0
0 1-2 days/week
0 3-4 days a week
0 5-6 days a week
0 About every day
smoked cigars, how
¡ 0 8
0 9+
IF YOU HAVE m|| USED AMY TOBACCO
PRODUCTS, PLEASE GO TO QUESTION #31
20.Below is a list of reasons people
give for STARTIEO to use CIGARETTES,
CIGARS, and/or PIPES, and CBEWIEO
TOBACCO, SEUPP, and/or DIP.
For each possible reason, mark SO or
YES for both the "CIGARETTES, CIGARS,
and/or PIPES* (C,C&/orP) column, and
the "CHEWING TOBACCO, SNUFF, and/or DIP"
(CT,S£/orD) column to indicate whether
it was a reason why you C,C CT,
started to use any of these & St
tobacco products after or or
recruit training. P D
a) I was bored
b) Most of my friends did
c) I wanted to be “cool"
d) I liked the image
e) I liked the taste
f) It gave me a kick
E
O
Y
E
S
0 o
o 0
o 0
0 o
0 0
o 0
E Y
O E
s
00
0 o
o o
o 0
0 0
0 0
g) I wanted to show that I
was tough
h) I wanted to take a dare
0 0
0 0
0 0
0 0
i)I wanted to lose weight
0 0
0 0
j)It calmed me
0 0
o o
k)I wanted to be masculine
0 0
o 0
l) I didn't want to feel
left out of a group
m) I wanted to show I
wasn’t afraid
0 0
0 0
0 0
0 0
E Y BY
n) Parents/friends back
home smoke/use smokeless
tobacco
o) I wanted to be able to
take a break
p) I had no desire to stay
tobacco-free after boot
camp
q) I was curious
r) Smokeless tobacco was
less noticeable to use in
"restricted" areas than
cigarettes
s) Smokeless tobacco was
less offensive to non-
smokers
0 0
0 O
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
RESTRICTIONS
21. Sow do you think that the smoke-free
policy at your recruit training command
influenced your tobacco use during the 3
months after leaving that command?
0 NA-I was not a tobacco user
0 It helped me STOP using tobacco
0 It helped me REDUCE my tobacco use
0 It did NOT CHANGE my tobacco use
0 It PROBABLY INCREASED my use when I left
22. How do you think the smoking education
classes offered at your recruit training
command influenced your tobacco use during
the 3 months after leaving that command?
0 NA-I was not a tobacco user
0 It helped me STOP using tobacco
0 It helped me REDUCE my tobacco use
0 It did NOT CHANGE my tobacco use
0 It PROBABLY INCREASED my use when I left
23. Do you think it is a good policy to
prohibit tobacco use during recruit
training?
0 No 0 Yes
24. a. Are there restrictions on tobacco
use in your current work
environment?
0 No 0 Yes
b. If YES, how often are these
restrictions enforced
0 Never O Sometimes 0 Always
0 Rarely O Usually
25. Are you in favor of a smoke-free work
environment?
0 No 0 Yes

129
26.How do you think that a smoke-free work
environment would (or does) influence your
tobacco use?
0 NA-I am not a tobacco user
0 It would help me STOP using tobacco
0 It would help me REDUCE my tobacco use
0 It would NOT CHANGE my tobacco use
0 It PROBABLY would INCREASE my tobacco use
ORIENTATIONS
36.Do you plan to make the Navy a career?
0 No 0 Yes
INTENTIONS
For questions 37-40 circle answer:
NA if Not Applicable
1 if No Chance At All
2 if Slight Chance
3 if Somewhat Likely
4 if Quite likely
5 if Extremely likely
27. Does it bother you when someone is
smoking around you?
0 No O Yes
28. When you are inside public areas that
have no rules about smoking and someone
lights up a cigarette, wnat are you most
likely to do?
0 Just do nothing
0 Move away from the
person
0 Ask the person not to
smoke
0 Something
else( specify) -* -*
Over the next year...
37. If you currently ssoke cigarettes,
cigars, or a pipe, how likely it is that you
will stop smoking?
NA I 2 3 4 5
38. If you currently use chewing tobacco,
snuff, or dip, how likely it is that you
will stop using these tobacco products?
NA 1 2 3 4 5
39. If you do not saoke cigarettes,
cigars, or a pipe now, how likely is it that
you will remain a non-smoker?
NA 1 2 3 4 5
29. Do you believe smoking...
No
Yes
a) is related to heart disease
0
0
b) is related to cancer
0
0
c) is related to emphysema
0
0
d) is addictive
0
0
30. Are you concerned about the
health effects of...
NO
Yes
a) Cigarettes
0
0
b) Cigars/Pipes
0
0
c) Chewing Tobacco
0
0
d) Snuff/Dip
0
0
31. How important is it to you to not use
tobacco products?
0 Not at all important 0 Very important
0 Somewhat important 0 Extremely
0 Moderately important important
32. what percent of the U. S. population do
you think currently smoke cigarettes?
0 20% 0 30% 0 40%
0 50% 0 60% 0 75%
33. What percent of all Navy members do you
think currently smoke cigarettes?
0.20% O 30% 0 40%
0 50% O 60% 0 75%
34. Should tobacco companies be allowed to
direct advertising toward certain groups in
order to recruit new customers?
O No O Yes
40. If you currently do not use chewing
tobacco, snuff, or dip now, how likely is it
that you will remain a non user?
NA 1 2 3 4 5
In the future, do you
N
Y
N
see yourself as...
o
e
8
A
41. Someone who smokes?
0
0
42. Someone who uses
smokeless tobacco
In the future are you
likely to be a non¬
user of tobacco...
0
0
43. Out of concern for
your health?
0
0
0
44. Because a medical
professional has told you
to quit?
0
0
0
45. Because of the cost of
tobacco products?
0
0
0
46. Because of social
pressures not to use
tobacco?
0
0
0
47. Because of hassles
related to smoking
restrictive areas?
0
0
0
48. Because few of your
peers/friends use tobacco?
0
0
0
35.Do you expect to complete a college
degree sometime in the future? THAHE-YOU VXIY MUCH FOE YOU»
O No O Yes COOPERA! I OH

APPENDIX D
HUMAN FACTORS COMMITTEE APPROVAL

UNIVERSITY OF FLORIDA
INSTITUTIONAL REVIEW BOARD
114 PSYCHOLOGY BUILDING
GAINESVILLE. FL 32611-2065
(904) - 392 - 0433
August 6, 1991
TO:
Mr. Thomas L. Pokorski
5 FLG
/
FROM:
C. Michael Levy, Chair, |_^vy
University of Florida Ins tonal
Review Board
SUBJECT: Approval of Project #91.241
The effect of an education intervention program on smoking
relapse for Navy recruits in a smoking restrictive environment
I am pleased to advise you that the University of Florida Institutional
Review Board has recommended the approval of this project. The Board
concluded that your subjects will not be placed at risk in this research.
Given your protocol it is essential that you obtain written informed consent
from each participant.
If you wish to make any changes in this protocol, you must disclose your
plans before you implement them so that the Board can assess their impact
on your project. In addition, you must report to the Board any unexpected
complications arising from the project which affect your subjects.
If you have not completed this project by August 6, 1992, please telephone
our office (392-0433) and we will tell you how to obtain a renewal.
By a copy of this memorandum, your Chair is reminded of the importance of
being fully informed about the status of all projects involving human subjects
in your department, and for reviewing these projects as often as necessary
to insure that each project is being conducted in the manner approved by this
memorandum.
CML/her
cc: Vice President for Research Unfunded
College Dean
R. Morgan Pigg
Dr. W. William Chen
illiam Chen
EQUAL EMPLOYMENT OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
131

APPENDIX E
CONSENT STATEMENT
You and several hundred other new members of the U.S. Navy have been
selected to participate in this survey. Originally designed by the
Naval Health Research Center to study tobacco use, we are using this
same survey as part of a trial at RTC Orlando to assess tobacco use
before and after "boot camp". Your participation in this study involves
completing the following survey, which should take about 30 minutes and
asks about tobacco use prior to your arrival at RTC. In addition we
will be administering two similar follow-up surveys: one at the end of
your current training and one in approximately five months.
Your participation is strictly voluntary. You do not have to answer any
question you do not wish to answer. Refusal to participate will involve
no penalty or loss of any benefits to which you are otherwise entitled.
All data collected from this survey will be kept at the University of
Florida or the Naval Health Research Center, and will be used for
research purposes only. Please answer questions honestly and to the
best of your ability. In order to assure privacy of your answers, the
personal identification information you provide will be destroyed after
the data is entered into a data base. A non-traceable serial number
will then be assigned to match data to your future survey responses.
In all cases, the data will be reported so that no individual
respondent can be identified. The information gathered will
not become part of your service record or medical record.
A random check of urine samples for the presence of nicotine will be
conducted as a check of accuracy of self-reporting. This is being done
only to satisfy a research procedure requirement and results will in no
way affect you. The urine sample you have already provided will be used
if needed.
By signing this consent form, you state that your participation is
voluntary, without force or duress of any kind. You also acknowledge
that you understand the purpose of this study and that you are free to
withdraw your consent at any time without prejudice to yourself or your
military or civilian career. Should questions arise, feel free to
contact LCDR T.L. Pokorski, University of Florida, Department of Health
Science Education, #5 FLG, Gainesville, FL 32611 / (904)372-7574.
Retain the top portion of this form after signing.
I have read and I understand the procedure described above. I agree to
participate in the recruit tobacco use study and have received a copy of
this description.
SIGNATURES:
Participant date Witness date
132

APPENDIX F
EDUCATION CURRICULUM
UNIVERSITY OF FLORIDA
DEPARTMENT OF HEALTH SCIENCE EDUCATION
#4 FLG
GAINESVILLE, FLORIDA 32611
TOPIC: Recruit Tobacco Prevention
INSTRUCTIONAL MATERIALS:
TRAINING AIDS:
1. Chalkboard/chalk/eraser
2• TV monitor/ Video projector
3. 1/2 inch VCR
4. 3/4 inch VCR
5. Video "Performance Edge"
6. Video "The Feminine Mistake"
7. Video "Clearing the Air"
SAVPEN # 803504DN
8. Tobacco training aids:
-consequences of smoking
-mechanical smoker
-passive smoke demo
-Mr. Grossmouth
9. Overhead/transparencies
TERMINAL OBJECTIVE:
1. Upon completion of this lecture the student will be able to
recall the main benefits of not using tobacco after recruit training,
with 90% accuracy.
ENABLING OBJECTIVES:
1. The student will be able to:
a. give the true side of the smoking myths discussed
b. describe the RTC smoking policy and the overall Navy
stance on tobacco use
c. describe the short and long term effects of tobacco use
d. describe common reasons for starting and continuing to
smoke cigarettes, and use other tobacco products
e. describe strategies to remain tobacco-free after RTC
graduation.
CRITERION TEST: PREPARED BY: DATE:
1. None LCDR T.L. POKORSKI 23AUG91
133

134
INTRODUCTION (10 minutes)
For the next 3 periods we will discuss cigarette smoking, and the use
of other tobacco products. We will examine:
-Navy tobacco use policies
-Some myths about tobacco use
-What happens to the body when you smoke
-Why people decide either to start smoking or choose not to smoke
-The benefits of not starting/returning to smoking after RTC
graduation
During each period we will cover a few topics, look at a videotape, do
some demonstrations, and discuss the material.
-I'd prefer if you save most of your questions for the discussion
period unless you have one you feel can’t wait
-I've got some displays that I'd like everyone to look at during one
of the breaks
The first video stresses teamwork (something the Navy stresses on,
as well as off, the job) and how the effects of tobacco and alcohol can
affect the performance of individuals, thus affecting the team. It is
set in a High School football setting but the message is the same for
each of you working as part of the Navy team.
*** SHOW VIDEO "PERFORMANCE EDGE" *** (7 min.)
(23 minutes)
-So you see that ETOH and nicotine can affect your performance
-You have committed to being a part of a very important team in the
Navy
-If too many team members’ performance is hampered in football you
may lose a game.
-But if too many team members performance is hampered in many Navy
tasks - a life may be lost.

135
-The Navy is full of complicated jobs, jobs which many of you will
be expected to perform before long.
No matter what your chosen rating - you will be working on most jobs as
a team. Whether it be painting the hull of a ship or preparing a
multimillion dollar jet aircraft for flight - every team member is
counted on to perform to his/her best ability. You'll start by doing
what you think are trivial tasks but will quickly work up to where you
are supervising the whole task. This is why you will hear so many
messages about maintaining top performance. Anything that affects the
performance of one person can affect many others in a military
environment.
Smoking Myths
ASK How many smokers in the Navy
How many smokers in the general U.S. population
WRITE correct numbers on board
NAVY 43%
U. S.28%
1. Harmful effects of smoking are exaggerated?
How many deaths per year are related to smoking?
500,000/yr
- if you all were smokers ( 1 murdered, 2 traffic accidents, 25
smoking related diseases) WRITE on board (double for 2
companies)
What is the biggest cause of these excess deaths?
#1 (50%) Heart disease - drug effect of nicotine on circulatory system
#2 Lung cancer
#3 Other cancers (trachea, bladder, mouth, throat, esophagus)
Smokeless
#4
Emphysema, bronchitis

136
2. Polluted air is just as bad as smoking
No. Although it is hazardous to breathe, it is no where as concentrated
as cigarette smoke - 1200 toxic chemicals have been identified as
product of tobacco smoke. Air pollution is controlled much tighter than
cigarette smoking.
3. Cigarette smoking makes one glamorous?
ASK How many non-smokers would not date a smoker?
4. No reason to worry what will happen to your body as it takes
several years for any harm to occur?
- True, that cancer does not occur overnight but your body is harmed
with cigarettes( eg. Smoker's cough develops pretty quick)
- other short-term problems seen in video later.
shortness of breath, increased heart rate, bad breath, smelly
clothes
5. Cigarettes relax a person?
-Nicotine is a stimulant, increases heart rate and blood pressure
-Relaxing effect mostly comes from addiction process
-Nicotine withdrawal symptoms can occur within hours of the last
cigarette and smoking the next cigarette is a way of relieving the
symptoms
6. Once you start you can't kick the habit?
-It is very hard to do but millions of people are successful each
year.
-At graduation, all smokers will have quit for 8 weeks- a
tremendous accomplishment
- At graduation you need to make the choice whether it is
beneficial to start again.
-Boot Camp may be the easiest place to quit because the option
to start is removed for eight weeks. People pay good money to be
placed in treatment programs like a boot camp environment.

137
7. Passive Smoking does not harm anyone
-can be harmful being around others who smoke
-non smokers married to smokers have a 30% greater risk of
developing lung cancer.
-Cigarette smoke is an irritant and causes discomfort for most non-
smokers .
-It deceases the performance of others around the smoker.
PASSIVE SMOKE DEMO & MECHANICAL LUNG DEMO
For this reason, many policies are in effect which protect non-smokers
health:
-Smoking is now banned in many public places and each year more
policies are instituted which further restrict where smoking is
permitted.
"When I smoke I feel like an outcast"... PFA participant
The Navy is also banning smoking from many areas. Currently tobacco use
is banned:
-In auditoriums, conference rooms, classrooms, and libraries
-Elevators
-Official buses, vans and shuttle vehicles
-Gymnasiums, child care centers and youth centers
Other policies are implemented by the local commanding officers and may
include banning smoking in:
-Work spaces
-Berthing areas
-Messing areas
In the future, entire commands may be designated as no smoking areas
- as have all Navy RTC' s
- Explain RTC policy
Why does the Navy do this?
-Not anti-smoker but anti-smoke (Official Navy position)

138
-To provide a work environment that is safe and pleasant to work in
for all workers
-To encourage the work force to become smoke free thus increasing
performance of all
The Navy is not trying to force anyone to quit smoking
- "We want a positively motivated force that chooses not to smoke"
Quote from VADM Zimble former Navy Surgeon General
Next period we will see a video that discusses the effects on your body
when you smoke a cigarette. Many of the ill effects we have discussed
thus far are long term effects. It is true that many of these
effects take years of smoking to develop. At your age it may be hard to
relate to some of the long term effects (heart disease, cancer,
emphysema, etc.) unless a friend or parent had them. I'd like to
discuss some of the short term effects of smoking and use of other
tobacco products, as these things affect almost everyone who uses
tobacco. I'll touch briefly only on 4 areas:
-Tar
-Gases from smoke
-Carbon monoxide
-Nicotine
Breathing cycle
-oxygen is needed for body functioning
-carbon dioxide, a byproduct, is expelled
Cigarette smoking interferes with this process
-carbon monoxide prevents the red blood cells from carrying
oxygen (the more cigarettes are smoked, the greater the problem)
-CO is what kills people who commit suicide by running a automobile
in a closed garage

139
-regular smokers have a CO concentration in their blood streams
2-3 times higher than the EPA protection level
-as CO concentration rises above this safe level mental capacity d
rops, judgement is decreased, and the overall performance of a
person drops
Other toxic gases are present in smoke that can also have detrimental
effects
-one example is hydrogen cyanide (gas chamber gas)— although not
found in smoke in lethal doses, the concentration is much higher
than levels considered safe for long term exposure
-other gases immobilize the hairlike cells in air passages that
help clear foreign particles. Failure to remove these particles
from the lung results in "smokers cough"
Particles suspended in smoke can irritate the eyes and nasal passages,
and trigger allergic reactions
-these small particles (aka Tar) can cause many other problems (eg.
cancer)
-normally the body defenses can cleanse small particles from the air
we breathe, but when overloaded by regular smoking these mechanisms
can't keep up and the tar is deposited on respiratory tract cells
causing irritation and possibly cancer in the long run.
(1 pack a day—1 quart of tar per year
Nicotine is the last item we will discuss here
-it is the primary drug found in tobacco and is classified as a
central nervous system stimulant
-in smokers it is absorbed through the lungs and gets to the brain
within 8 seconds after inhalation
-with smokeless tobacco, nicotine is absorbed through the lining of
the mouth
-nicotine increases heart rate and blood pressure
-nicotine is also thought to cause the physical and psychological
addiction to tobacco products that is seen in most users - this

140
addiction is part of the reason it is so hard to stop using tobacco
after regular use
Smoking can cause short term problems other than just to the smoker
themselves
-passive smoke (that smoke expelled to the air around the smoker)
cause eye, nose, and lung irritation to those around the smoker, and
can cause some headaches, nausea, and dizziness
-lung cancer risks for non-smoking spouse of smokers has been
shown to be increased by 30%
-non-smokers exposed to 20 cigarettes or more per day at home or
work, have their lung cancer risk doubled
-children of smokers have higher incidence rates of colds,
bronchitis, chronic coughs, ear infections, and reduced hearing
function
-babies born to smoking mothers have a greater chance of being born
prematurely - too small and too soon - nicotine, CO, and other
chemicals are passed from mother to the baby's bloodstream
-tar from cigarette smoke has been found to damage sensitive
equipment and clog air filtration systems in aircraft and other v
essels
These type of reasons have driven the Navy to set the no-smoking
policies that have been instituted
-to protect non-smokers by providing a healthy work area
-to protect sensitive/expensive equipment
-create a healthy work environment, and encourage smokers to make
the decision to quit
Again, the Navy is not anti-smoker, but rather anti-smoke
Short term problems for smokeless tobacco users include bad breath,
discolored teeth, gum recession, and tooth destruction
-can also contribute to increased risk of cardiovascular disease,
especially in individuals with high blood pressure
MENTION MR GROSSMOUTH

141
During the break I'd like you to discuss among yourselves why you
started smoking or why you did not start. I'll ask a few of you
to report your discussions after the break. There are some displays up
here that I'd like you to see during this break or the next one.
*** 10 MINUTE BREAK ****
(7 minutes)
ASK FOR INPUT ON REASONS FOR STARTING TO SMOKE
WRITE THE ONES GIVEN ON THE BOARD THEN COMPLETE LIST BELOW:
-bored
-friends did
-to be cool
-liked the image (advertising > $ 1 billion per year spent)
-liked the taste
-gave me a kick
-wanted to show I was tough
-wanted to take a dare
-it calmed me
-wanted to lose weight
-to look and feel like an adult
-wanted to be masculine
-didn't want to be left out of a group
-to show I wasn't afraid
-parents smoked
-curiosity
ASK FOR INPUT FOR REASONS FOR NOT STARTING SMOKING
WRITE THE ONES GIVEN ON THE BOARD THEN COMPLETE LIST BELOW
-health
-parent/relative smoked and had smoking related disease
-tried but hated the taste/feeling
-did not like the smell on clothes
-parents/teachers influence

142
-social pressures not to use tobacco
-hassles related to smoking-resticted areas
-few friends/peers use tobacco
-cost (figure cost for pack a day smoker for year
$1.79 x 365 days = $653.35 Discuss PX pricing policy)
The next video I’m going to show is entitled "The Feminine Mistake".
Although the film is directed toward females, most of the information is
applicable to anyone who smokes. Except for the pregnancy part, the
physiology changes described can happen in both sexes. Pay particular
attention to the physiological changes that occur with smoking and to
effects shown.
*** SHOW "FEMININE MISTAKE" *** (24 minutes)
Any questions on the video
Quitting smoking (9 minutes)
-Quitting cigarettes or other tobacco products is very difficult
and becomes more difficult the longer a person uses them
The most important part of a successful quit attempt making the
commitment to quit and deciding to quit for yourself, as
opposed to quitting to please someone else or to conform to a policy
-those of you who made a conscious decision to quit before you
entered the Navy will be more committed to stay quit after
graduation
-those who have never used tobacco will have a very strong
motivation to remain tobacco free
-but those who were regular tobacco users prior to entry need to
make a commitment now, if you wish to remain tobacco after
graduation. Yes you have quit, and by the time you graduate you
will have made it through what is typically the most trying time for
those who try to stop.

143
Cigarette smoking and other tobacco use can become addicting. It is
physically addicting because of the drug nicotine, and psychologically
addicting because it has become part of the lifestyle of the tobacco
user. We discussed some reasons people start using tobacco, but let us
now discuss some reasons they continue to use, as these reasons are
different and often need to be overcome to successfully quit:
-to cope with stresses (phone, car, work, etc.)
-to calm them (relief from nicotine withdrawal)
-to help concentrate on a task
-as a reward for accomplishing things
-increasing enjoyment of other things
-addicted to nicotine - many long time smokers say they would like
to quit smoking but feel they are addicted and just don’t believe
they can do it
The key to changing any health behavior is first believing you can
do it. If you used tobacco products before entry, and thought you could
never quit, you now know you can as you've been tobacco-free for over 2
weeks and by the time you graduate you will indeed accomplished
something, that for most people, is very difficult, something millions
of Americans wish the could accomplish; stopping smoking or other
tobacco use.
During the next break I'd like you to discuss your feelings about
having quit tobacco products. If you never used tobacco, lend an ear
and share ways that you have used to stay tobacco-free. All of you
should discuss strategies that can be used after graduation, when you
enter the general Navy population of 40% smokers, to not be
influenced to start using tobacco.
*** 10 MINUTE BREAK ***
ASK ABOUT FEELINGS OF QUITTING (10 minutes)
List strategies to stay quit
-what strategies do you think will work?

144
-do any of the reasons you for why you started seem like valid
reasons to start again after graduation???
-remember your accomplishment of quitting or the dangers of
starting
-remember that if you start again you may find yourself at a later
time wanting or having to quit without the help of being in an
environment like RTC
The next video was produced by the Navy and is entitled "Clearing the
Air"
-It follows a petty officer as he makes the decision to quit
-It discusses many things we have already touched on
-Look for tobacco avoidance strategies in the movie that you
can use after graduation
*** SHOW "CLEARING THE AIR" *** (21 minutes)
QUESTIONS ABOUT THE MOVIE?
WRAP UP (9 minutes)
We've discussed a lot of things about tobacco use.
We've used 3 full periods - the Navy has allowed this time because
smoking is one of the most preventable of all health problems.
The Navy is concerned about the many diseases associated with smoking
and other tobacco use, and is anxious to see the health and
readiness of its members rise as more and more people make the
decision quit smoking or remain tobacco-free. In fact the Navy has set
a goal of being "Smoke-free by the year 2000". To reach this goal
policies will be instituted to restrict tobacco use from more and more
places. I don't think we will see a ban on tobacco products totally, as
tobacco is a legal drug, but more and more tobacco prevention (like this
one) and cessation programs will be made available to help Navy members
make the decision to stop.

145
We've discussed the fact that stopping smoking, or the use of any
tobacco product, is not easy. For the Navy to reach its year 2000 goal,
a total team effort will be required.
-A commitment on the part of smokers is needed.
-A commitment on the part of non-smokers is also needed to
encourage and help smokers to stop. This is particularly true for ex¬
smokers, as they can have a great influence on current smokers, as we
saw in the last video.
Successful quitting requires a great deal of support, but that is what
the "Navy family” is all about. You all entered the Navy with the
expectation of bettering yourself in one way or another. RTC
graduation will mark a great accomplishment for all of you. You
will have bested many mental and physical challenges. You will have
done so by yourselves, without the support of parents, without the
crutch of tobacco, alcohol, or any other drugs you may have used in
the past. You will have drawn on the support of your fellow
company members for any assistance needed.
When you graduate, recognize your achievements, congratulate
yourself, and make the commitment to become a strong member of the
Navy team. Those who smoke have accomplished something else that will
affect your lives. You have control over your life. Make the
choices that are right for you. Don't let others pressure you into
unhealthy habits. Remember the benefits of remaining tobacco-free and
incorporate what you have learned here today into a commitment to
health for the rest of your life.
QUESTIONS
*** REMIND ABOUT THE FOLLOW-UP SURVEY ***

APPENDIX G
SHAM TREATMENT CURRICULUM
UNIVERSITY OF FLORIDA
DEPARTMENT OF HEALTH SCIENCE EDUCATION
#4 FLG
GAINESVILLE, FLORIDA 32611
TOPIC: Recruit Tobacco Prevention
"Sham treatment class"
TIME: 40 minutes
INSTRUCTIONAL MATERIALS:
TRAINING AIDS:
1. Chalkboard/chalk/eraser
2. TV monitor/ Video projector
3. 3/4 inch VCR
4. Video "Weight and Fat Control / Nutrition Education"
SAVPEN # 803507DN
TERMINAL OBJECTIVE:
1. Upon completion of this lecture the student will feel that
they are part of an ongoing program of tobacco prevention in the Navy.
ENABLING OBJECTIVES:
1. The student will be able to:
a.discuss reasons why the Navy is concerned about tobacco
use
b.describe the association of cigarettes and heart disease
CRITERION TEST:
1. None
PREPARED BY:
LCDR T.L. POKORSKI
DATE
22SEP91
146

147
INTRODUCTION (10 min)
Introduce yourself
Remind them about tobacco use survey from previous week
"Your company is part of a trial program to help improve your
health after graduation and we believe this program will help you
remain tobacco free after boot camp."
Explain Navy's concern about its members use of tobacco products
- hence RTC no-smoking policy
- hence the Navy's overall goal of having a healthy work-force
Explain that as they progress through training they will have other
classes that will discuss tobacco use and other ways to improve health
Tie in Video to smoking
-Describe video
-made by Navy
-discusses weight control and effect of being overfat on
risk of heart disease
-tobacco use has also been found to contribute to increasing the
risk of heart disease
-pay attention to things in the movie that you can do when you
leave boot camp, that can decrease your risk of heart disease
SHOW VIDEO (24 minutes)
Any questions on the video?
Wrap up (6 minutes)
-use all the things you learn at RTC to help you make healthy
decisions that will affect the rest of you life
-the Navy is very concerned about maintaining a healthy,
productive workforce
-in light of recent budget cuts—the Navy needs everyone to be
able to perform at peak potential
-we want you to make healthy choices with respect to tobacco,
alcohol, nutrition, and exercise
-we can't force you to be healthy—only you can make a commitment
to health!

APPENDIX H
QUIT SMOKING WALLET CARD
Front Side
Reasons to Remain Tobacco-Free
1. COST - 1 pack/day = between $700-$1,000 per year
2. HEALTH - over 1,000 people will die today from
smoking related diseases
3. SOCIAL - smokers are the minority—most people do
not want to be around tobacco smoke
4. SMELL - so my clothes don't constantly smell of
smoke
5. Add your own top reason here:
Back Side
Ways to Avoid Smoking
1. Remember your reasons to stay tobacco-free
2. Four D's
Delay
Deep breathing
Drink water
Do something else
3. Avoid smokers, and situations or places, you know
will tempt you to smoke
4. Exercise—Recall how much better you feel now while
exercising
5. Help others try to quit
148

APPENDIX I
CERTIFICATE OF PARTICIPATION

^rlific<5/e
Participation
This certifies that the below named Individual has participated in a four hour Tobacco Use
Prevention program while at the Recruit Training Center, Orlando, Florida.
This program has been presented In conlunction with the American Cancer Society and the
University Of Florida
AMERICAN
V CANCER
? SOCIETY*
I pledge to assist the Navy, In whatever way I can. In
reaching its goal of being "Smoke-Free, by the year 2000"
Witnessed: LCDR T.L. Pokorskl, KSC. USN
Program Director
Date
Date
Congratulations on making the commitment to Improve your health In every way possible.
K. M. BRUYERE
CAPTAIN, U.S. NAVY
COMMANDING OFFICER
150

LIST OF REFERENCES
Aday, L. A. (1989). Designing and constructing health
surveys. San Francisco: Josey-Bass.
Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and
predicting social behavior. Englewood Cliffs, NJ:
Prentice-Hall.
Ballweg, J. A., & Bray, R. M. (1989). Smoking and tobacco use
by U.S. military personnel. Military Medicine. 154. 165-
168.
Bandura, A. (1989). Human agency in social cognitive theory.
American Psychologist. September. 1175-1184.
Banspach, S. W., Lefebvre, R. G., & Carleton, R. A. (1989).
Increasing awareness of the pressures related to
smoking: An analysis of two models of anti-smoking
curriculum in the classroom. Health Education Research.
4, 69-78.
Blake, S. M., Knut-Inge, K., Pechacek, T. F., Folsom, A. R.,
Luepker, R. V., Jacobs, D. R., & Mittelmark, M. B.
(1989). Differences in smoking cessation strategies
between men and women. Addictive Behaviors. 14. 409-418.
Brandon, T. H., Tiffany, S. T., Obremski, K. M., & Baker, T.
B. (1990). Postcessation cigarette use: The process of
relapse. Addictive Behaviors. 15. 105-114.
Bray, R. M., Marsden, M. E., Guess, L. L., & Herbold, J. R.
(1989). Prevalence, trends, and correlates of alcohol
use, nonmedical drug use, and tobacco use among U.S.
military personnel. Military Medicine. 154. 1-11.
151

152
Bray, R. M., Marsden, M. E., Guess, L. L., Wheeless, S. C.,
Iannacchione, V. G., & Keesling, S. R. (1988). 1988
worldwide survey of substance abuse and health behaviors
among military personnel (Report No. RTT/4000/06-02FR).
Research Triangle Park, NC: Research Triangle Institute.
Bray, R. M., Marsden, M. E., & Peterson, M. R. (1991).
Standardized comparisons of the use of alcohol, drugs,
and cigarettes among military personnel and civilians.
American Journal of Public Health. 81. 865-869.
Brink, S. G., Simons-Morton, D. G., Harvey, C. M., Parcel, G.
S., & Tiernan, K. M. (1988). Developing comprehensive
smoking control programs in schools. Journal of School
Health. 58, 177-180.
Brownell, K. D., Glynn, T. J., Glasgow, R., Lando, H., Rand,
C., Gottlieb, A., & Pinney, J. M. (1986). Task force 5:
Interventions to prevent relapse. Health Psychology. 5
(Suppl.), 53-68.
Carmody, T. P. (1990). Preventing relapse in the treatment of
nicotine addiction: Current issues and future
directions. Journal of Psvchoactive Drugs. 22, 211-238.
Carroll, D. A., Lednar, W., & Carter, W. B. (1989). The short
term impact of Army smoking policies. Military Medicine.
154. 603-607.
Centers for Disease Control. (1991a). Cigarette smoking and
youth-United States, 1989. Morbidity and Mortality
Weekly Report. 40, 712-715.
Centers for Disease Control. (1991b). Smoking-attributable
mortality and years of life lost—United States, 1988.
Morbidity and Mortality Weekly Report, 40, 62-63; 69-71.
Chief of Naval Technical Training. (1991a). Recruit training
syllabus; Lesson topic 2.22 & 3.10B. Millington, TN:
U.S. Navy.
Chief of Naval Technical Training. (1991b). [Statistical
averages for U.S. Navy recruits]. Unpublished raw data.

153
Conway, T. L., & Cronan, T. A. (1988). Smoking and physical
fitness among Navy shipboard personnel. Military
Medicine, 153. 589-94.
Cronan, T. A., & Conway, T. L. (1988). Is the Navy attracting
or creating smokers? Military Medicine. 153. 175-178.
Cronan, T. A., Conway, T. L., & Hervig, L. (1989). Evaluation
of smoking intervention in recruit training. Military
Medicine. 154, 371-375.
Curry, S., Marlatt, G. A., & Gordon, J. R. (1987). Abstinence
violation effect: Validation of an attributional
construct with smoking cessation. Journal of Consulting
and Clinical Psychology, 55. 145-149.
Curry, S., Marlatt, G. A., Gordon, J., & Baer, J. S. (1988).
A comparison of alternative theoretical approaches to
smoking cessation and relapse. Health Psychology. 7,
545-556.
Epstein, L. H., Grunberg, N. E., Lichtenstein, E., & Evans,
R. I. (1989). Smoking research: Basic research,
intervention, prevention, and new trends. Health
Psychology, 8, 705-721.
Ershler, J., Leventhal, H., Fleming, R., & Glynn, K. (1989).
The quitting experience for smokers in sixth through
twelfth grades. Addictive Behaviors. 14, 365-378.
Evans, R. I., Hansen, W. B., & Mittelmark, M. B. (1977).
Increasing the validity of self-reports of smoking
behavior in children. Journal of Applied Psychology, 62
521-523.
Fagerstrom, K. 0. (1978). Measuring degree of physical
dependence to tobacco smoking with reference to
individualization of treatment. Addictive Behaviors.
235-241.
1,

154
Ferrence, R. G. (1989). Deadly fashion: The rise and fall of
cigarette smoking in North America. New York: Garland.
Fielding, J. E. (1986). Smoking: Health effects and control.
(Educational Publication 86-50M-NO. 3406-PE). New York:
American Cancer Society.
Fingerhut, M. A., Kleinman, J. C., & Kendrick, J. S. (1990).
Smoking before, during, and after pregnancy. American
Journal of Public Health. 80, 541-544.
Fitzpatrick, J. (1991). Urinary cotinine. CCN, January. 11-
17.
Flay, B. R. (1985). Psychosocial approaches to smoking
prevention: A review of findings. Health Psychology. 4,
449-488.
Foley, P., & Rucker, L. S. (1989). An overview of the Armed
Services Vocational Aptitude Battery (ASVAB). In R. F.
Dillon, & J. F. Pellegrino (Eds.), Testing: Theoretical
and applied perspectives (pp. 17-35). New York: Praeger.
Gardner, L. I. Jr (1991). Substance abuse in military
personnel: Better or worse? American Journal of Public
Health. 81, 837-838.
Gibbons, F. X., McGovern, P. G., & Lando, H. A. (1991).
Relapse and risk perception among members of a smoking
cessation clinic. Health Psychology. 10. 42-45.
Girdano, D. A., & Dusek, D. E. (1988). Drug education:
Content and methods (4th ed.). New York: Random House.
Glanz, K., Lewis, F. M., & Rimer, B. K. (1990). The scope of
health education: Parameters of a maturing field. In K.
Glanz, F. M. Lewis, & B. K. Rimer (Eds.), Health
behavior and health education (pp. 3-16). San Francisco:
Josey-Bass.

155
Glasgow, R. E., & Lichtenstein, E. (1987). Long-term effects
of behavioral smoking cessation interventions. Behavior
Therapy, 18, 297-324.
Glynn, T. J. (1989). Essential elements of school-based
smoking prevention programs. Journal of School Health.
59, 181-188.
Glynn, T. J. (1990). School programs to prevent smoking: The
National Cancer Institute guide to strategies that
succeed (NIH Publication No. 90-500). Washington, DC:
U.S. Government Printing Office.
Glynn, T. J., Boyd, G. M., & Gruman, J. C. (1991). Self-
guided strategies for smoking cessation (NIH Publication
No. 91-3104). Washington, DC: U.S. Government Printing
Office.
Gritz, E. R., Carr, C. R., & Marcus, A. C. (1991). The
tobacco withdrawal syndrome in unaided quitters. British
Journal of Addictions. 86, 57-69.
Grochmal, D. (1990). [Tobacco use prevalence among Navy
recruits: Recruit Training Center, Orlando], Unpublished
raw data.
Haley, N. J., Axelrad, C. M., & Tilton, K. A. (1983).
Validation of self-reported smoking behavior:
Biochemical analyses of cotinine and thiocyanate.
American Journal of Public Health. 73, 1204-1207.
Haley, N. J., Colosimo, S. G., Axelrad, C. M., Harris, R., &
Sepkovic, D. W. (1989). Biochemical validation of self-
reported exposure to environmental tobacco smoke.
Environmental Research. 49, 127-135.
Horn, D. (1979). Psychological analysis of establishment and
maintenance of the smoking habit. In N. A. Krasnegor
(Ed.), Cigarette smoking as a dependent process. NIDA
Monograph No. 23. (DHEW Publication No. ADM 79-800).
Washington, DC: U.S. Government Printing Office.

156
Hughes, J. R., & Hatsukami, D. K. (1986). Signs and symptoms
of tobacco withdrawal. Archives of General Psychiatry.
43, 289-294.
Jarvik, M. E., & Hatsukami, D. K. (1989). Tobacco dependence.
In T. Ney & A. Gale (Eds.), Smoking and human behavior
(pp. 57-68). Chichester, England: John Wiley & Sons.
Jarvis, M. J., Tunstall-Pedoe, H., Feyerabend, C., Vesey, C.,
& Saloojee, Y. (1987). Comparison of tests used to
distinguish smokers from nonsmokers. American Journal of
Public Health. 77. 1435-1438.
Johnston, L. D., O'Malley, P. M., & Bachman, J. G. (1989).
Drug use among high school seniors, college students.
and young adults (DHHS Publication No. ADM 89-1638).
Washington, DC: U.S. Government Printing Office.
Johnston, L. D., O'Malley, P. M., & Bachman, J. G. (1991).
Drug use among high school seniors, college students,
and young adults (DHHS Publication No. ADM 91-1835).
Washington, DC: U.S. Government Printing Office.
Kottke, T. E., Battista, R. N., DeFriese, G. H., & Brekke, M.
L. (1988). Attributes of successful smoking cessation
interventions in medical practice. Journal of the
American Medical Association. 259, 2883-2889.
Langone, J. J., Cook, G., Bjercke, R. J., & Lifschitz, M. H.
(1988). Monoclonal antibody ELISA for cotinine in saliva
and urine of active and passive smokers. Journal of
Immunological Methods. 114. 73-78.
Lee, P. N. (1987). Lung cancer and passive smoking:
Association an artifact due to misclassification of
smoking habits? Toxicology Letters. 35, 517-524.
Leventhal, H., Baker, T., Brandon, T., & Fleming, R. (1989).
Intervening and preventing cigarette smoking. In T. Ney
& A. Gale (Eds.), Smoking and human behavior (pp. 313-
336). Chichester, England: John Wiley & Sons.

157
Marlatt, G. A., Curry, S., & Gordon, J. R. (1988). A
longitudinal analysis of unaided smoking cessation.
Journal of Consulting and Clinical Psychology, 46, 703-
712.
Marsden, M. E., Bray, R. M., & Herbold, J. M. (1988).
Substance use and health among U.S. military personnel:
Findings from the 1985 worldwide survey. Preventive
Medicine. 17. 366-376.
Mazur, J. E. (1986). Learning and behavior. Englewood Cliffs
NJ: Prentice-Hall.
McBeth, K. (1989, October). Tobacco enters the twilight zone
Military Market, pp. 68-74.
McBride, C. M., & Pirie, P. (1990). Postpartum smoking
relapse. Addictive Behaviors. 15, 165-168.
Mullen, P. D., Quinn, V. P., & Ershoff, D. H. (1990).
Maintenance of nonsmoking postpartum by women who
stopped smoking during pregnancy. American Journal of
Public Health. 80. 992-994.
Murray, D. M., O'Connell, C. M., Schmid, L. A., & Perry, C.
L. (1987). The validity of smoking self-reports by
adolescents: A reexamination of the bogus pipeline
procedure. Addictive Behaviors. 12. 7-15.
Nelson, S. S. (1991, June 17). Desert Storm suggested a
retreat from anti-smoking campaign. Navy Times, p. 16.
Nelson, S. S., & Roth, M. (1991, June 17). Butting out:
Smoking rates fall but DoD sending mixed messages. Navy
Times. pp. 14-15.
O'Connell, K. A. (1990). Smoking cessation: Research on
relapse crises. Annual Review of Nursing Research, 8,
83-100.

158
Pentz, M. A., Brannon, B. R., Charlin, V. L., Barrett, E. J.,
MacKinnon, D. P., & Flay, B. R. (1989). The power of
policy: The relationship of smoking policy to adolescent
smoking. American Journal of Public Health. 79, 857-862.
Perry, C. L., Baranowski, T., & Parcel, G. S. (1990). How
individuals, environments, and health behavior interact:
Social Learning Theory. In K. Glanz, F. M. Lewis, & B.
K. Rimer (Eds.), Health behavior and health education
(pp. 161-186). San Francisco: Josey-Bass.
Petersen, L. R., Helgerson, S. D., Gibbons, C. M., Calhoun,
C. R., Ciacco, K. H., & Pitchford, K. C. (1988).
Employee smoking behavior change and attitudes following
a restrictive policy on worksite smoking in a large
company. Public Health Reports. 103. 115-120.
Prochaska, J. 0., & DiClemente, C. C. (1982).
Transtheoretical therapy: Toward a more integrative
model of change. Psychotherapy: Theory, Research, and
Practice. 19. 276-288.
Prochaska, J. 0., & DiClemente, C. C. (1983). Stages and
processes of self-change of smoking: Toward an
integrative model of change. Journal of Consulting and
Clinical Psychology. 51. 390-395.
Prochaska, J. 0., & DiClemente, C. C. (1984). The
transtheoretical approach: Crossing traditional
boundaries of therapy. Pacific Grove, CA: Brooks/Cole.
Rimer, B. K. (1990). Perspectives on interpersonal theories
in health education and health behavior. In K. Glanz, F.
M. Lewis, & B. K. Rimer (Eds.), Health behavior and
health education (pp. 140-158). San Francisco: Josey-
Bass.
Rosenstock, I. M. (1990). The Health Belief model: Explaining
health behavior through expectancies. In K. Glanz, F. M.
Lewis, & B. K. Rimer (Eds.), Health behavior and health
education (pp. 39-62). San Francisco: Josey-Bass.
Scali, W. K. (1989). A submarine shipboard smoking cessation
program. Military Medicine. 154. 551-552.

159
Schwartz, J. L. (1987). Review and evaluation of smoking
cessation methods: The United States and Canada. 1978-
1985 (NIH Publication No. 87-2940). Washington, DC: U.S.
Government Printing Office.
Sepkovic, D. W., & Haley, N. (1985). Biomedical applications
of cotinine quantitation in smoking related research.
American Journal of Public Health. 75, 663-665.
Shiffman, S., Read, L., Maltese, J., Rapkin, D., & Jarvik, M.
E. (1985). Preventing relapse in ex-smokers: A self¬
management approach. In G. A. Marlatt & J. R. Gordon
(Eds.), Relapse prevention (pp. 472-520). New York:
Guilford Press.
Shiffman, S., Shumaker, S. A., Abrams, D. B., Cohen, S.,
Garvey, A., Grunberg, N. E., & Swan, G. E. (1986). Task
force 2: Models of smoking relapse. Health Psychology. 5
(Suppl.), 13-27.
Skarping, G., Willers, F., & Dalene, M. (1988). Determination
of cotinine in urine using glass capillary gas
chromatography and selective detection, with special
reference to the biological monitoring of passive
smoking. Journal of Chromatography. 454, 293-301.
Stevens, V. J., & Hollis, J. F. (1989). Preventing smoking
relapse, using an individually tailored skills-training
technique. Journal of Consulting and Clinical
Psychology. 57, 420-424.
Steigman, D. S. (1992, April 13). Cheap smokes: Exchange
policy fuels habit. Navy Times. p. 6.
Sutton, S. (1989). Smoking attitudes and behavior:
Applications of Fishbein and Ajzen's Theory of Reasoned
Action to predicting and understanding smoking
decisions. In T. Ney & A. Gale (Eds.), Smoking and
human behavior (pp. 289-312). Chichester, England: John
Wiley & Sons.

160
Swan, A. V. (1991). Smoking behavior from pre adolescence to
young adulthood. Aldershot, England: Glover House.
Thompson, S. G., Stone, R., Nanchahal, K., & Wald, N. J.
(1990). Relation of urinary cotinine concentrations to
cigarette smoking and to exposure to other people's
smoke. Thorax. 45, 356-361.
Tuakli, N., Smith, M. A., & Heaton, C. (1990). Smoking in
adolescence: Methods for health education and smoking
cessation. The Journal of Family Practice. 31. 369-374.
U.S. Department of Health and Human Services. (1986). The
health conseguences of involuntary smoking. A report of
the Surgeon General (DHHS Publication No. CDC 87-8398).
Washington, DC: U.S. Government Printing Office.
U.S. Department of Health and Human Services. (1987).
Smoking, tobacco, and health: A fact book (DHHS
Publication No. CDC 87-8397). Washington, DC: U.S.
Government Printing Office.
U.S. Department of Health and Human Services. (1988). The
health conseguences of smoking: Nicotine addiction. A
report of the Surgeon General (DHHS Publication No. CDC
88-8406). Washington, DC: U.S. Government Printing
Office.
U.S. Department of Health and Human Services. (1989).
Reducing the health conseguences of smoking: 25 years of
progress. A report of the Surgeon General (DHHS
Publication No. CDC 89-8411). Washington, DC: U.S.
Government Printing Office.
U.S. Department of Health and Human Services. (1990a). The
health benefits of smoking cessation. A report of the
Surgeon General (DHHS Publication No. CDC 90-8416).
Washington, DC: U.S. Government Printing Office.
U.S. Department of Health and Human Services. (1990b).
Smoking and Health, a National Status Report (DHHS
Publication No. CDC 87-8396 [Revision 02/90]).
Washington, DC: U.S. Government Printing Office.

161
U.S. Public Health Service. (1964). Smoking and health.
Report of the advisory committee to the Surgeon General
of the Public Health Service (PHS Publication No. 1103).
Washington, DC: U.S. Government Printing Office.
Wall, M. A., Johnson, J., Jacob, P., & Benowitz, N. L.
(1988). Cotinine in serum, saliva, and urine of
nonsmokers, passive smokers, and active smokers.
American Journal of Public Health. 76. 699-701.
Wojcik, J. V. (1988). Social learning predictors of the
avoidance of smoking relapse. Addictive Behaviors. 13.
177-180.
Zolton, M. (1991, June 17). Study shows Navy needs stronger
kick the habit message. Navy Times. p. 17.
Zolton, M. (1992, April 13). Medical toll. Navy Times. p. 4.

BIOGRAPHICAL SKETCH
Thomas Lee Pokorski was born on 21 April, 1953, in
Huntington Park, California—a suburb of Los Angeles. He
graduated from Pius X High School in Downey, California, in
1971. He attended one year at the University of California,
Los Angeles, during which time he received a draft lottery-
pick of "2" and joined the U.S. Navy.
Tom has served on active and reserve duty with the Navy
since 1972. Entering as a seaman apprentice, he attended
Hospital Corps "A" school and Operating Room Technician "C"
school before serving three years aboard the USS Prairie. He
performed three years reserve duty with the 1st Marine
Division Medical Detachment while finishing his undergraduate
degree. In 1979, after completion of his baccalaureate and
Aviation Officer Candidate School, he received a commission
of Ensign. Two years later he moved to the Navy's Medical
Service Corps and was designated as an Aerospace
Physiologist. He has served in this capacity the past 10
years in tours with the Naval Medical Clinics Command, San
Diego, Commander Training Air Wing Six, Pensacola, and Marine
Air Group Thirty-one, Beaufort, SC. Throughout his career
Tom has expressed an interest in conveying health knowledge,
and motivating others to choose healthy lifestyles.
162

163
Tom received a Bachelor of University Studies from the
University of New Mexico in 1979. His Master of Science
degree in health science education was conferred in 1986 from
the University of West Florida. He is a member of the honor
society of Phi Kappa Phi and the professional health science
honorary of Eta Sigma Gamma. He is a member of the American
Public Health Association, the Aerospace Medical Association,
and the Association of Medical Surgeons of the U.S.
Tom and his wife Liz have two children, Michael 12 and
Nicole 7. Following graduation Tom will report to the Naval
Aerospace Medical Research Laboratory in Pensacola, Florida.
He will be conducting research on a number of aviation
related medical topics, and hold the title "Chief,
Operational Medicine Research Division".

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
(ka u C/t'-
Wei William Chen, Chair
Associate Professor of
Health Science Education
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
a dissertation for the degree of Doctor of Philosophy^
K ¡ih'iMiJ
as
R. Morgan IPiggf|
Professor of Hea
Education
Science
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
rh , A UJ
Steve M. Dorman
Associate Professor of
Health Science Education
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philoso
LlCAí^¿-A/ L ' fs
Claudia K. Probart
Assistant Professor of
Health Science Education

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Marc N. Branch
Professor of Psychology
This dissertation was submitted to the Graduate Faculty
of the College of Health and Human Performance and to the
Graduate School and was accepted as part^al—fulfiJ.lment of
the requirements for the degree of Doctor/ofr PhLtojsqfcpy.
August, 1992
fan', College of Health and
iHuman Performance
Dean, Graduate School

UNIVERSITY OF FLORIDA
3 1262 08557 0231



I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Marc N. Branch
Professor of Psychology
This dissertation was submitted to the Graduate Faculty
of the College of Health and Human Performance and to the
Graduate School and was accepted as part^alfulf^Llmont of
the requirements for the degree of Doctor M PhitOjsgfcpy
August, 1992 /J Jj_
Den, College of Health and
^Human Performance
Dean, Graduate School


68
"12 things to do instead of smoking" #2106.LE.
Other visual aids and demonstrations were used during
the lecture periods and the breaks. The following teaching
aids were utilized:
Consequences of smokingDisplay which
graphically depicts detrimental physical effects of
smoking, such as emphysema, lung cancer, and heart
attack
Second-hand smoke demonstratorDevice which
shows the effect of sitting in a closed room with
smokers, by filtering smoke passively released from
a smoked cigarette
Mr. GrossmouthDisplay which shows the physical
effects of smokeless tobacco to the mouth, tongue,
teeth, and palate
American Cancer Society pamphlet "50 questions
about smoking".
The education intervention was taught in the same
classroom each time and by the same instructor (the
researcher). Classes started at 7:00 a.m. and ran until
10:00 a.m. Students were told to relax and that the material
was not testable, but they were free to take notes. The
temperature of the room was maintained at 78 F and the
students were allowed to stand, or walk to an in-classroom
drinking fountain, if they got drowsy. Two 15 minute breaks
were given, during which students were asked to discuss
topics for subsequent group discussions. The students were


87
A chi-square procedure was used to analyze differences
between groups. The differences observed were found to be
not significant (x2 = 1.44, p>.l).
Smoking attitudes
The attitude score was obtained by summing adjusted
values for the following variables: concern about cigarettes,
concern about pipe smoking, concern about chewing tobacco,
concern about snuff use, the importance of being a non-
smoker, feeling about working in a smoke-free environment,
and attitude toward targeted cigarette advertising. The
range of possible scores was zero to ten (ten being the most
positive attitude toward not smoking).
Two sets of analyses were conducted for attitude
changes. Smoking attitude scores for all participants were
examined, then scores were examined for those participants
who were current smokers at entry to the Navy. Table 13
presents the attitude score means and standard deviations
observed (for all participants) at each measurement period by
treatment group.


97
did not affect cessation during recruit training. Findings
in the present study indicate light smokers (< 6 cigarettes
per day) were affected more by the intervention. Since
almost all heavier, addicted smokers relapsed in this study,
additional research is needed to find effective ways of
reaching them.
Uncontrolled confounding variables may have had an
effect on relapse rates. The company showing the highest
relapse rate also showed the highest response that recruits
sneaked tobacco products during training. Many factors could
have contributed to why more recruits violated the rules (or
reported doing so) in this company. One possible factor is
the attitude of the company commanders concerning RTC smoking
policy, though the present study cannot support this
assumption. Future studies are needed to examine confounding
variables such as these.
Important to recognize here is, though most of the
subjects relapsed to smoking, for many this was their first
attempt at cessation. Since most smokers require several
cycles through the change process before quitting for good
(Prochaska & DiClemente, 1984) the recruit quitting attempt
will bring the smokers closer to final quitting. Entering
the change cycle is important and if the recruits relapsed,
it is equally important they move back to the action stage as
soon as possible. The present intervention may not have
succeeded in full behavior change but hopefully it moved


UNIVERSITY OF FLORIDA
3 1262 08557 0231


138
-To provide a work environment that is safe and pleasant to work in
for all workers
-To encourage the work force to become smoke free thus increasing
performance of all
The Navy is not trying to force anyone to quit smoking
- MWe want a positively motivated force that chooses not to smoke"
Quote from VADM Zimble former Navy Surgeon General
Next period we will see a video that discusses the effects on your body
when you smoke a cigarette. Many of the ill effects we have discussed
thus far are long term effects. It is true that many of these
effects take years of smoking to develop. At your age it may be hard to
relate to some of the long term effects (heart disease, cancer,
emphysema, etc.) unless a friend or parent had them. I'd like to
discuss some of the short term effects of smoking and use of other
tobacco products, as these things affect almost everyone who uses
tobacco. I'll touch briefly only on 4 areas:
-Tar
-Gases from smoke
-Carbon monoxide
-Nicotine
Breathing cycle
-oxygen is needed for body functioning
-carbon dioxide, a byproduct, is expelled
Cigarette smoking interferes with this process
-carbon monoxide prevents the red blood cells from carrying
oxygen (the more cigarettes are smoked, the greater the problem)
-CO is what kills people who commit suicide by running a automobile
in a closed garage


TABLE OF CONTENTS
page
ACKNOWLEDGEMENTS ii
LIST OF TABLES vi
ABSTRACT vii
INTRODUCTION 1
Statement of the Research Problem 6
Purpose of the Study 7
Hypotheses 8
Significance of the Study 8
Delimitations 11
Limitations 12
Assumptions 13
Definition of Terms 13
REVIEW OF LITERATURE 16
Introduction 16
Problems Related to Tobacco Use 17
Tobacco Use in the U.S 18
Military Tobacco Use and Related Problems 19
Navy Tobacco Use 24
Smoking Relapse 26
Smoking Policy and Effect on Smoking Cessation 36
Other Relapse Research 39
Smoking Prevention 39
Educational Intervention 45
Validation of Smoking Status Self-Report 47
Bogus Pipeline 48
Biochemical Tests 49
Concluding Statement 52
METHODS AND MATERIALS 55
Introduction 55
Subjects 55
Instruments 59
Self-Report Validation Techniques 62
Procedures 64
Data Preparation 75
Analysis Plan 76
iv


LIST OF REFERENCES
Aday, L. A. (1989). Designing and constructing health
surveys. San Francisco: Josey-Bass.
Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and
predicting social behavior. Englewood Cliffs, NJ:
Prentice-Hall.
Ballweg, J. A., & Bray, R. M. (1989). Smoking and tobacco use
by U.S. military personnel. Military Medicine. 154. 165-
168.
Bandura, A. (1989). Human agency in social cognitive theory.
American Psychologist. September. 1175-1184.
Banspach, S. W., Lefebvre, R. G., & Carleton, R. A. (1989).
Increasing awareness of the pressures related to
smoking: An analysis of two models of anti-smoking
curriculum in the classroom. Health Education Research.
4, 69-78.
Blake, S. M., Knut-lnge, K., Pechacek, T. F., Folsom, A. R.,
Luepker, R. V., Jacobs, D. R., & Mittelmark, M. B.
(1989). Differences in smoking cessation strategies
between men and women. Addictive Behaviors. 14. 409-418.
Brandon, T. H., Tiffany, S. T., Obremski, K. M., & Baker, T.
B. (1990). Postcessation cigarette use: The process of
relapse. Addictive Behaviors. 15. 105-114.
Bray, R. M., Marsden, M. E., Guess, L. L., & Herbold, J. R.
(1989). Prevalence, trends, and correlates of alcohol
use, nonmedical drug use, and tobacco use among U.S.
military personnel. Military Medicine. 154. 1-11.
151


RESULTS AND DISCUSSION
79
Introduction 79
Population Description 79
Results 82
Discussion 95
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS 107
Summary 107
Conclusions 110
Recommendations 113
APPENDIX A INTAKE SURVEY 116
APPENDIX B GRADUATION SURVEY 123
APPENDIX C THREE MONTH FOLLOW-UP SURVEY 126
APPENDIX D HUMAN FACTORS COMMITTEE APPROVAL 131
APPENDIX E CONSENT STATEMENT 132
APPENDIX F EDUCATION CURRICULUM 133
APPENDIX G SHAM TREATMENT CURRICULUM 146
APPENDIX H QUIT SMOKING WALLET CARD 148
APPENDIX I CERTIFICATE OF PARTICIPATION 150
LIST OF REFERENCES 151
BIOGRAPHICAL SKETCH 162
v


163
Tom received a Bachelor of University Studies from the
University of New Mexico in 1979. His Master of Science
degree in health science education was conferred in 1986 from
the University of West Florida. He is a member of the honor
society of Phi Kappa Phi and the professional health science
honorary of Eta Sigma Gamma. He is a member of the American
Public Health Association, the Aerospace Medical Association,
and the Association of Medical Surgeons of the U.S.
Tom and his wife Liz have two children, Michael 12 and
Nicole 7. Following graduation Tom will report to the Naval
Aerospace Medical Research Laboratory in Pensacola, Florida.
He will be conducting research on a number of aviation
related medical topics, and hold the title "Chief,
Operational Medicine Research Division".


37
1991) and results are not yet available. This study began
last year to look at tobacco use in all new Navy accessions.
Participants were surveyed at the beginning of training, at
graduation, and at 1 month follow-up. Interventions were not
included.
The current Navy policy is not as restrictive overall as
it is for recruits, but does meet the Department of Defense
directives. Tobacco use is not permitted in: 1) auditoriums,
conference rooms, classrooms, or libraries; 2) elevators; 3)
official buses, vans, and shuttle vehicles; and 4)
gymnasiums, child care and youth activity centers (SECNAVINST
5100.13A, July 17, 1986). Other limitations are placed on
working areas, eating facilities, aircraft, living quarters,
and medical facilities, but guidelines are left to the
individual Commanding Officer. In contrast though, sales of
tobacco products are still discounted from civilian prices at
Navy Exchange facilities, although they may not be purchased
at medical and dental facilities (USDHHS, 1990b).
There is no evidence that policy alone affects smoking
prevalence. In fact, the 1989 Surgeon General's report
(USDHHS, 1989) reported insufficient research has been
undertaken to determine what effect, if any, smoking
restrictions have had on smoking prevalence. Two studies did
examine a no-smoking policy which has been successful in
decreasing consumption of cigarettes in settings affected by
the policy, but not prevalence rates (Pentz et al., 1989;
Petersen et al., 1988). Policy combined with education does


62
This project, including the instruments and consent
statement, was reviewed and approved by the University of
Florida Institutional Review Board (see Appendix D). The
instruments were destroyed after data analysis to satisfy
Institutional Review Board requirements.
Self-Report Validation Techniques
During the instruction period prior to completion of the
intake survey, participants were briefed on possible self-
report cross checks using urine tests. It was explained that
some of their urine samples submitted upon entry would be
screened for a substance which would tell us their smoking
status. They were also told future random drug screen
samples also might be used to validate follow-up self
reports. Subjects were assured the results would in no way
negatively affect them, but that this procedure was a
requirement of an academic research committee. It was
anticipated this bogus pipeline approach would increase
truthfulness of self-reporting for all three surveys.
Cotinine analysis of urine specimens was accomplished
for a random sampling of participants in the intake and
graduation surveys. Urine specimens provided as part of the
Navy drug screening program were used in the study. All
recruits are required to provide a urine sample within hours
of reporting to recruit training. These samples are tested
locally by means of radioimmunoassay and positive samples are


13
Assumptions
{1) Recruit company commanders uniformly followed no
smoking policies set for the command.
(2) The sample population were uniformly exposed to
outside variables which might affect treatment outcome.
(3) Subjects in each treatment group self-reported
tobacco usage with the same degree of truthfulness.
(4) Subjects in differing treatment groups had no
interaction affecting results.
Definition of Terms
The following are working definitions for selected terms
used in this study.
Smoking relapse/recidivism was defined as at least one
puff per day for seven days. This definition was
recommended by a conference of the National Heart, Lung,
and Blood Institute (Carmody, 1990). Relapse does not
necessarily mean a return to the previous smoking rate.
Current smokers were defined for this study as
individuals who have smoked at least 100 cigarettes in
their lifetime and have smoked a cigarette, cigar, or
pipe within 2 months prior to entering the Navy (intake
survey); or since graduation from recruit training (3
month follow-up survey).


21
stress at work (Bray, Marsden, Guess, & Herbold, 1989;
Carroll, Lednar, & Carter, 1989).
-Tobacco products are available at much lower prices at
military outlets than in the civilian market (Cronan &
Conway, 1988; Nelson & Roth, 1991). Many programs are
funded by tobacco sales revenue. Fiscal 1988 saw $102.1
million in tobacco sales by Navy exchanges (McBeth,
1989) and in 1989 $20 million of tobacco profits were
given back to Morale Welfare and Recreation funds.
Fiscal 1991 sales topped $126 million (Steigman, 1992).
-Military life brings an increase in interpersonal
communication and social participation due to higher
density in living quarters and increased group
activities. These conditions are conducive to
initiation/continuance of the smoking behavior
(Ferrence, 1989).
-The military encourages cohesiveness and uniformity,
and members may begin smoking to become like each other,
and "one of the group" (Cronan & Conway, 1988).
-Work breaks and other opportunities to relax are often
paired with opportunities to smoke (Cronan & Conway,
1988).
-Civilian publications aimed at the military populations
contain a large amount of sponsorship/advertisement from
the tobacco industry (Nelson & Roth, 1991).


Ill
(3) effect of smoking education on smoking initiation
after boot camp for recruits who did not smoke at Navy
entry
(4) booster effect on education consequences on smoking
knowledge and smoking attitudes.
It is clear that while the study population resembled
civilian counterparts in some respects, they certainly were
different in most areas of tobacco use. Selection of higher
prevalence smokers into the Navy does not improve the outlook
for decreasing overall Navy smoking prevalence in the near
future. It was encouraging to see at least some recruits not
relapsing to smoking after boot camp, but it is clear that
policy alone will not significantly reduce the number of
smokers entering the general Navy population. The relapse
rate for recruits seems to reflect relapse rates for most
smoking cessation programs, which is encouraging considering
the non-voluntary status of entry to cessation.
Though nicotine addiction and prior cigarette
consumption best predicted smoking relapse for Navy recruits,
a firm intention to resume smoking always predicted relapse.
This agrees with the theory of reasoned action which believes
intention to perform a behavior is the best predictor (Ajzen
& Fishbein, 1980). Smoking behavior change must be brought
about by producing changes in beliefs. Beliefs are affected
by the attitude toward behavior and perceived social


27
Theory of Reasoned Action
One model which has been used to describe likelihood of
behavior change has been termed the theory of reasoned action
(Ajzen & Fishbein, 1980). This theory states the best
predictor of behavior is a person's intention to perform the
behavior. Behavioral intention is seen as a function of two
determinants; the person's attitude toward the behavior, and
the perceived expectation of important others with regard to
performance of the behavior (subjective norm). In a review
of this theory Sutton (1989) said, "In other words, a
person's behavioral intentions, and hence behavior, depend
ultimately on the persons belief concerning; (a) the
possible consequences of the behavior, and (b) the
expectations of important others. It follows that in order
to change behavior it is necessary to change the underlying
beliefs" (p 291). The theory goes on to explain that
external variables can influence intentions, and thus
behavior, but only by influencing attitude toward behavior or
the subjective norm, or the relative importance of the two
components. Since starting or stopping cigarette smoking is
a behavior that falls in the domain of this theory (a
behavior that can be regarded as a decision) intention to
stop/reduce smoking should be a good predictor of behavior.


61
Table 3. Test-retest reliability
Question #
Frequency of
Non-aqreement
Spearman's R
Pearson's R
1
10%
.93
.90
2
12%
.92
o>
00

3
10%
.90
.95
4
9%
.75
.75
5
17%
.51
.51
6
27%
.79
.76
7
34%
.65
.62
8
14%
.71
.71
9
17%
CN
00
*
.68
10
38%
.80
.79
11
31%
.89
.88
12
17%
.86
.86
13
25%
.92
.93
Question/Variable Key:
1. Smoking status at entry
2. Smokeless tobacco use at entry
3. During the last 30 days prior to entering the Navy how many
cigarettes did you usually smoke on a typical day when you
smoked cigarettes
4. Do you believe cigarette smoking is related to heart disease
5. Are you concerned about the health effects of cigarette
smoking
6. How important is it to you to be a non-user of tobacco
products
7. Over the next year, how likely is it that you'll stop smoking,
if you now smoke
8. In the future, do you see yourself as someone who smokes
9. Would you be in favor of being placed in a smoke-free work
environment
10. What percent of the U.S. population do you believe are current
smokers
11. What percent of all members of the Navy do you believe are
current smokers
12. Should tobacco companies be allowed to target advertising
toward certain groups in order to recruit new customers
13. Fagerstrom nicotine tolerance level


z **<*
SMV3A
jeaA auo ueui ssaiQ
oooeqoi oasn aAeu jaAau vnO
(ODDcqoj 6uisn unto no A uaqAA
atn agi apnpui jou op) siseq jejnbaj e uo ODDeqoi
(sn noA pip jo) pasn noA @abu sjeaA Aueui aaol) jo j g t
jepp jo 13O 21 O
01 01 O p, SjeaA Z[ i#PunO
I Si O oooeqoi pasn aAeq jaAau vnO
Apeinbej A|Jtej sjonpojd
oooBQOi 6utsn ubis isjq noA pip a6e jbmaa jv Vi
onO
saO
III jnoA ut souajatoto 001 pa>fOujs noA oabh El
r? ;
asn ooovaoi c
paAAODiAA/naDJOAip/paicjedas Q
Daujeuj se 5uiaii jo oatuey\j0
oauJC'Oj JdA9N Q
SOLVlS IVHUVIAi
X3S
aajtoap leuoissajoj jo aianpej^Q
aejtoap ou inq Apms leuotssajojd jo aienpejo Q
aaj6ap abaiioD jeaA v0
aaiioD aiuosQ
aienpcj6 fooips leoiutpai jo aoejj. Q
aienpejto lootps g6iH0
aieoqiuao 38v Jo ago q
ssai jo sjeaA 1i Q
WOI1V3QQ3 JO 13AT1 1S3HDIH
JLl
3
jfcuo'O
ueisv
oeia 0
OUKH|3 0
oiueosiH Q
ueiseDoeo 0
3DVW
21
AOiapeDV IBABJNJ 0
Kxxps uoueuiJiDopui Jeoi**oO
loogos aiepipueo jao|*oO
opuBfjQ jaiuao toutmej^ unjoayQ
sa^ei eajo Jaiuao tooiuiejj, uruoay Q
otoaiQ ue$ jaiuan 6u>uiejj. unjoayQ
aNVWW001N3bHnD
KD000
5)1


5)l
(
I)
j
booi
I
It
usawnN
AJJUDD3S 1VIDOS .
i 3oaq

1 AON0J

ido oj


6nv 0

pro!

unp 0


AeiM0

Oi
vQ
wQ
Ill
1
0dQ
HV3A |
AVO 1
UBfQ
I
I!
i0
I
KD
I
I
<$
IO<^
t00
31V0
S.AVOOlg
I30VU0

||
I
I
g
q
q
g
100
iq
(q
I
@l
10

KD0
0
I
|@
I
I
I
@(
I
)
I DNLLVW j
laiurao
u
|0
i
g0
000000
p
i
i00
I
i
1000000
|0
(0 I
0
i-
I
i j
0
g
8i
000000
I
i
l ll '
)

!0q-
00 0)1"
000 |
0000000000
0 j
q
000 0
0 0
01-
0-
I00000O0000O00"
OOOOOOOOOO'-
0
00000000 0
l@'
I1
g00000 00000
@ q
q-
0g-
i
i t
3WVN
AieiPKkuoo lojto mi ox unt oq po>|M 3S0 ION OO-
jnoA gaquoy^^>q jaabuc qi oi 6u>puo0fcjop faJO t
-Ti on 3d ovn xdva v asn
* U MOid :SI
II


144
-do any of the reasons you for why you started seem like valid
reasons to start again after graduation???
-remember your accomplishment of quitting or the dangers of
starting
-remember that if you start again you may find yourself at a later
time wanting or having to quit without the help of being in an
environment like RTC
The next video was produced by the Navy and is entitled "Clearing the
Air"
-It follows a petty officer as he makes the decision to quit
-It discusses many things we have already touched on
-Look for tobacco avoidance strategies in the movie that you
can use after graduation
*** SHOW "CLEARING THE AIR" *** (21 minutes)
QUESTIONS ABOUT THE MOVIE?
WRAP UP (9 minutes)
We've discussed a lot of things about tobacco use.
We've used 3 full periods the Navy has allowed this time because
smoking is one of the most preventable of all health problems.
The Navy is concerned about the many diseases associated with smoking
and other tobacco use, and is anxious to see the health and
readiness of its members rise as more and more people make the
decision quit smoking or remain tobacco-free. In fact the Navy has set
a goal of being "Smoke-free by the year 2000". To reach this goal
policies will be instituted to restrict tobacco use from more and more
places. I don't think we will see a ban on tobacco products totally, as
tobacco is a legal drug, but more and more tobacco prevention (like this
one) and cessation programs will be made available to help Navy members
make the decision to stop.


10
For recruits who believe they have not quit, or are
determined to start again, interventions used in this study
may still be of benefit. If they can realize they have quit
smoking, and the quitting was a beneficial achievement for
them, they may be able to enter the behavior change cycle at
the maintenance stage. If this measure fails, the program
still may be of benefit if it moves smokers from the pre
contemplation stage toward the contemplation stage in which
they may give serious consideration to quitting at a later
date. If so, these individuals may be more receptive to
Navy-wide smoking policies and programs they will be exposed
to throughout their careers.
Research indicates light smokers often make the
transition to heavy smoking during the first two years after
high school (Johnston et al., 1991). If this transition can
be prevented in Navy accessions, receptiveness to later
cessation efforts also may be assisted. Successful
recidivism prevention and earlier cessation will certainly
boost progress toward the goal of a smoke free Naw by the
year 2000.
Another group that will benefit from the smoking relapse
program includes recruits who have never smoked, especially
those who may already be susceptible to social influences.
According to the National Institutes of Health, information
about the health and social consequences of smoking proves
critical for cessation (Glynn, Boyd, & Gruman, 1991). This
same information has been shown effective in smoking


90
different for any two treatment groups. The only significant
differences seen for posttest and follow-up scores are
summarized below:
Posttest
scores
TRT
1 TRT
2
F = 5.59,
P
<
.10
TRT
1 TRT
3
F = 5.13,
P
<
.10
TRT
1 TRT
4
F = 6.19,
P
<
.10
Follow-up
scores
TRT
2
- TRT 3
F =
3.07,
P <
.10
TRT
2
- TRT 4
F =
4.57,
P <
.10
Smoking Knowledge
Knowledge on certain aspects of tobacco use were
examined for all treatment groups. The knowledge score was
obtained by summing adjusted values for the following
variables: smoking effect on heart disease, smoking effect
on cancer, smoking effect on emphysema, smoking
addictiveness, smoking prevalence in U.s. population, and
smoking prevalence in Navy population. The possible range
for scores was zero to six. A score of six indicated a high
level of smoking knowledge and a score of zero indicated a
low knowledge.
Table 15 presents the mean scores and standard
deviations observed at each occasion by treatment group along
with the differences observed between occasions.


69
also encouraged to look at the displays and posters during
the breaks. No unusual external events took place during any
of the class periods.
The entire treatment program was designed to motivate
recruits (both smokers and non-smokers) to not initiate
smoking after graduation. A recent personal communication
with Dr T. J. Glynn (September 16, 1991), of the National
Institutes of Health indicated that the primary component of
this program should be motivation to maintain nonsmoking
status, and to want to do so. The benefits of remaining non-
smokers were stressed, and ex-smokers were challenged to make
the decision to not start again. The program was designed to
instill confidence in the recruits ability to remain smoke
free. It was stressed that the Navy is anti-smoke and not
anti-smoker, and only the individual can make the choice of
being smoke-free. Every effort was made to ensure the
intervention program was not viewed as coercive.
The intervention curriculum was presented to the
supervisory committee, and to several outside experts for
review. The committee was composed of four health educators
and one experimental behavioral psychologist. The outside
reviewers included:
Carlo Diclemente, Ph D
Behavioral Researcher
University of Houston


AMERICAN
VCANCER
* SOCIETY*
Participation
This certifies that the below named individual has participated in a four hour Tobacco Use
Prevention program while at the Recruit Training Center, Orlando, Florida.
This program has been presented in conjunction with the American Cancer Society and the
University Of Florida
I pledge to assist the Navy, in whatever way I can, in
reaching its goal of being "Smoke-Free, by the year 2000'*
Witnessed: LCDR T.L. Pokorski, MSC. USN
Program Director
Date
Date
Congratulations on making the commitment to improve your health in every way possible.
K. M. BRUYERE
CAPTAIN, U.S. NAVY
COMMANDING OFFICER
150


20
related to use of alcohol, drugs, and tobacco. Substance
users, particularly heavy users, were more likely to have
experienced ill health during the past 12 months. When
controlling for background variables, which also related to
ill health, number of illnesses was still significantly
related to reported drinking level, drug use, and smoking.
Smokers of one or more packs per day averaged 0.22 more
illnesses per year than non-smokers. Ballweg and Bray (1989)
also reported smokers were more likely than non-smokers to
describe their health as fair or poor. Though the military
smoking rate is high, it reflects a significant decrease from
1980 when 51% of military members smoked (Bray, et al.,
1988).
Many explanations have been hypothesized to account for
the high military smoking prevalence seen today. The
following are descriptions of some of these hypotheses.
-Distinctive military conditions such as relocation
overseas, family separation, or a greater perceived
acceptance of use may foster higher rates of use (Bray
et al., 1991).
-Military personnel are not demographically
representative of the general population (this will be
discussed at length later in this chapter).
-The military has been selecting individuals who are
predisposed to smoke (Gardner, 1991). Smoking can be
predicted by pay-grade, race/ethnicity, education,
service branch, age, poor health practices, and higher


4
results showing Navy recruits actually starting to smoke
while in basic training (Cronan et al., 1988). Though a near
100% effective cessation rate is encouraging, smoking relapse
after recruit training is suspected to be very high. A study
to determine current relapse rates is underway at the Naval
Health Research Center (T. L. Conway, personal communication,
May 9, 1991).
The specific problem addressed in the present study
involved finding ways to decrease smoking relapse as recruits
leave boot camp and enter the general Navy population. If
relapse of recruit smoking can be prevented, the number of
new smokers entering the general Navy population can be
reduced. Navy recruits represent a segment of the U.S.
population highly resistant to smoking cessation: young
smokers (Ferrence, 1989). They are usually between 17 and 30
years old with a mean of about 19 years (Cronan, Conway, &
Hervig, 1989; Chief of Naval Technical Training [CNTECHTRA],
1991). Young smokers tend to show less concern about
potential hazards of smoking, though they show a high
awareness of the health risks (Tuakli, Smith, & Heaton,
1990). Therefore, it is a challenge to find effective
methods of lasting smoking cessation for Navy recruits.
Smoking development progresses through several stages
over a course of two or more years (Leventhal, Baker,
Brandon, & Fleming, 1989). Many smoking recruits may not
have reached the final stage of dependence and regular use.
For these individuals smoking relapse rates after recruit


154
Ferrence, R. G. (1989). Deadly fashion; The rise and fall of
cigarette smoking in North America. New York: Garland.
Fielding, J. E. (1986). Smoking: Health effects and control.
(Educational Publication 86-50M-NO. 3406-PE). New York:
American Cancer Society.
Fingerhut, M. A., Kleinman, J. C., & Kendrick, J. S. (1990).
Smoking before, during, and after pregnancy. American
Journal of Public Health. 80. 541-544.
Fitzpatrick, J. (1991). Urinary cotinine. CCN, January. 11-
17.
Flay, B. R. (1985). Psychosocial approaches to smoking
prevention: A review of findings. Health Psychology. 4,
449-488.
Foley, P., & Rucker, L. S. (1989). An overview of the Armed
Services Vocational Aptitude Battery (ASVAB). In R. F.
Dillon, & J. F. Pellegrino (Eds.), Testing: Theoretical
and applied perspectives (pp. 17-35). New York: Praeger.
Gardner, L. I. Jr (1991). Substance abuse in military
personnel: Better or worse? American Journal of Public
Health. 81, 837-838.
Gibbons, F. X., McGovern, P. G., & Lando, H. A. (1991).
Relapse and risk perception among members of a smoking
cessation clinic. Health Psychology. 10. 42-45.
Girdano, D. A., & Dusek, D. E. (1988). Drug education:
Content and methods (4th ed.). New York: Random House.
Glanz, K., Lewis, F. M., & Rimer, B. K. (1990). The scope of
health education: Parameters of a maturing field. In K.
Glanz, F. M. Lewis, & B. K. Rimer (Eds.), Health
behavior and health education (pp. 3-16). San Francisco:
Josey-Bass.


94
The observed trend overall was a reduction of heavy
smoking with respondents moving gradually to Categories 1 and
2. This overall change in cigarette consumption was found to
be significant (x2 = 8.94, p<.l). individual chi-square
statistics were calculated, using observed and expected
consumption responses at follow-up, for treatment groups.
Though all groups showed a decrease in percentage of heavy
smokers, the only individual group differences proving to be
significant were in treatment Group 2 (x2 = 5.584, p<.l).
Smoking Habits
In order to provide insight to characteristic difference
between smokers in this study and in the general population,
several survey results regarding tobacco use are presented
here.
-Forty-three percent of the study population (41% of men
and 50% of women) indicated they were current smokers
upon entry to recruit training. Another 7% indicated
they were former smokers.
-A breakdown of current smoking by race showed the
following:
- Caucasian
45%
(202)
- Hispanic
39%
(11)
- Filipino
20%
(1)
- Black
21%
(18)
- Asian
20%
(1).


LIST OF TABLES
page
Table 1. Population comparisons 23
Table 2. Study group comparison 58
Table 3. Test-retest reliability 61
Table 4. Treatment group assignments 65
Table 5. Repeated measures design 77
Table 6. Chi-square frequency table 77
Table 7. Percent survey completion at each measurement
period 80
Table 8. Percentage of smokers in non-respondent group
and original study population 81
Table 9. Percent of current smokers at each measurement
period 82
Table 10. Percent of current smokers by gender and
corresponding relapse rates 83
Table 11. Nicotine tolerance levels reported with
corresponding relapse rates 84
Table 12. Percentage smoking initiation 86
Table 13. Attitude scores at each measurement period
and differences pre to post for all subjects 88
Table 14. Attitude scores at each measurement period
and differences pre to post for smokers 89
Table 15. Knowledge scores at each measurement period
and differences observed 91
Table 16. Percent of respondents indicating intention
not to smoke in the future 92
Table 17. Cigarette consumption 93
vi


CHAPTER 3
METHODS AND MATERIALS
Introduction
This chapter describes the methods employed to conduct
the study. Subjects are described with a discussion of the
sampling methods used. The survey instruments are described
and validity and reliability are discussed. A detailed
description of the study procedures is given including survey
administration, educational interventions, and the booster
program. A discussion of self-report validation techniques
incorporated in the study is then given. Finally, a
description of how data were handled is presented along with
the plan for data analysis.
Subjects
Seven companies of recruits from the Navy Recruit
Training Center (RTC) in Orlando, FL were used in this study.
Five companies were male and two female. Participants were
357 men and 139 women. The mean age of participants was
19.26 years (standard deviation [SD] = 2.27). Over 99% held
a high school degree or equivalent, 22% had some college or
were trade/technical school graduates, and 2% had a four year
college degree. The mean Armed Forces Qualification Test
55


31
to permanently quit smoking though, which may affect smoking
relapse seen after graduation.
Relapse Prevention
The topic of relapse prevention has received a lot of
research attention recently. Since most smoking cessation
programs report from 50-80% abstinence at the end of
treatment (Schwartz, 1987) improvement of long-term quit
rates is a logical next step in smoking cessation research.
In reviewing current issues in preventing smoking relapse,
Carmody (1990) found smoking relapse is influenced by a host
of variables, including: physiological factors, withdrawal
symptoms, conditioning processes, stress and negative mood
states, level of commitment and motivation to remain
abstinent, social support, weight gain, and repertoire of
cognitive and behavioral coping strategies in response to
temptations to smoke. He concluded that the primary
theoretical framework for relapse prevention is social
learning theory.
Mazur (1986) points out that social learning theory adds
the principles of observational learning and imitation to
traditional principles of classical and operant conditioning.
He suggests Bandura's social learning theory can help account
for the acquisition of many addictive behaviors including
smoking. Others (Carmody, 1990; Perry, Baranowski, & Parcel,
1990; Rimer, 1990) believe this theory is particularly


22
Because of the nature of military employment, any
substance abuse can often cause consequences of graver impact
than in the civilian community. Greater responsibilities are
placed in the hands of younger people in the military than
would ever be allowed in the civilian work force. A twenty
year old may be responsible for actual steerage of a large
naval vessel, for preparation of a multimillion dollar
aircraft for flight, or for emergency medical treatment of a
seriously injured person. If that individual's performance
is hindered because of use of any psychoactive substance,
including tobacco, lives and expensive hardware can be placed
in jeopardy. The u.s. Surgeon General has concluded nicotine
is a psychoactive substance (USDHHS, 1988).
The safety aspects of even legal substances such as
tobacco can be crucial. Smoking is restricted at certain
times on ships. The smoking lamp is either lit or out on
board a naval ship. This refers to a practice years ago
aboard naval vessels in which the captain would order a lamp
lit for sailors to light their cigarettes when their duties
had ended for the day. The lamp is gone but the term is
still used to tell when it is safe or not to smoke. A lit
cigarette can be a hazard around fuel, ordinance, or any
volatile substance. On submarines the air must be
recirculated, and cigarette smoke is a significant
contributor to atmospheric contaminants (Scali, 1989).
The military population is not demographically
representative of the general population, which may account


CHAPTER 4
RESULTS AND DISCUSSION
Introduction
The purpose of this chapter is to present the results of
data analysis and an explanation of how these results support
or do not support the hypotheses. The data presentation and
discussion are organized around individual hypotheses.
The chapter begins with a precise description of the
study population as it evolved through the study period.
Next, the actual results as they apply to each hypothesis are
presented. The last section is an interpretation of the
findings, a discussion of the implications of additional
knowledge in the smoking field, and a discussion of potential
applications of the findings.
Population Description
The study began with a total of 557 subjects in 7
recruit companies. Fourteen percent of these subjects were
lost due to normal attrition from their original recruit
company. This attrition was equally distributed across
subject companies. Therefore, the total number of subjects
who completed a pretest and graduated with their original
company was 496 (only two subjects refused to complete the
79


157
Marlatt, G. A., Curry, S., & Gordon, J. R. (1988). A
longitudinal analysis of unaided smoking cessation.
Journal of Consulting and Clinical Psychology. 46. 703-
712.
Marsden, M. E., Bray, R. M., & Herbold, J. M. (1988).
Substance use and health among U.S. military personnel:
Findings from the 1985 worldwide survey. Preventive
Medicine. 17. 366-376.
Mazur, J. E. (1986). Learning and behavior. Englewood Cliffs,
NJ: Prentice-Hall.
McBeth, K. (1989, October). Tobacco enters the twilight zone.
Military Market, pp. 68-74.
McBride, C. M., & Pirie, P. (1990). Postpartum smoking
relapse. Addictive Behaviors. 15. 165-168.
Mullen, P. D., Quinn, V. P., & Ershoff, D. H. (1990).
Maintenance of nonsmoking postpartum by women who
stopped smoking during pregnancy. American Journal of
Public Health. 80# 992-994.
Murray, D. M., OConnell, C. M., Schmid, L. A., & Perry, C.
L. (1987). The validity of smoking self-reports by
adolescents: A reexamination of the bogus pipeline
procedure. Addictive Behaviors. 12, 7-15.
Nelson, S. S. (1991, June 17). Desert Storm suggested a
retreat from anti-smoking campaign. Navy Times, p. 16.
Nelson, S. S., & Roth, M. (1991, June 17). Butting out:
Smoking rates fall but DoD sending mixed messages. Navy
Times, pp. 14-15.
O'Connell, K. A. (1990). Smoking cessation: Research on
relapse crises. Annual Review of Nursing Research. 8,
83-100.


CHAPTER 1
INTRODUCTION
Cigarette smoking can be linked to 1 in 6 deaths in the
United States each year. Surgeons' General for the past 10
years named cigarette smoking as the most important
preventable cause of death in society (U.S. Department of
Health and Human Services [USDHHS], 1989, 1990).
Specifically, cigarette smoking has been linked to the three
leading causes of death in the U.S. (heart disease, cancer,
and cerebrovascular disease). Likewise, involuntary smoking
causes many of the same diseases associated with active
smokers (USDHHS, 1986). The annual cost to society in
disease, death, and absenteeism related to smoking has been
estimated in excess of $50 billion (Fielding, 1986).
In response to this problem, health professionals have
provided tobacco prevention and smoking cessation programs
for many years. These efforts have shown encouraging results
in the general population. Smoking prevalence has dropped
from 40% in 1965 to 29% in 1987 (USDHHS, 1989). The Surgeon
General reports that while over 50 million Americans continue
to smoke, more than 90 million would be smoking in the
absence of recent changes in the smoking and health
environment (USDHHS, 1989). Smoking cessation produces major
and immediate health benefits for smokers of all ages
1


45
is important that prevention efforts also be presented during
this period. Cronan & Conway (1988) concluded the Navy must
develop and evaluate programs directed toward preventing
personnel from smoking. They felt prevention programs should
probably be implemented as early as recruit training.
Educational Intervention
Because of the mix in smoking status among recruits, a
similarly mixed intervention/prevention strategy may prove
most effective. In a meta-analysis of 39 smoking cessation
interventions Kottke, Battista, DeFriese, and Brekke (1988)
found the most effective programs employed more than one
modality for motivating behavior change. Cronan et al.
(1989) evaluated smoking interventions in recruit training.
They found a one-hour education program significantly reduced
the number of recruits who started smoking during training,
but did not increase the number of smokers who quit. Their
educational intervention stressed the hazards of smoking and
techniques for stopping.
In 1987, the NCI convened an expert advisory panel to
assess the question "What are the essential elements of a
school-based smoking prevention program?" (Glynn, 1989). The
panel concluded that existing programs have been consistently
effective in delaying the onset of smoking. Programs with a
smoking-only focus have about an equal effect as those with a


9
permanent change on smoking decisions. The theory of
prevention education as an effective measure for behavior
change also was tested. This study should prove useful for
determining if subject tailored smoking prevention classes,
in the context of a strict no-smoking policy, reduce
recidivism after the policy is removed.
Since this study was the first smoking relapse
prevention research conducted with military recruits it
should produce new knowledge applicable to all military
training commands. The results will provide a basis for
further research in discovering program variables which
increase success, and subject variables which determine who
is suited for particular interventions. Portions of the
results may also prove applicable to behavior change of other
detrimental health habits (eg. drug and alcohol use, poor
nutrition habits, seat belt usage).
Smoking relapse for recruits will be affected by many
factors they encounter after leaving boot camp. The present
study cannot change any of these factors. However, the
interventions were designed to help participants recognize
and cope with many of these factors. For recruits who
believe they have quit, establishing a firm intention to
remain quit is very important. This aspect of prevention
stems from the theory of reasoned action which states the
best predictor of behavior is a person's intention to perform
the behavior (Ajzen & Fishbein, 1980).


93
In an effort to explain relapse differences, smoking
intention by gender were examined. On the pretest survey 68%
of women and 83% of men indicated intention not to smoke in
the future. The difference observed was found to be
significant (x2 = 11.23, p<.001).
Cigarette consumption
Cigarette consumption was measured for smokers on each
survey occasion. The responses were partitioned into three
groups for analysis: no smoking/very light (< 1 per day),
moderate smoking (1-20 per day), and heavy smoking (> 20
per day). Table 17 summarizes the percent of respondents in
each category, by treatment group, on both the pretest and
follow-up. Since smoking was not authorized at time of
posttest, cigarette consumption at posttest is not reported.
Table 17
Cigarette consumption
Treatment group
1 2 3 4 Total
Cigarette
usage
I
j pre
tin
pre
f/u
pre
f/u
¡pre
f/u
pre
f/u
No/light
l
54.7
57.5
1 68.9
!
75.2
60.0
64.6
| 65.7
80.0
65
68
Moderate
35.3
37.5
22.3
22.7
31.9
30.5
1 26.9
15.0
26
28
Heavy
10.1
5.0
8.8
2.1
8.1
4.9
I 7.5
5.0
9
4
Note: Results reported in percentage


18
involuntary smoking as a cause of disease, including lung
cancer, in healthy non-smokers (USDHHS, 1986).
Cigarette smoking is the number one preventable cause of
death in the U.S. today (USDHHS, 1989). Smoking causes more
premature deaths than cocaine, heroin, alcohol, fire,
automobile accidents, homicide, and suicide combined (USDHHS,
1990). It has been estimated that smoking costs society over
$50 billion annually in smoking related diseases, death, and
absenteeism (Fielding, 1986). However, more than 50 million
Americans continue to smoke (USDHHS, 1990b).
Tobacco Use in the U.S.
Smoking prevalence in the adult U.S. population was
about 29% in 1987, which is down from the 40% prevalence seen
in 1965 (USDHHS, 1989). Unfortunately, this decrease in
smoking is not seen uniformly throughout the population. The
Surgeon General reported the prevalence of smoking in women
has declined more slowly than men, and smoking rates will be
about equal for men and women in the mid-1990's (USDHHS,
1989). The report also states female adolescents not
planning on higher education show a much higher smoking
initiation rate than for male adolescents. A higher smoking
prevalence was also reported among black and Hispanic men
than white men. More disturbing is the fact that smoking
prevalence among teenagers has not declined over the past
decade. Johnston, et al. (1991), reporting on their 15th


40
goal of a smoke-free Navy/society. The Surgeon General
(USDHHS, 1989) reported children and adolescents hold the key
to progress toward curbing tobacco use in future generations.
This report also said there is a growing recognition that
prevention and cessation efforts need to target specific
populations with a high smoking prevalence and a high risk of
smoking related disease. The military population is listed
as one of the groups that needs to be targeted.
Many approaches have been tried over the years, both in
school and community settings, to prevent adolescents from
beginning to smoke. Early campaigns to increase information
and create fear of long term consequences did not succeed.
Although succeeding in changing knowledge, beliefs, and
attitudes, very few programs consistently reduced the onset
of smoking (Flay, 1985). In a review of psychosocial
approaches to smoking prevention, Flay (1985) examined the
success of such programs and the theory involved in their
evolution. He states these programs incorporate complexities
of the psychosocial process of becoming a smoker into the
design of prevention interventions. He lists the following
components as part of a life/social skills approach to
smoking prevention:
-long term consequences of cigarette smoking
-the prevalence of smoking
-correcting students perception of social norms
concerning smoking
-teaching students about the social influences to smoke


29
action. The key to successful change lies in exiting the
maintenance stage after replacing the behavior in their
lifestyle. If the intervention method is tailored to the
individual's stage of change, the chances of success can be
enhanced. Rimer (1990) says people in the process of change
must have access to interventions which start at their stage
in the change process. Because of this, she says
intervention should include a range of options to reach
people in all stages. Intervention programs may not succeed
in behavior change, but may succeed in moving the individual
to a higher stage, which is important (Prochaska &
DiClemente, 1983). No studies have as yet been reported
concerning any education effect on this recycling phenomenon.
Social Cognitive Theory
Bandura's (1989) social cognitive theory revolves around
smokers' beliefs about ability to exercise control over
events which control their lives. Bandura sees self-efficacy
as influencing thought patterns, motivation, level of stress,
and selection of environments; thus affecting smoking
cessation outcome expectations.
All of these theories have commonalties, and show that
smoking relapse is individualistic and complex. Recruits who
smoked before entering the Navy have been placed in the
action stage of change while in recruit training, even though


47
smoking, 2) focus on social influences to smoke (family,
peer, media), and 3) decision to integrate information on
smoking to individual's own smoking environment and a public
commitment procedure about their decision of whether or not
to smoke. Three booster sessions were included in the
program.
Banspach et al. (1989) assessed two smoking prevention
programs: 1) a five-lesson, video presentation on resisting
pressures to smoke, and 2) a four-lesson teacher led
discussion of smoking and advertising. They found both
programs had a similar positive effect on preventing smoking
in students. The effects seen were significantly different
from those observed in a control group. They concluded that
increasing a students awareness about the messages they
receive can be enhanced by either a video presentation with
discussion, or a teacher led discussion with student
involvement.
Validation of Smoking Status Self-Report
Cigarette smoking behavior is most often measured by
self-report of frequency and intensity. Researchers find
this procedure simple, efficient, and inexpensive. Murray,
O'Connell, Schmid, and Perry (1987) state because many
adolescents smoke infrequently and episodically, it may be
difficult for them to characterize their usual pattern of
smoking. Adolescents may also try to mislead the


33
-eating/drinking
-engaging in a distractive activity
-escape
-delay
-engaging in a physical activity
-relaxing
-engaging in any other activity.
Cognitive coping strategies were:
-willpower
-self-punitive thoughts
-positive health consequences
-negative health consequences
-distracting thoughts
-intent to delay
-other self-talk.
People who expect smoking cessation to require active coping
have been shown to be more successful in maintenance
(Shiffman et al., 1986). They determined it is probably most
useful to teach ex-smokers a broad repertoire of coping
responses to prevent relapse.
Other approaches to relapse prevention include
motivational enhancement, social support, coping skills
training, reinforcement, lifestyle balancing, and the use of
various pharmacological agents (Carmody, 1990). Several
studies have shown that use of refusal skill training
techniques is beneficial in maintenance of smoking cessation
(Curry, Marlatt, & Gordon, 1987; Curry, Murray, Gordon, &


100
Smoking knowledge, attitudes, and intentions
The present study showed significant changes in smoking
knowledge between pre and post testing. Significant
treatment group differences were present only between the
education only (Group 2) and the control (Group 1). The
booster group showed the best knowledge retention, but the
differences observed were not significant. The increases in
knowledge seen in both the control and sham groups may be
explained by the attitude increases also seen in both groups.
Attitude change resulting from smoking policy and the
emphasis on smoking and health portrayed in the sham
treatment may have caused some survey respondents to answer
"yes" to all questions relating diseases to smoking. Since
all correct answers were "yes", this may have inflated all
knowledge scores enough to nullify any significant
differences.
Attitude changes were clearly evident and moved toward
more positive attitudes about non-smoking. At graduation the
attitude changes for smokers were even more obvious, though
the sham treatment group changed exactly the same as both
education groups. The booster group did not seem to have any
additional effect on maintaining attitude change as suggested
by Brownell et al. (1986). Possible explanations for the
attitude change seen in the sham group are differing
perception of importance of no smoking by the Navy because of


54
crucial in any smoking cessation effort; programs must be
designed around providing motivational incentives and
building self-efficacy.
Health behavior change programs should be guided by
social learning theory to encompass environmental, personal,
and behavioral constructs. Participants must decide for
themselves that smoking is potentially detrimental, recognize
the pressures on them to smoke, and develop their own ways to
cope with these pressures. Alternatives must be presented in
order for informed choices to be made. Recruit smoking
education programs should build on what many recruits will
have already had in their formal education. Misconceptions
about tobacco use must be corrected. Long-term consequences
of smoking should be discussed, but short-term effects also
need to be stressed. Current Navy policy, and future policy
direction, should be discussed to give the new Navy member a
picture of what will be expected of them. Recruits who
entered as smokers have to believe they have actually quit
smoking, if they are expected to stay quit after graduation.
Recruit training is a period when a complete lifestyle
transformation is taking place. Recruits are making
wholesale changes in the ways they live, work, and socialize.
They are taking on added responsibilities, receiving personal
and financial independence, and adjusting many health
practices. They should be encouraged at this time to make
decisions, in all areas, that will lead to self-fulfillment
and better health.


77
chi-square statistic. This test statistic looks at the
goodness of fit between the distribution observed and the
distribution expected (Aday, 1989).
Table 5. Repeated measures design
Pre-test
Post-test
3 Month f/u
0
Tl
0
0
0
T2
0
0
0
T3
0
0
0
T4
0
0
Notes: Tl = Policy only
T2 = Policy + education
T3 = Policy + education + booster
T4 = Policy + sham treatment
Smoking relapse and smoking initiation were examined
according to Table 6, using differences between pretest and
follow-up.
Tl
T2
T3
T4
Notes:Dl=current smoking at pretest and at follow-up (RELAPSE)
D2=current smoking at pretest but not at follow-up (NON-RELAPSE)
D3=no smoking at pretest or follow-up (NON-INITIATION)
D4=no smoking pretest but current smoking follow-up (INITIATION)
Table 6. Chi-square frequency table
D1
D2
D3
D4


127
For each time period, please mark the type of duty station you were assigned and indicate
your tobacco use during that time period.
TIME
FIAME
TYPE OF DUTY STATION
TOBACCO USE
Never
Used
Former
User
Current
User
6. JUST
NOT APPLICABLE
a) Cigarettes
0
0
0
PRIOR TO
b) Cigars
0
0
0
ENTERING
c) Pipe Tobacco
0
0
0
NAVY
d) Chewing Tobacco
0
o
0
e) Snuff/Dip
0
0
0
7. 1-2
RECRUIT TRAINING
a) Cigarettes
0
o
0
MONTHS
b) Cigars
0
o
0
AFTER
c) Pipe Tobacco
0
o
0
ENTERING
d) Chewing Tobacco
0
0
0
(during
e) Snuff/Dip
0
0
0
training)
8. 3-4
0 Ship 0 Submarine
a) Cigarettes
0
0
0
MONTHS
0 Air Squadron 0 Shore
b) Cigars
0
0
0
AFTER
0 "A" School CONUS
c) Pipe Tobacco
0
0
0
ENTERING
0 Other School
d) Chewing Tobacco
0
0
0
NAVY
0 Shore-Overseas
e) Snuff/Dip
0
0
0
9. AT THE
0 Ship 0 Submarine
a) Cigarettes
0
0
0
PRESENT
0 Air Squadron 0 Shore
b) Cigars
0
0
0
TIME (5-6
0 "A* School CONUS
c) Pipe Tobacco
0
0
0
months
0 Other School
d) Chewing Tobacco
0
0
0
after)
0 Shore-Overseas
e) Snuff/Dip
0
0
0
Iamouht of tobacco products used j
10. When was the most recent time you
smoked a cigarette?
0 Never smoked a
cigarette
0 10 or more years
ago
O 6-9 years ago
0 3-5 years ago
0 1-2 years ago
0 7-11 months ago
O 4-6 months ago
O 2-3 months ago
O During the past
30 days
0 Today
11. During the last 30 days, how many
cigarettes did you usually smoke on a
typical day when you smoked cigarettes?
O Did not smoke any O 11-15 cigarettes
cigarettes
0 Fewer than 1, on
the average
0 1-5 cigarettes
0 6-10 cigarettes
O 16-20
O 20-25
O 26 or more
cigarettes
DURIVG THE LAST 5 MONTHS...
12. On the average, how
chewing tobacco?
O Never/Don't use it
O Once or twice in the
last 5 months
0 3-6 days in the
last 5 months
O 7-11 days in the
last 5 months
often did you use
0 Appx once/month
O 2-3 days/month
0 1-2 days/ week
0 3-4 days a week
0 5-6 days a week
O About every day
13.On the days you used chewing tobacco,
how many times per day did you use it?
ONA 0 2 04 06 08
Ol 03 05 07 0 9+
14.On the average,
snuff/dip?
O Never/Don't use it
0 Once or twice in the
last 5 months
0 3-6 days in the
last 5 months
0 7-11 days in the
last 5 months
how often did you use
0 Appx once/month
02-3 days/month
0 1-2 days/week
0 3-4 days a week
0 5-6 days a reek
0 About every day
15.On the days you used snuff/dip, how
many times per day did you use it?
O NA O 2 04 06 08
Ol 03 05 07 0 9+
16. On the average, how often did you
a pipe?
0 Never/Don't use them 0
0 Once or twice in the 0
last 5 months 0
0 3-6 days in the 0
last 5 months 0
0 7-11 days in the 0
last 5 months
Appx once/month
2-3 days/month
1-2 days/week
3-4 days a week
5-6 days a reek
About every day
17. On the days you smoked a pipe, how
many pipefuls of tobacco did you smoke?
O NA 0 2 04 06 *0 8
01 03 05 07 0 9+


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
a dissertation for the degree of Doctor of Philosophy.
{lsu L> if ft &^ C/t^
as
Wei William Chen, Chair
Associate Professor of
Health Science Education
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope an^ quality, as
a dissertation for the degree of Doctor of Philosophy
Doctor of Phil
K JiviO&'frJ
R.'Morgan IPigg,(JyJ
Professor of Health Science
Education
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
, /A? l) ua
Steve M. Dorman
Associate Professor of
Health Science Education
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
a dissertation for the degree of Doctor of Philosophy.
as
Claudia K. Probart
Assistant Professor of
Health Science Education


14
Current smokeless tobacco users were defined as having
categorized themselves as users of chewing tobacco or
snuff and have used at least 3 days in the past 12
months.
Former smokers were defined as once current smokers, but
having not smoked a cigarette, cigar, or pipe in the
last 2 months.
Former smokeless tobacco users were defined as once
current users, but having not used chewing tobacco or
snuff in the last 2 months.
Never smokers were defined as having smoked less than
100 cigarettes in their lifetime, indicated they never
regularly smoked, and characterized themselves as having
never used cigarettes, cigars, or pipes.
Never users of smokeless tobacco were defined as having
categorized themselves as never using chewing tobacco or
snuff on a regular basis.
Light smoking was considered using less than one
cigarette per day.
Moderate smoking was considered using from 1-19
cigarettes per day.
Heavy smoking was considered using a pack, or more, of
cigarettes per day.
Smoking relapse rate was determined by dividing the
number of participants (categorized as current smokers
at intake) indicating they started smoking again after


Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
EFFECT OF PREVENTION EDUCATION ON SMOKING RELAPSE FOR NAVY
RECRUITS
By
THOMAS LEE POKORSKI
August, 1992
Chairman: Wei William Chen, PhD
Major Department: Health and Human Performance
This study examined impact of an education program on
smoking knowledge, attitudes, and intentions of Navy recruits
undergoing 8 weeks of training in a normal no-smoking
environment. Also examined were smoking relapse and
cigarette consumption subsequent to recruit graduation.
Specifically the study was designed to (1) add to literature
information on effective educational smoking
prevention/cessation techniques; (2) measure effect of
current no-smoking policy at Recruit Training Center,
Orlando, FL; (3) examine differences in observed levels of
smoking knowledge, attitudes, intentions, and relapse after
intervention; (4) examine smoking initiation rate differences
(for non-smokers prior to recruit training); and (5) examine
variables affecting smoking relapse.
vii


38
seem to be more beneficial than policy alone. Pentz et al.
(1989) found a policy which emphasized adolescent education
to prevent and stop smoking, rather than regulating it by
punishment, was significantly related to lower recent
smoking. Education, designed to reorient the ex-smoker's
attitudes toward more realistic expectations about quitting
smoking, is an important first step in relapse prevention
(Carmody, 1990).
A survey to assess short-term impact of Army smoking
policies (Carroll et al., 1989) reported no influence of
policy on decision to quit, though a consumption drop was
reported in some areas. This study also showed intention to
quit is related to knowledge of smoking-related diseases.
The current recruit smoking policy lacks support of a strong
prevention education component (CNTECHTRA, 1991a). Results
of the current recruit policy study may reflect those of the
Army survey because of this fact. The Navy has a long way to
go to meet its goal of being smoke free by the year 2000
(Zolton, 1991). New restrictions are being proposed, but
Navy guidelines must include positive approaches to help
individuals make the decision not to smoke. Vice Admiral
Zimble, the Navy Surgeon General, said: "We want a
positively motivated force that chooses not to smoke"
(Nelson, 1991). Health educators also realize coercion of
positive health behavior is not only unethical, but is
usually not a very successful tactic. The challenge, in this
study of prevention education supplemented with strict


134
INTRODUCTION (10 minutes)
For the next 3 periods we will discuss cigarette smoking, and the use
of other tobacco products. We will examine:
-Navy tobacco use policies
-Some myths about tobacco use
-What happens to the body when you smoke
-Why people decide either to start smoking or choose not to smoke
-The benefits of not starting/returning to smoking after RTC
graduation
During each period we will cover a few topics, look at a videotape, do
some demonstrations, and discuss the material.
-I'd prefer if you save most of your questions for the discussion
period unless you have one you feel can't wait
-Ive got some displays that Id like everyone to look at during one
of the breaks
The first video stresses teamwork (something the Navy stresses on,
as well as off, the job) and how the effects of tobacco and alcohol can
affect the performance of individuals, thus affecting the team. It is
set in a High School football setting but the message is the same for
each of you working as part of the Navy team.
*** SHOW VIDEO "PERFORMANCE EDGE" *** (7 min.)
(23 minutes)
-So you see that ETOH and nicotine can affect your performance
-You have committed to being a part of a very important team in the
Navy
-If too many team members performance is hampered in football you
may lose a game.
-But if too many team members performance is hampered in many Navy
tasks a life may be lost.


17
are presented, followed by an overview of recent research in
ways of increasing truthfulness of smoking self-report, and
means to verify smoking self-report. A concluding statement
ends this chapter, in which the theoretical framework is
related to the actual experimental design of the study.
Problems Related to Tobacco Use
Cigarette smoking remains a major problem in U. S.
society today. A recent report (CDC, 1991b) says more than
434,000 deaths, and an estimated 1,199,000 years of potential
life lost (YPLL) before age 65, were caused by cigarette
smoking in 1988 in the United States. In 1964, the Surgeon
General reported (Public Health Service [PHS], 1964)
cigarette smoking causes lung and laryngeal cancer in men,
and causes bronchitis. The 1989 Surgeon General's report on
the health consequences of smoking (USDHHS, 1989) showed
cigarette smoking also causes coronary heart disease,
cerebral vascular disease (stroke), atherosclerotic
peripheral vascular disease, lung and laryngeal cancer in
women, oral cancer, esophageal cancer, chronic obstructive
pulmonary disease, intrauterine growth retardation, and low
birth weight babies. Smoking was also found to be a
contributing factor for cancers of the bladder, pancreas, and
kidney; and associated with cancers of the stomach and
uterine cervix (USDHHS, 1989). Research also has established


66
Participants were then asked to sign the consent forms if
they agreed to participate in the study. The signatures were
witnessed, dated, serialized, and retained for a period of 5
years. The statement portions of the consent forms were
collected and given to the company yeomen (recruit in charge
of all company paperwork) for later re-distribution to the
participants. The intake surveys (see Appendix A) were then
completed by the participants. The pilot group participants
were administered the same intake survey approximately 72
hours later.
Education intervention
The education intervention phase was conducted for
participants on their 2-2 day of training. The curriculum
(see Appendix F) consisted of lecture, video-tapes, visual
aids, demonstrations, and group discussions. Participants
were encouraged to ask questions and participation was
solicited during large group discussions.
The main lecture topic areas were:
Navy tobacco use policies
myths about tobacco use
physiological effects of smoking (short and long
term)
reasons for choosing to use/not use tobacco
benefits of not starting/resuming tobacco use
after RTC graduation.


141
During the break I'd like you to discuss among yourselves why you
started smoking or why you did not start. I'll ask a few of you
to report your discussions after the break. There are some displays up
here that I'd like you to see during this break or the next one.
*** 10 MINUTE BREAK ****
(7 minutes)
ASK FOR INPUT ON REASONS FOR STARTING TO SMOKE
WRITE THE ONES GIVEN ON THE BOARD THEN COMPLETE LIST BELOW:
-bored
-friends did
-to be cool
-liked the image (advertising > $ 1 billion per year spent)
-liked the taste
-gave me a kick
-wanted to show I was tough
-wanted to take a dare
-it calmed me
-wanted to lose weight
-to look and feel like an adult
-wanted to be masculine
-didn't want to be left out of a group
-to show I wasnt afraid
-parents smoked
-curiosity
ASK FOR INPUT FOR REASONS FOR NOT STARTING SMOKING
WRITE THE ONES GIVEN ON THE BOARD THEN COMPLETE LIST BELOW
-health
-parent/relative smoked and had smoking related disease
-tried but hated the taste/feeling
-did not like the smell on clothes
-parents/teachers influence


106
should keep in mind the limitations of the study and the
assumptions which were presented in chapter 1. Several other
factors should also be kept in mind when interpreting the
results:
-the sham treatment group had fewer subjects than the
other groups and a 25% response rate on the follow-up
survey further reduced the sample size used in some
analyses
-the control group only had a 50% completion of post
test surveys which decreased sample size in some
analyses
-the overall follow-up response rate and other
attrition factors made the final smoker population less
than was originally anticipated; this reduction in
sample size had an effect on analyses power
-more surveys were returned completed from participants
who went on to longer training programs after boot
camp, as opposed to those who had finished all their
training before follow-up
-follow-up was difficult due to tracking problems in the
Navy system.


26
Smoking Relapse
"To cease smoking is the easiest thing I ever did; I
ought to know because I've done it a thousand times"
-Mark Twain
Most relapse does not occur immediately, but rather long
after signs of physiological abstinence have disappeared
(Jarvik & Hatsukami, 1989). Research shows approximately 70%
of successful quitters relapse within 3 months, and an
additional 10-15% relapse between 3 and 12 months after
quitting (Schwartz, 1987; Shiffman et al., 1985). Several
theories have been offered to explain why relapse rates are
so high. Shiffman et al. (1986) have suggested three types
of variables influence relapse proneness: a) enduring
personal characteristics, b) background variables, and c)
precipitants. Craving for nicotine and the positive
reinforcement nicotine brings has also been theorized as
reason for relapse (Carmody, 1990). Gritz, Carr, and Marcus
(1991) conducted a study on tobacco withdrawal syndrome in
unaided quitters. They found tobacco dependence to be a good
indicator of smoking relapse. Higher Fagerstrdm tolerance
scores predicted higher probability of relapse. Their other
main finding was higher cigarette consumption at enrollment
predicted higher short and long term relapse.


139
-regular smokers have a CO concentration in their blood streams
2-3 times higher than the EPA protection level
-as CO concentration rises above this safe level mental capacity d
rops, judgement is decreased, and the overall performance of a
person drops
Other toxic gases are present in smoke that can also have detrimental
effects
-one example is hydrogen cyanide (gas chamber gas) although not
found in smoke in lethal doses, the concentration is much higher
than levels considered safe for long term exposure
-other gases immobilize the hairlike cells in air passages that
help clear foreign particles. Failure to remove these particles
from the lung results in "smokers cough"
Particles suspended in smoke can irritate the eyes and nasal passages,
and trigger allergic reactions
-these small particles (aka Tar) can cause many other problems (eg.
cancer)
-normally the body defenses can cleanse small particles from the air
we breathe, but when overloaded by regular smoking these mechanisms
can't keep up and the tar is deposited on respiratory tract cells
causing irritation and possibly cancer in the long run.
(1 pack a day1 quart of tar per year
Nicotine is the last item we will discuss here
-it is the primary drug found in tobacco and is classified as a
central nervous system stimulant
-in smokers it is absorbed through the lungs and gets to the brain
within 8 seconds after inhalation
-with smokeless tobacco, nicotine is absorbed through the lining of
the mouth
-nicotine increases heart rate and blood pressure
-nicotine is also thought to cause the physical and psychological
addiction to tobacco products that is seen in most users this


32
valuable to health educators because it illuminates the
dynamics of individual behavior and gives direction for
intervention design in behavior change programs. Bandura
(1989) says people make causal contributions to their own
motivation and action within a system of triadic reciprocal
causation. The model shows action, personal factors, and
environmental events operating as environmental determinants.
In the model, people partly determine the nature of their
environment and are influenced by it.
The preceding theories lend well to the multi-component
interventions thought to be important in relapse prevention
strategies. They can easily be applied to multi-level change
strategies because of inclusion of environmental, personal,
and behavioral constructs.
Social cognitive theory is an outgrowth of social
learning theory (Bandura, 1989). This theory appears to be
useful as a model in studying smoking relapse (Carmody,
1990). People's beliefs about their ability to exercise
control over events that affect their lives are central to
the theory. Wojcik (1988) found the strongest prediction of
abstinence versus relapse in a sample of 75 smokers
attempting to quit on their own was self-efficacy.
Shiftman et al. (1985) emphasize education, assessment,
and coping-skills training in their approach to relapse
prevention. They also found combining cognitive and
behavioral coping enhanced effectiveness of preventing
relapse. Seven types of behavioral coping were listed:


99
Glynn (personal communication, September 16, 1991)
reported a possible second uptake period for smoking; during
employment transition. A recent study by Cronan et al.(1989)
reflected this uptake period for Navy recruits. They found
14% smoking initiation in a control group and 10% initiation
in all their study groups during boot camp. Their study was
conducted before a non-smoking policy had been instituted in
recruit training. They also found a reduction of initiation
for a no-smoking and an education treatment group. It's
possible that since smoking initiation cannot occur now
during boot camp, any smoking uptake due to employment
transition in the Navy will occur immediately after training.
The present study shows this is indeed the case but to a
lower extent than indicated by Cronan et al. (1989). Since
the present study shows no significant treatment group
difference for smoking initiation it must be assumed that the
effect of the recruit smoking policy on smoking perceptions
is responsible for the lower numbers seen. These results
show promise that the recruit no-smoking policy is having a
positive effect on preventing non-smokers from starting the
habit. Policy alone may affect smoking cessation slightly
(eg. early adopters in diffusion of innovation) but for
prevention of relapse, additional structured education
programs may be needed.


113
Recommendations
Evident in the present study is that no factor by itself
affects relapse. Many things predict and affect relapse.
The present study has highlighted numerous variables which
together can decrease smoking relapse in recruits after
graduation. These factors need now to be used in a
comprehensive smoking program for all recruits. Further
studies should be performed to determine additional elements
which will better reach heavier, addicted smokers who were
not affected by the present interventions. The following
recommendations are made.
(1) Further studies should be conducted using
interventions addressing the top reasons given for
returning to smoking (eg. stress, peer/family pressure,
boredom).
(2) A 12 month and 36 month follow-up should be
conducted with the present study population to examine
long term effects.
(3) Further studies should be conducted varying the
education dosage (eg. 1 hr, 3 hr, 6 hr) to determine if
"more is better".
(4) improve present research design by:
-balancing treatment group cell size by total
number and gender


APPENDIX H
QUIT SMOKING WALLET CARD
Front Side
Reasons to Remain Tobacco-Free
1. COST 1 pack/day = between $700-$l,000 per year
2. HEALTH over 1,000 people will die today from
smoking related diseases
3. SOCIAL smokers are the minoritymost people do
not want to be around tobacco smoke
4. SMELL so my clothes don't constantly smell of
smoke
5. Add your own top reason here:
Back Side
Ways to Avoid Smoking
1. Remember your reasons to stay tobacco-free
2. Four D's
Delay
Deep breathing
Drink water
Do something else
3. Avoid smokers, and situations or places, you know
will tempt you to smoke
4. ExerciseRecall how much better you feel now while
exercising
5. Help others try to quit
148


159
Schwartz, J. L. (1987). Review and evaluation of smoking
cessation methods: The United States and Canada. 1978-
1985 (NIH Publication No. 87-2940). Washington, DC: U.S.
Government Printing Office.
Sepkovic, D. W., & Haley, N. (1985). Biomedical applications
of cotinine quantitation in smoking related research.
American Journal of Public Health. 75. 663-665.
Shiffman, S., Read, L., Maltese, J., Rapkin, D., & Jarvik, M.
E. (1985). Preventing relapse in ex-smokers: A self
management approach. In G. A. Marlatt & J. R. Gordon
(Eds.), Relapse prevention (pp. 472-520). New York:
Guilford Press.
Shiffman, S., Shumaker, S. A., Abrams, D. B., Cohen, S.,
Garvey, A., Grunberg, N. E., & Swan, G. E. (1986). Task
force 2: Models of smoking relapse. Health Psychology. 5
(Suppl.), 13-27.
Skarping, G., Willers, F., & Dalene, M. (1988). Determination
of cotinine in urine using glass capillary gas
chromatography and selective detection, with special
reference to the biological monitoring of passive
smoking. Journal of Chromatography. 454. 293-301.
Stevens, V. J., & Hollis, J. F. (1989). Preventing smoking
relapse, using an individually tailored skills-training
technique. Journal of Consulting and Clinical
Psychology. 57. 420-424.
Steigman, D. S. (1992, April 13). Cheap smokes: Exchange
policy fuels habit. Naw Times, p. 6.
Sutton, S. (1989). Smoking attitudes and behavior:
Applications of Fishbein and Ajzen's Theory of Reasoned
Action to predicting and understanding smoking
decisions. In T. Ney & A. Gale (Eds.), Smoking and
human behavior (pp. 289-312). Chichester, England: John
Wiley & Sons.


APPENDIX A
INTAKE SURVEY
Reprinted with permission of Dr. Terry L. Conway, Naval
Health Research Center, San Diego, CA


24
smoking prevalence (Bray et al.f 1991). Bray et al. (1991)
reported, controlling for key sociodemographic
characteristics known to be associated with substance abuse,
military personnel are in general still substantially more
likely than civilians to be smokers and heavy smokers. They
also reported differences among military and civilian women
are more pronounced than among military and civilian men.
The rates for men differed by 4 and 7 points respectively,
while the rates for women differed by 13 and 14 points.
Naw Tobacco Use
The most recent Worldwide survey of substance abuse and
health behaviors among military personnel (Bray, et al.,
1988) showed prevalence of any smoking in the Navy was 43.8%
in 1988. A 1986 survey of shipboard personnel indicated
49.8% smoked (Conway, & Cronan, 1988). Smokeless tobacco is
used by 16.1% of Naval personnel. A 1987 Navy report (Cronan
& Conway, 1988) found about 28% of incoming recruits were
regular smokers with another 13% claiming to be former
smokers.
An informal tobacco use survey was conducted by the
dental staff at the Orlando Recruit Inprocessing Facility.
The survey was designed by Lieutenant Commander David
Grochmal, Dental Corps, and was accomplished as part of the
dental screening process. The survey was conducted from
March to October, 1990 and included over 13,000 recruits.


124
Ikhowlepge or shoring policy
11. Do you know what tho pacific
ruins tr for saoking or using other
tobacco products while at this
coaaand?
0 No 0 Yes
12.How often were the coaaand saoking
rules enforced during recruit
training? HALT 0 T
TBE TIKE
0%10120130%40%50I60%70%801901100%
0000000000 o
NEVER ALWAYS
13.Were these saoking rules enforced
for everybody?
O No O Yes
20.How iaportant is it to you to not usi
tobacco products?
O !Tot at ail important O Very important
0 Somewhat important 0 Extremely
O Moderately important important
21.What percent of the U. 8. population
do you think are current eaokers?
0 20% 0 30% 0 40%
O 30% 0 60% 0 75%
22*What percent of all aeabars of the
Wavy do you believe are current
saokers ?
0.20% 0 30% O 40%
0 50% O 60% O 75%
14.How often did people sneak a
cigarette even though they were in a
saoking restrictive area?
0 Never O Sometimes 0 Always
O Rarely 0 Usually
23.Should tobacco coapanies be allowed
to target advertising toward certain
groups in order to recruit new
cuetoners ?
O No 0 Yes
15.Would you be in favor of being
placed in a saoke-free work eaviroaaent
after leaving RTC?
0 No O Yes
16.How do you think that the saoke-
free policy at your recruit training
coaaand will influence your tobacco
use after leaving that coaaand?
O NA-I was not a tobacco user
0 Will help me STOP using tobacco
O Will help me REDUCE my tobacco use
O Will NOT CHANGE my tobacco use
0 PROBABLY WILL INCREASE my use
17.How do you think the saoking
education classes offered at recruit
training coaaand will influence your
tobacco use after leaving the
coaaand?
0 NA-I was not a tobacco user
0 Will help me STOP using tobacco
0 Will help me REDUCE my tobacco use
0 Will NOT CHANGE my tobacco use
0 PROBABLY WILL INCREASE my use
I ORIENTATIONS I
18.Do you believe saoking..
a) is related to heart
disease?
b) is related to cancer?
c) is related to emphysema?
d) is addictive?
19.Are you concerned about
the health effects of...
a) Cigarettes?
b) Cigars/Pipes?
c) Chewing Tobacco?
d) Snuff/Dip?
No
Yes
0
0
0
O
0
0
0
0
NO
Yes

0
0
0
0
0
0
0
[INTENTIONS 1
24.On a scale of 1 5r bow likely
are you to start saoking cigarettes
after graduation froa recruit
training?
1 2 3 4 5
not very likely definitely will
25.On s scale of 1 5, bow likely
are you to start using saokeless
tobacco products after graduation
froa recruit training?
1 2 3 4 5
not very likely definitely will
In the future, do you see
yourself as
No
Yes
26.Someone who saokes?
O
O
27.Someone who uses
saokeless tobacco?
In the future are you
likely to be a non-user
of tobacco.
O
0
28. Out of concern for
your health?
0
0
29. Because a medical
professional has told you
to quit?
0
0
30. Because of the cost of
tobacco products?
0
0
31. Because of social
pressures not to use
tobacco ?
0
0
32. Because of hassles
related to smoking
restrictive areas?
0
0
33. Because few of your
peers/friends use
tobacco ?
0
0


5
training may be affected several ways: 1) they may have never
considered themselves smokers and may not start again; 2) the
eight week gap may represent a brief lapse in their
development cycle, and they may continue to smoke whether or
not they see themselves as future smokers; or 3) they may
think they can stop just as easily in the future, feel immune
to possible risks, be influenced by smoking friends they
subsequently meet, and eventually progress to the last stage
of development.
Recruits who progress to the last stage of smoking
development before entering the Navy should relapse like any
other ex-smoker in the cessation population. However, one
would expect these recruits to exhibit some relapse
differences in that most have not really quit smoking
voluntarily; they quit, not by choice, but to conform to
existing policy. Since smoking relapse rates have never been
studied for this type of population it is difficult to
predict exactly what will effect reduction of relapse.
The transtheoretical model of behavior change, as
applied to smoking cessation (Prochaska & DiClemente, 1983),
shows that smokers cycle through various stages (pre
contemplation, contemplation, action, and maintenance) in
their quit attempts. Progression through these stages
requires voluntary incorporation of a number of processes of
change. Smoking recruits are placed into the action stage
and may revert to their pre-recruit stage upon graduation and
reinstitution of free-choice concerning tobacco use.


82
Results
Smoking relapse
Participants were asked to respond to questions
regarding current smoking status, as part of each of the
three surveys. Current smoking status for the pretest
reflected status just before entering recruit training. A
summary of current smoking by treatment group, at each
measurement period, is presented in Table 9. This table also
shows the smoking relapse rate for each treatment group.
Table 9. Percent of current smokers at each measurement
period
Treatment
qroup
1
2
3
4
Total
n=161
n=171
n=166
n=69
N=496
Pre
50.7%
35.8%
46.3%
39.1%
43.3%
(71)
(54)
(63)
(27)
(215)
Post
27.1%
3.8%
2.6%
18.9%
10.2%
(19)
(5)
(3)
(11)
(38)
F/U
42.5%
25.5%
33.7%
25.0%
32.7%
(34)
(25)
(28)
(5)
(92)
Relapse
Rate
82.5%
66.6%
76.5%
66.6%
75.5%
Note: Actual
numbers
in parentheses
While relapse
rates (at follow-up)
are lower
among
participants in the treatment groups, results of chi-square
statistics calculated for these differences showed they were
not significantly different than the control (x2 = 1.68,
p>.l). Since the RTC smoking policy still applied to


CHAPTER 5
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
"The reason I don't smoke is because I don't want my
younger brothers and sisters to smoke, and they look up
to me"
-A Navy recruit, Sept 1991
Summary
This study examined the impact of an education program
on smoking knowledge, attitudes, and intentions of Navy
recruits undergoing 8 weeks of training in a normal no
smoking environment. The study also examined smoking relapse
and cigarette consumption subsequent to recruit graduation.
Specifically the study was designed to: (1) add to the
literature information on effective prevention and cessation
of smoking using education techniques; (2) measure effect of
current no-smoking policy at Recruit Training Center,
Orlando, FL; (3) examine differences in observed levels of
the above listed variables, for various treatment conditions;
(4) examine smoking initiation rate differences (for non-
smokers prior to recruit training) for various treatment
conditions; and (5) examine variables affecting smoking
relapse.
107


161
U.S. Public Health Service. (1964). Smoking and health.
Report of the advisory committee to the Surgeon General
of the Public Health Service (PHS Publication No. 1103).
Washington, DC: U.S. Government Printing Office.
Wall, M. A., Johnson, J., Jacob, P., & Benowitz, N. L.
(1988). Cotinine in serum, saliva, and urine of
nonsmokers, passive smokers, and active smokers.
American Journal of Public Health. 76. 699-701.
Wojcik, J. V. (1988). Social learning predictors of the
avoidance of smoking relapse. Addictive Behaviors. 13,
177-180.
Zolton, M. (1991, June 17). Study shows Navy needs stronger
kick the habit message. Navy Times, p. 17.
Zolton, M. (1992, April 13). Medical toll. Naw Times. p. 4.


42
of the disease symptoms, they feel these effects are a long
way off, and they will be able to stop smoking well before
disease onset. In general, adolescents feel invulnerable to
accidents and chronic diseases (Glanz, Lewis, & Rimer, 1990).
One of the axioms of health education is that knowledge
is necessary, but not sufficient for behavior change.
Information is necessary but not sufficient for knowledge
(Rimer, 1990). Therefore, teaching young students about the
long term effects of smoking may be a good tactic, but by
itself, will not win the prevention war.
In order for people to quit smoking for health reasons,
they must believe cessation will benefit their health, and
also that they are capable of quitting (Rosenstock, 1990).
Knowledge about the risks of smoking is better now than it
ever has been. The 1989 Surgeon General's report (USDHHS,
1989) states the proportion of adults who believed cigarette
smoking increases the risk of emphysema and chronic
bronchitis rose from 50% in 1964 to 81% (chronic bronchitis)
and 89% (emphysema) in 1986. These proportions increased
among current smokers from 42% in 1964 to 75% (chronic
bronchitis) and 85% (emphysema) in 1986. Johnston et al.
(1989) reported that 70% of young adults perceive regular
pack-a-day cigarette smoking as entailing high risk. Despite
these findings, and despite the fact that 80% of all smokers
indicate a desire to quit, over 50 million Americans still
smoke.


67
The videos used were:
"The Performance Edge", from the U.S. Department
of Health and Human Services. It shows the effect
of tobacco and alcohol on performance. A
motivational pitch for non-use is given
"The Feminine Mistake", from Pyramid films. Shows
the physiological effects of smoking, benefits of
quitting, and long term hazards of smoking
"Clearing the Air", from the U.S. Navy. Shows
the effects of smoking, Navy tobacco use policies,
and strategies to quit and stay quit.
The videos used were previewed by 12 recruits 7 weeks before
the education intervention began. Positive feedback was
received for their use in the curriculum.
Posters were displayed throughout the classroom. Poster
placement was the same for each lecture period. Those used
were from the American Cancer Society, and included:
Animals-"It looks as stupid when you do it"
#F-651/90
Animals-"Butts are gross" #F-652/90
"Smoking is very debonair" #2163.03-LE
"Smoking is very sophisticated" #2163.02-LE
"Smoking is very glamorous" #2163.01-LE
"Smoking doesn't work" #2418.04-LE
"Life, the only race you don't win by finishing
first...Don't smoke" #2122.LE
"Are you a draggin lady?


56
(AFQT) score was 65.76 (SD=18.62). The AFQT score provides a
measure of general trainability of recruits. The Navy
requires a minimum AFQT score of 17 with a high school
degree, 31 for other credential holders, and 50 without a
high school diploma (Foley & Rucker, 1989). Seventy-eight
percent of participants were white, 15% were black, 5% were
Hispanic, and 2% were from other ethnic backgrounds.
Recruit training is an intensive 8 week program designed
to indoctrinate the new members as to the ways of Navy life
and prepare them for military duties. The mission of RTC
Orlando is to conduct a training program which will effect a
smooth transition from civilian to Navy life; foster
patriotic behavior; affirm the dignity of the individual;
encourage high standards of personal responsibility, conduct,
manners, and morals; create a desire for self-improvement and
advancement; provide the recruit with knowledge and skills
basic to all naval personnel; develop pride in the unit and
in the Navy and a desire to observe appropriate naval
customs, ceremonies, and traditions; and provide the
Department of the Navy with personnel possessing an effective
level of physical fitness. The mission is carried out
through an intense training and educational program.
The educational program includes health/hygiene classes,
and classes on substance abuse. The current curriculum
however, includes no specific tobacco-use prevention
information (CNTECHTRA, 1991a). There are approximately 75 -
85 recruits in each company and about 5 classes start every


75
Data Preparation
Once the surveys were completed the answers were
transferred to a 240 item general purpose answer sheet
formatted for optical mark reading. The number of questions
asked on the three surveys totalled 279. Many of the answers
were eliminated or combined so that only 168 data points were
actually coded. The answer sheets had only five response
circles per answer. Some survey questions that had more than
five responses had to be collapsed to fit this requirement.
This was done consistently for questions which were repeated
in surveys. All answers were coded by numbers one through
five (eg. No=l; Yes=2) for data entry, and a survey layout
(codebook) was composed to avoid confusion during analysis.
This layout was used during the coding process to ensure
answers were coded consistently and transferred to the
appropriate circles on the answer sheets. This process was
completed by two individuals who were versed on the
procedure. This process was chosen for a number of reasons
including:
-multiple surveys were involved
-illogical answering could be identified before entry
-the answer sheets could be re-scanned in the event of
data file loss on the computer
-computer entry errors, due to the large data set, could
be minimized.


25
This survey found 39.7% (34.1% male and 56.7% female)
reported they were smokers before entering the Navy. Also,
7.4% of the men indicated they were smokeless tobacco users
(Grochmal, 1990).
In 1988 a survey of high school seniors and young adults
(Johnston, et al., 1989) found an 18% prevalence of daily
smoking for seniors and a 29% rate of current (casual)
smokers. This same study reported a drastically higher
smoking rate in respondents 1-4 years past high school who
were not in college. Other studies have shown that smoking
rates are higher for seniors who do not plan on pursuing
higher education (Glynn, 1990; Johnston et al., 1991). Since
the majority of the recruit population comes from this group,
the higher recruit smoking prevalence is not surprising.
Though the vast majority of Navy recruits have a high school
diploma (or equivalent), some have obtained it in a non-
traditional manner, and thus are part of a group at much
higher risk to smoke.


86
knowledge score range was zero to six. The mean knowledge
gain for non-relapsers was 0.95 (16%) and for relapsers was
0.34 (6%). This difference was significant (F = 5.09, df =
1# 77, p<.l).
In an effort to understand why recruits start smoking
again after boot camp, participants were asked to list
reasons they began smoking again. The top five reasons
relapsers listed for starting smoking after boot camp were:
- "It calmed me" 81%
- "I liked the taste 56%
- "Parents or friends back home smoke" 53%
- "Friends smoked" 49%
- "I had no desire to quit" 44%.
Smoking initiation
The other side of the smoking status analysis concerned
non/former smokers who began smoking during the three month
follow-up period. Table 12 is a summary of smoking
initiation by treatment group.
Table 12.
Percentage
smoking
initiation
Treatment
group
1
2
3
4
Total
Smoking
2.5%
7.3%
4.1%
7.1%
5.3%
started
(1)
L5J
L2J
J
L2J
Note: Actual numbers in parentheses


APPENDIX F
EDUCATION CURRICULUM
UNIVERSITY OF FLORIDA
DEPARTMENT OF HEALTH SCIENCE EDUCATION
#4 FLG
GAINESVILLE, FLORIDA 32611
TOPIC: Recruit Tobacco Prevention
INSTRUCTIONAL MATERIALS:
TRAINING AIDS:
1. Chalkboard/chalk/eraser
2* TV monitor/ Video projector
3. 1/2 inch VCR
4. 3/4 inch VCR
5. Video "Performance Edge"
6. Video "The Feminine Mistake"
7. Video "Clearing the Air"
SAVPEN # 803504DN
8. Tobacco training aids:
-consequences of smoking
-mechanical smoker
-passive smoke demo
-Mr. Grossmouth
9. Overhead/transparencies
TERMINAL OBJECTIVE:
1. Upon completion of this lecture the student will be able to
recall the main benefits of not using tobacco after recruit training,
with 90% accuracy.
ENABLING OBJECTIVES:
1. The student will be able to:
a. give the true side of the smoking myths discussed
b. describe the RTC smoking policy and the overall Navy
stance on tobacco use
c. describe the short and long term effects of tobacco use
d. describe common reasons for starting and continuing to
smoke cigarettes, and use other tobacco products
e. describe strategies to remain tobacco-free after RTC
graduation.
CRITERION TEST: PREPARED BY: DATE:
1. None LCDR T.L. POKORSKI 23AUG91
133


34
Baer, 1988; Shiffman et al., 1985; Stevens & Hollis, 1989).
In a randomized study using skills training and social
support as relapse prevention methods, Stevens and Hollis
(1989) found skills training significantly decreased relapse
rates, while social support showed no significant differences
from a no-treatment control.
In addition to skills training, the National Institutes
of Health (NIH) say information about the health and social
consequences of smoking is critical for cessation (Glynn et
al., 1991). Gibbons, McGovern, and Lando (1991) showed the
utility of including information on the risks of smoking as
well as the benefits of quitting, in a study of relapse in a
smoking cessation clinic. The NIH study states high risk
perception declines significantly over time for those who
fail in their quit attempt. Perception is an important
factor related to cessation commitment and efforts to
counteract this tendency to decline may reduce relapse rates,
or may help relapsers maintain cessation motivation to try
again. Several studies suggest booster sessions may help
maintain motivation to stay quit when used as part of a
multicomponent strategy (Brink, Simons-Morton, Harvey,
Parcel, & Tiernan, 1988; Brownell et al., 1986). Brownell et
al. (1986), suggest booster sessions may be useful in the
perception that one is part of a continuing process of
change. They also point to the usefulness of giving self-
help manuals to those who have quit, as another means of
enhancing vigilance in maintaining non-smoking. They believe


153
Conway, T. L., & Cronan, T. A. (1988). Smoking and physical
fitness among Navy shipboard personnel. Military
Medicine. 153. 589-94.
Cronan, T. A., & Conway, T. L. (1988). Is the Navy attracting
or creating smokers? Military Medicine. 153. 175-178.
Cronan, T. A., Conway, T. L., & Hervig, L. (1989). Evaluation
of smoking intervention in recruit training. Military
Medicine. 154. 371-375.
Curry, S., Marlatt, G. A., & Gordon, J. R. (1987). Abstinence
violation effect: Validation of an attributional
construct with smoking cessation. Journal of Consulting
and Clinical Psychology. 55. 145-149.
Curry, S., Marlatt, G. A., Gordon, J., & Baer, J. S. (1988).
A comparison of alternative theoretical approaches to
smoking cessation and relapse. Health Psychology. 7,
545-556.
Epstein, L. H., Grunberg, N. E., Lichtenstein, E., & Evans,
R. I. (1989). Smoking research: Basic research,
intervention, prevention, and new trends. Health
Psychology. 8, 705-721.
Ershler, J., Leventhal, H., Fleming, R., & Glynn, K. (1989).
The quitting experience for smokers in sixth through
twelfth grades. Addictive Behaviors. 14, 365-378.
Evans, R. I., Hansen, W. B., & Mittelmark, M. B. (1977).
Increasing the validity of self-reports of smoking
behavior in children. Journal of Applied Psychology. 62,
521-523.
Fagerstrom, K. 0. (1978). Measuring degree of physical
dependence to tobacco smoking with reference to
individualization of treatment. Addictive Behaviors. 3,
235-241.


52
al., 1987). Other studies have also set non-smoking values
at 50 ng/ml (Fitzpatrick, 1991; Jarvis et al., 1987).
Fitzpatrick sums up nicely the benefits of cotinine
analysis:
The cotinine assay used today can determine either
active or passive exposure to tobacco smoke. It is
specific for exposure to nicotine. It can use urine,
which like saliva, is easy to collect, but it can also
use serum. It has a long half-life of 16 hours so that
a person cannot easily prepare for the test by not
smoking for short periodsideally, an assay should be
able to detect an individual who has not smoked for 48
hours. It is inexpensive, so that it may be performed
routinely in large screening programs. (Fitzpatrick,
1991, p.ll)
There is no biochemical test which can be expected to
yield perfect separation of non-smokers passive smokers, and
active smokers under field conditions. Wall et al. (1988)
give several reasons for this: intersubject variance in
nicotine metabolism, time of day of sample collection,
underreporting of active smoking, adjustment of cigarette
consumption for nicotine content, and perhaps over or
underreporting of passive smoke exposure. However, the use
of biochemical analyses definitely increase the validity of
smoking self-reports.
Concluding Statement
Because of the impact of health, health care costs, and
readiness, the Navy Surgeon General has set a goal of a
Smoke-Free Navy by the year 2000. Prevention efforts in new


83
participants at time of posttest, indications of current
smoking were considered violations of rules (smoking on
liberty) rather than relapse. The education treatment groups
(Groups 2 & 3) showed lower violation of smoking rules and
results of chi-square analysis showed these differences to be
significant (x2 = 22.08, pc.001).
Several variables were examined that may have confounded
the relapse results: participant gender, AFQT scores,
Fagerstrom nicotine tolerance scores, age started smoking,
and cigarette consumption prior to entry. Covariance of the
continuous variables (AFQT and Fagerstrom scores) was
initially examined by a general linear means procedure (SAS
PROC GLM) to determine if further analysis was warranted.
Categorical modeling procedures were then run
controlling for the variables of possible significance.
Table 10 summarizes the smoking status at entry and relapse
rate by gender, for the study population.
Table 10. Percent of current smokers by gender and
corresponding relapse rates
Male
Female
Current smokers at
40.9%
49.6%
entry
Relapse rate
72.6%
79.2%
The differences seen in relapse rate by gender were found not
to be significant (x2 = .634, p>.l).


109
chi-square statistic, and a categorical modeling procedure
(SAS PROC CATMOD).
The results indicated subjects in the education only
treatment relapsed to smoking less frequently than the
control or education plus booster groups, but these group
differences were not statistically significant. No signifi
cant group differences were observed for smoking initiation,
though the overall smoking initiation rate observed was less
than anticipated. A knowledge gain was observed for all
subjects, but the only significant treatment group difference
occurred between the education only and control groups.
Positive changes in smoking attitudes were observed for all
subjects and differences were significant between the
education groups and the control and sham groups. No added
booster effect was observed for smoking attitudes or
knowledge. The booster treatment subjects showed the only
consistent improvement in positive future smoking intentions,
but the effect was not significant. A significant education
effect was seen in reducing the number of recruits violating
the no-smoking policy during the uncontrolled liberty
weekend. An overall decrease in cigarette consumption was
observed for smoking relapsers in all categories, but the
only significant changes occurred in the education only
group.


105
The results of this study can be used to design a
comprehensive smoking prevention/smoking cessation program to
be used at all Recruit Training Centers. Knowledge of why
recruits use tobacco and why smokers relapse after graduation
will allow interventions to be better tailored to this group.
Retaining methods that seem to reach light smokers while
adding methods to affect heavier smokers better would be
prudent. For example: knowing 81% of smokers indicated they
started smoking again after boot camp because "it calmed me",
suggests a stronger stress coping skills section must be
incorporated in programs.
Findings concerning the type of smokers entering the
Navy can be used to better target cessation efforts for the
general Navy population. If most of the smokers relapsing
after boot camp are the heavier more addicted ones, then
cessation efforts need to address them. The reasons given by
these smokers (eg. stress relief, peer pressure, boredom) can
be used to help these individuals cope with relapse. Navy
cessation programs need to be adapted to specifically help
the Navy smoker.
Cautions
As with any study, the reader should be cautious to not
assume too much from the results of the present study.
Significant differences found have been combined with trends
observed in an effort to explain the results. The reader


49
conducted a study to determine effectiveness of the approach
and effectiveness of different methods of message delivery.
Their data supported the hypothesis that adolescent smokers
are more willing to disclose cigarette use under pipeline
conditions. They concluded it is both prudent and
conservative to employ as credible a pipeline procedure as
possible, and use of this procedure offers the best assurance
of a valid assessment.
Biochemical Tests
A number of biochemical markers can be used to validate
smoking self-reports including measures of thiocyanate,
carbon monoxide, nicotine, and cotinine (Fitzpatrick, 1991;
Jarvis et al., 1987; Sepkovic & Haley, 1985). Levels of
carbon monoxide and thiocyanate (a metabolite of hydrogen
cyanide) are easier and less expensive to determine, but may
be raised through exposures unrelated to smoking, such as
auto emissions and diet (USDHHS, 1988; Jarvis et al., 1987).
Neither can they be used as a marker for smokeless tobacco.
All tobacco products contain substantial amounts of nicotine,
which is absorbed from tobacco smoke in the lungs, and from
smokeless tobacco in the mouth and nose. Nicotine is
metabolized in the liver and lungs, and cleared from the body
by the kidneys (USDHHS, 1988). Measures based on nicotine
have the advantage of being tobacco specific (all forms of
tobacco), but require extensive laboratory instrumentation.


results recommend that smoking prevention/cessation education
be part of recruit training, but further research is needed
to identify more effective ways of reaching the heavier,
addicted smokers entering the Navy.
ix


30
they were probably in a lower stage before they came in. No
previous studies have reported or predicted what effect this
will have. It is not known what effect this will have on
their intentions to stay quit. Certainly it will show they
are capable of not smoking for an extended period of time.
What is known is young adult smokers do quit, or at least
attempt to quit, smoking. Thirteen percent of recruits
surveyed indicated they were former smokers (Cronan & Conway,
1988). A prospective cohort study from pre-adolescence to
young adulthood (Swan, 1991) found about 14% of 21 22 year
olds reported being ex-smokers. Another study (Ershier,
Leventhal, Fleming, & Glynn, 1989) states 52% of 6 12 grade
smokers had indicated at least one quit attempt. A survey by
Tuakli et al. (1990) indicated 69% of the 12 20 year old
smokers had tried to quit. The top reasons for quitting
were: 1) didn't enjoy smoking, 2) health concerns, 3)
pregnancy, 4) costs, and 5) parents or friends asked. This
indicates even young smokers are aware of the risks of
smoking, and some may have progressed through the cycle of
changing their smoking behavior.
Relapse is defined in the literature as a smoking
episode after a period of voluntary abstinence that is
followed by a return to continuous smoking (O'Connell, 1990).
To include recruit graduates in this category may be
stretching this definition, but since we now have an all
voluntary armed forces, all recruits enter the Navy of their
own free will. All recruits may not enter with the intention


96
1985). The cessation programs normally studied are voluntary
cessation programs. The overall relapse rate in this study
of 76% is in agreement with previous research even though
this study was a non-voluntary program. Though the results
indicate no significant differences in relapse rates between
treatment groups, several confounding variables seemed to
influence the significance.
Unlike the results of Blake et al. (1989) this study did
not find significant relapse differences due to gender
(though relapse rate for women was higher). Results of
smoking intention by gender, though, were similar to the
finding of Blake et al. They found women more tentative and
less committed to quitting completely; the present study
found that while 83% of men initially reported an intention
not to smoke only 68% of women indicated the same intention.
This difference in future smoking intentions cannot be
explained by the difference in smoking status alone.
Nicotine tolerance and cigarette consumption at entry
proved to be the best indicators of relapse in this study.
These results are in agreement with the study by Gritz et al.
(1991) and the meta-analysis of behaviorally based smoking
cessation studies by Glasgow and Lichtenstein (1987). The
results of the present study support what many retrospective
studies have alluded to previously (Hughes & Hatsukami,
1986), that withdrawal symptoms affect short and long term
quitting. The results are not the same as seen in the study
by Cronan et al. (1989) who found entry cigarette consumption


135
-The Navy is full of complicated jobs, jobs which many of you will
be expected to perform before long.
No matter what your chosen rating you will be working on most jobs as
a team. Whether it be painting the hull of a ship or preparing a
multimillion dollar jet aircraft for flight every team member is
counted on to perform to his/her best ability. Youll start by doing
what you think are trivial tasks but will quickly work up to where you
are supervising the whole task. This is why you will hear so many
messages about maintaining top performance. Anything that affects the
performance of one person can affect many others in a military
environment.
Smoking Myths
ASK How many smokers in the Navy
How many smokers in the general U.S. population
WRITE correct numbers on board
NAVY 43%
U. S.28%
1. Harmful effects of smoking are exaggerated?
How many deaths per year are related to smoking?
500,000/yr
- if you all were smokers ( 1 murdered, 2 traffic accidents, 25
smoking related diseases) WRITE on board (double for 2
companies)
What is the biggest cause of these excess deaths?
#1 (50%) Heart disease drug effect of nicotine on circulatory system
#2 Lung cancer
#3 Other cancers (trachea, bladder, mouth, throat, esophagus)
Smokeless
#4
Emphysema, bronchitis


160
Swan, A. V. (1991). Smoking behavior from pre adolescence to
young adulthood. Aldershot, England: Glover House.
Thompson, S. G., Stone, R., Nanchahal, K., & Wald, N. J.
(1990). Relation of urinary cotinine concentrations to
cigarette smoking and to exposure to other people's
smoke. Thorax. 45. 356-361.
Tuakli, N., Smith, M. A., & Heaton, C. (1990). Smoking in
adolescence: Methods for health education and smoking
cessation. The Journal of Family Practice. 31. 369-374.
U.S. Department of Health and Human Services. (1986). The
health conseouences of involuntary smoking. A report of
the Surgeon General (DHHS Publication No. CDC 87-8398).
Washington, DC: U.S. Government Printing Office.
U.S. Department of Health and Human Services. (1987).
Smoking, tobacco, and health: A fact book (DHHS
Publication No. CDC 87-8397). Washington, DC: U.S.
Government Printing Office.
U.S. Department of Health and Human Services. (1988). The
health conseouences of smoking: Nicotine addiction. A
report of the Surgeon General (DHHS Publication No. CDC
88-8406). Washington, DC: U.S. Government Printing
Office.
U.S. Department of Health and Human Services. (1989).
Reducing the health conseouences of smoking: 25 years of
progress. A report of the Surgeon General (DHHS
Publication No. CDC 89-8411). Washington, DC: U.S.
Government Printing Office.
U.S. Department of Health and Human Services. (1990a). The
health benefits of smoking cessation. A report of the
Surgeon General (DHHS Publication No. CDC 90-8416).
Washington, DC: U.S. Government Printing Office.
U.S. Department of Health and Human Services. (1990b).
Smoking and Health, a National Status Report (DHHS
Publication No. CDC 87-8396 [Revision 02/90]).
Washington, DC: U.S. Government Printing Office.


BIOGRAPHICAL SKETCH
Thomas Lee Pokorski was born on 21 April, 1953, in
Huntington Park, Californiaa suburb of Los Angeles. He
graduated from Pius X High School in Downey, California, in
1971. He attended one year at the University of California,
Los Angeles, during which time he received a draft lottery
pick of "2" and joined the U.S. Navy.
Tom has served on active and reserve duty with the Navy
since 1972. Entering as a seaman apprentice, he attended
Hospital Corps "A school and Operating Room Technician "C"
school before serving three years aboard the USS Prairie. He
performed three years reserve duty with the 1st Marine
Division Medical Detachment while finishing his undergraduate
degree. In 1979, after completion of his baccalaureate and
Aviation Officer Candidate School, he received a commission
of Ensign. Two years later he moved to the Navy's Medical
Service Corps and was designated as an Aerospace
Physiologist. He has served in this capacity the past 10
years in tours with the Naval Medical Clinics Command, San
Diego, Commander Training Air Wing Six, Pensacola, and Marine
Air Group Thirty-one, Beaufort, SC. Throughout his career
Tom has expressed an interest in conveying health knowledge,
and motivating others to choose healthy lifestyles.
162


This study included 496 recruits (357 men and 139
women), in seven companies. Companies were randomly assigned
to 4 treatment conditions: (1) policy only comparison; (2)
policy plus education; (3) policy plus education, with a
booster; and (4) policy plus sham treatment. Tobacco use
knowledge/behavior surveys were administered to all subjects
at the beginning of recruit training, at graduation, and
three months after graduation. Subjects in both education
groups received a three-hour education intervention. The
booster group received an additional hour-long booster
program at the end of the training cycle. Cotinine analyses
of randomly selected urine samples were performed
concurrently with pre- and postsurveys.
Data analysis was accomplished using repeated measures
analysis of variance, frequency tables incorporating
Pearsons chi-square statistic, and categorical modeling
procedures (SAS PROC CATMOD). Results indicated significant
educational effects for smoking knowledge and attitude
scores, reduced violation of liberty no-smoking rules, and
cigarette consumption for relapsers. No significant
treatment group differences were noted for relapse rate,
smoking initiation, or smoking intentions.
In summary, the education program used, though not
significantly affecting smoking relapse in the short term,
may positively affect future cessation attempts. The best
predictors of smoking relapse in Navy recruits were nicotine
addiction and heavy prior cigarette consumption. Study
viii


152
Bray, R. M., Marsden, M. E., Guess, L. L., Wheeless, S. C.,
Iannacchione, V. G., & Keesling, S. R. (1988). 1988
worldwide survey of substance abuse and health behaviors
amono military personnel (Report No. RTI/4000/06-02FR).
Research Triangle Park, NC: Research Triangle Institute.
Bray, R. M., Marsden, M. E., & Peterson, M. R. (1991).
Standardized comparisons of the use of alcohol, drugs,
and cigarettes among military personnel and civilians.
American Journal of Public Health. 81. 865-869.
Brink, S. G., Simons-Morton, D. G., Harvey, C. M., Parcel, G.
S., & Tiernan, K. M. (1988). Developing comprehensive
smoking control programs in schools. Journal of School
Health. 58, 177-180.
Brownell, K. D., Glynn, T. J., Glasgow, R., Lando, H., Rand,
C., Gottlieb, A., & Pinney, J. M. (1986). Task force 5:
Interventions to prevent relapse. Health Psychology. 5
(Suppl.), 53-68.
Carmody, T. P. (1990). Preventing relapse in the treatment of
nicotine addiction: Current issues and future
directions. Journal of Psvchoactive Drugs. 22, 211-238.
Carroll, D. A., Lednar, W., & Carter, W. B. (1989). The short
term impact of Army smoking policies. Military Medicine.
154. 603-607.
Centers for Disease Control. (1991a). Cigarette smoking and
youth-United States, 1989. Morbidity and Mortality
Weekly Report. 40, 712-715.
Centers for Disease Control. (1991b). Smoking-attributable
mortality and years of life lostUnited States, 1988.
Morbidity and Mortality Weekly Report. 40. 62-63; 69-71.
Chief of Naval Technical Training. (1991a). Recruit training
syllabus: Lesson topic 2.22 & 3.10B. Millington, TN:
U.S. Navy.
Chief of Naval Technical Training. (1991b). [Statistical
averages for U.S. Navy recruits]. Unpublished raw data.


12
(6) Follow-up surveys were mailed to participants'
command, whenever possible, in an effort to increase
response.
Limitations
(1) Because previous research with the study population
was minimal, techniques used successfully with other
populations were adapted for the study.
(2) The original study population was reduced to its
final number due to unavoidable attrition resulting from
medical problems, reading aptitude, drug test results,
voluntary drops, and a number of other factors.
(3) Only recruits from one of the three Navy recruit
training facilities were used.
(4) Several potential threats to internal validity
remained beyond experimental control including company
commander influence, and seasonality differences in
recruits.
(5) Cotinine analysis was not accomplished for each
subject nor for each survey period.
(6) Addresses for follow-up mailings were obtained from
a Navy computerized personnel tracking network which may
be less than 100% accurate.


72
Clearing the Air: How to Quit Smoking and Quit
for Keeps National Cancer Institute NIH
Publication No. 89-1647.
These pamphlets are comprehensive guides to quitting smoking.
They cover much of the information which was given in class
and contain many suggestions to help avoid relapse. A wallet
card (see Appendix H) was also given to the recruits. This
card lists 5 reasons to remain tobacco-free and 5 ways to
avoid smoking.
The first part of the class period involved going
through the materials distributed. Those who had never
smoked were asked to pass the materials on to a friend or
relative who does smoke, or save it for a smoking shipmate
they may meet later. The ex-smokers were asked to keep the
material for future reference and to place the card in their
purse of wallet for reference as necessary after graduation.
A nineteen minute video (Hazards of Tobacco) was then
shown. This video was made by Captain David Moyer, a Navy
physician who has taught the material in the video to over
50,000 Navy and Marine Corps recruits at training centers in
San Diego, California. This video also covered many of the
same points the education intervention covered, as well as
some different reasons for the recruit to not start/resume
tobacco use.
The recruits were then asked to sign a pledge to assist
the Navy in reaching its goal of being smoke-free by the year
2000. Each recruit received a certificate of participation


84
The Fagerstrom scores were transformed to categorical
form by creating two levels:
- low tolerance (Fagerstrom scores 1-6)
corresponding to low nicotine addiction
- high tolerance (Fagerstrom scores 7-11)
corresponding to high nicotine addiction.
Table 11 summarizes nicotine tolerance level reported at
entry and corresponding relapse rates.
Table 11. Nicotine tolerance levels reported with
_____^__corresgondin2_rela£se_rates___^_____
Nicotine Tolerance
Level
Low
Hiqh
Reported at entry
74.7%
25.3%
Relapse Rate
76.1%
96.8%
The data seen in Table 11 seems to indicate that smokers
reporting a high nicotine tolerance relapsed to smoking at a
higher rate. The differences seen in relapse rate by
nicotine tolerance level were found to be significant (x2 =
3.58, p<.l).
Another category that seems to affect smoking relapse is
the number of cigarettes smoked prior to entry in recruit
training. Figure 1 summarizes the relapse rates for given
categories on smoking at entry.


140
addiction is part of the reason it is so hard to stop using tobacco
after regular use
Smoking can cause short term problems other than just to the smoker
themselves
-passive smoke (that smoke expelled to the air around the smoker)
cause eye, nose, and lung irritation to those around the smoker, and
can cause some headaches, nausea, and dizziness
-lung cancer risks for non-smoking spouse of smokers has been
shown to be increased by 30%
-non-smokers exposed to 20 cigarettes or more per day at home or
work, have their lung cancer risk doubled
-children of smokers have higher incidence rates of colds,
bronchitis, chronic coughs, ear infections, and reduced hearing
function
-babies born to smoking mothers have a greater chance of being born
prematurely too small and too soon nicotine, CO, and other
chemicals are passed from mother to the baby's bloodstream
-tar from cigarette smoke has been found to damage sensitive
equipment and clog air filtration systems in aircraft and other v
essels
These type of reasons have driven the Navy to set the no-smoking
policies that have been instituted
-to protect non-smokers by providing a healthy work area
-to protect sensitive/expensive equipment
-create a healthy work environment, and encourage smokers to make
the decision to quit
Again, the Navy is not anti-smoker, but rather anti-smoke
Short term problems for smokeless tobacco users include bad breath,
discolored teeth, gum recession, and tooth destruction
-can also contribute to increased risk of cardiovascular disease,
especially in individuals with high blood pressure
MENTION MR 6ROSSMOUTH


101
attention paid by the sham education session or confounding
variables such as company commander influence.
Intention not to smoke in the future is one of the
variables that did seem to be affected by the booster
program. Though time effect in treatment Group 3 was not
significant, this group was the only one which showed a
continual rise with time. All the other treatment groups
showed inconsistent intention changes across time. No
variables examined, other than the booster program, seem to
explain the intention change seen in the booster group. The
role of boosters session in changing intention is in
agreement with the suggestions given by Glynn et al. (1991)
for smoking cessation. As mentioned previously, females in
the study showed lower intentions not to smoke. The fact
that the booster group contained a female company, and still
showed a continual increase provides further evidence of a
booster effect.
Intention not to smoke in the future is very important.
Ajzen and Fishbein's (1980) theory of reasoned action views a
person's intention to perform, or not perform, a behavior as
the immediate determinant of the action. Therefore, the next
cessation attempt for smokers in the booster group may come
sooner than for smokers in other groups.
A clear example of how intention predicts behavior in
this population was seen with the pretest question "Do you
intend to resume smoking after graduation?" Relapse for
those who answered probably not was 64%, for those answering


APPENDIX G
SHAM TREATMENT CURRICULUM
UNIVERSITY OF FLORIDA
DEPARTMENT OF HEALTH SCIENCE EDUCATION
#4 FLG
GAINESVILLE, FLORIDA 32611
TOPIC: Recruit Tobacco Prevention
"Sham treatment class"
TIME: 40 minutes
INSTRUCTIONAL MATERIALS:
TRAINING AIDS:
1. Chalkboard/chalk/eraser
2. TV monitor/ Video projector
3. 3/4 inch VCR
4. Video "Weight and Fat Control / Nutrition Education"
SAVPEN # 803507DN
TERMINAL OBJECTIVE:
1. Upon completion of this lecture the student will feel that
they are part of an ongoing program of tobacco prevention in the Navy.
ENABLING OBJECTIVES:
1. The student will be able to:
a.discuss reasons why the Navy is concerned about tobacco
use
b.describe the association of cigarettes and heart disease
CRITERION TEST:
1. None
PREPARED BY:
LCDR T.L. POKORSKI
DATE
22SEP91
146


119
IF YOU HAVE NEVER USED CHEWING TOBACCO
SNUFF OR DIP PLEASE MARK HERE
C and

GO TO *33
32. Below is a list of reasons people give for START-
ING to use CHEWING TOBACCO. SNUFF.
ano/
or DIP For each possible reason, mark NO
or
YES to indicate whether it was a reason why you
started to use any of these tobacco products
mm
no
YES
tm
a) 1 was bored.
0
o
mm
b| Most of my friends did.
o
0
mm
c) I wanted to be coof."
O !
o
d) 1 liked the mage.
1
0
el 1 liked the taste.
O !
o
f) It gave me a kick.
O
o:

g) 1 wanted to show that 1 was tough.
0 1
o
mm
hi 1 wanted to take a dare
/"N .
w
W
w
il It calmed me
O i
O
j) 1 wanted to lose weight.
O :
c

k) 1 wanted to look and feel like an adult.
o:
Q

II 1 wanted to be masculine
o:
O ,
ml 1 didn't want to feel left out of a group
' o ;
c
n| 1 wanted to show 1 wasn t afraid.
O :
o:
m
oi My parents smoked.
o;
O :
p| 1 was curious.
0 !
C
qj Smokeless tobacco was less noticeable to
i :
o:
tm
use m 'restricted'' areas than cigarettes.
J
1

r) Smokeless tobacco was less offensive
Q :
o.
tm
to nonsmokers.
"I
k KNOWLEDGE ON
:l
" SMOKING POUCY
33. Has anyone in authority informed you about
this

command's policy on smoking/tobacco use?
mt
3 No 3 Yes
34 Do you know what the specific rules are for smoking or
using other tobacco products while you are at this
command?
O No 0 Yes
ORIENTATION AND INTENTIONS
£
35. Does it bother you when someone is smoking
around you?
; No 3 Y*s
/N l
36. When you are inside public areas that have no rules
about smoking and someone lights up a cigarette, what
are you most likely to do.?
O-Just do nothino
3 Move i*.* av trom roe person
3 Ask the person not to smnne
3 Someth in soecit*. k
37 Do you neiieve cigarette smoking
11 is related to heart disease?
ai is related to cancer?
ci is related to emphysema?
dl is addictive?
38 Are you concerned about the health effects of
NO
o
o
o
o
YES
Cigarettes?
bl Cigars/pipes?
cl Chewing tobacco?
dl Snuff/dip?
NO
o
0
o
o
yes
o
o
o
o
39 How important is it to you to be a non user of tobacco
products?
^ Not at ail important 3 Very imoort3nt
3 Somewhat important 3£x,rerheiy important
3 Mooerateiv important
f. ,
L\ /> s
Over the next year .
40. If you currently smoke cigar*
ettes, cigars, or a pipe, how
likely is it that you will stop
smoking?
41 If you currently use chewing to
bacco. snuff, or dip. how likely is
it that you will stop using these
smokeless tobacco products.
42. If you currently do not smoke
cigarettes, cigars, or a pipe, how
likely is it that you will reman a
non smoker?
43. If you currently do not use
chewing tobacco, snuff, or dip,
fiow likely is it that you will
remain a non user?
ooooioa
o
o
oooa
dooooa
In the future, do you see yourself as
44 Someone who smokes?
45. Someone who uses smokeless tobacco?
NO f YES
O I o
0 I o
o
o
o
o
In the future, are you likely to be a
NON-USER of tobacco
46 Out of concern for vour health?
47 Because a medical orofessionaf has told
vou to quit?
48. Because of the cost of tobacco products?
49 Because of the social oressure not to use
tobacco?
50 Because of the hassles related to
smoking-restricted areas?
51 Because few of vour peers/friends use
tobacco?
Thank you for Completing This Survey!
O O !
O { C !
ojo:
o! o i
£
v- I
ICI
~ ^ n
^ V
Page 4
oooo


APPENDIX E
CONSENT STATEMENT
You and several hundred other new members of the U.S. Navy have been
selected to participate in this survey. Originally designed by the
Naval Health Research Center to study tobacco use, we are using this
same survey as part of a trial at RTC Orlando to assess tobacco use
before and after "boot camp". Your participation in this study involves
completing the following survey, which should take about 30 minutes and
asks about tobacco use prior to your arrival at RTC. In addition we
will be administering two similar follow-up surveys: one at the end of
your current training and one in approximately five months.
Your participation is strictly voluntary. You do not have to answer any
question you do not wish to answer. Refusal to participate will involve
no penalty or loss of any benefits to which you are otherwise entitled.
All data collected from this survey will be kept at the University of
Florida or the Naval Health Research Center, and will be used for
research purposes only. Please answer questions honestly and to the
best of your ability. In order to assure privacy of your answers, the
personal identification information you provide will be destroyed after
the data is entered into a data base. A non-traceable serial number
will then be assigned to match data to your future survey responses.
In all cases, the data will be reported so that no individual
respondent can be identified. The information gathered will
not become part of your service record or medical record.
A random check of urine samples for the presence of nicotine will be
conducted as a check of accuracy of self-reporting. This is being done
only to satisfy a research procedure requirement and results will in no
way affect you. The urine sample you have already provided will be used
if needed.
By signing this consent form, you state that your participation is
voluntary, without force or duress of any kind. You also acknowledge
that you understand the purpose of this study and that you are free to
withdraw your consent at any time without prejudice to yourself or your
military or civilian career. Should questions arise, feel free to
contact LCDR T.L. Pokorski, University of Florida, Department of Health
Science Education, #5 FLG, Gainesville, FL 32611 / (904)372-7574.
Retain the top portion of this form after signing.
I have read and I understand the procedure described above. I agree to
participate in the recruit tobacco use study and have received a copy of
this description.
SIGNATURES:
Participant date Witness date
132


88
Table 13. Attitude scores at each measurement period and
differences pre to post for all subjects
Treatment
qroup
Total
1
2
3
4
6.31
6.37
6.33
6.23
6.32
Pre
(2.88)
(2.80)
(2.99)
(2.99)
(2.89)
6.46
7.41
7.36
6.87
7.12
Post
(2.93)
(2.58)
(2.65)
(2.73)
(2.71)
6.66
6.49
7.05
6.65
6.71
F/U
(3.09)
(2.94)
(2.77)
(2.89)
(2.92)
Diff.**
0.25
1.05
0.91
0.89
0.83
post-pre
(2.33)
(2.36)
(2.69)
(2.87)
(2-55)
Note: -Standard deviations in parentheses
Differences reflect only subjects completing both pre and post
tests.
Repeated measures ANOVA were performed to determine if
time, treatment group, or interaction effects were present.
A significant time effect was observed for all groups (F =
4.38, df = 6, 394, pc.l). Treatment effect differences were
not significant (F = 0.5, df = 3, 197, p>.l), but interaction
effects were significant (F = 1.89, df = 6, 394, pc.l). This
indicates the changes seen through time on the smoking
attitude scores of all subjects were different depending on
which treatment group the subject was in. Separate critical
F values were then calculated for paired attitude scores
based on the significant interaction analysis. Pretest
scores were not significantly different for any two treatment
groups, which was also the case for follow-up scores. For
this reason, only attitude differences pre to post are
reported. The only significant treatment differences seen
occurred on the posttest and are summarized below.


35
use of self-help manuals may be especially important in the
late maintenance stages of quitting. They state that
although initial abstinence rates from self-help books and
brochures are low, such materials may be effective in keeping
recent quitters from returning to smoking. Curry et al.
(1988) also found self-help materials were helpful in relapse
prevention, for those who used the materials. Motivation is
another factor which has been cited by many studies as
critical in maintaining cessation (Brandon, Tiffany,
Obremski, & Baker, 1990; Brownell et al., 1986; Carmody,
1990; Glynn et al., 1991; Shiffman et al., 1985).
A task force on interventions to prevent relapse
(Brownell et al., 1986) suggest that sustained smoking
cessation requires the modification of a range of social
skills. The removal of an ingrained personal and social
habit leaves a void that must be filled to prevent relapse.
They suggest the void be filled by new reinforcers, new
social skills, or general lifestyle changes. New, more
health oriented reinforcers, may include; exercise,
relaxation training, and meditation. An effort must be made
to find alternatives for which smoking was previously
employed.


71
Tobacco use was tied in to weight control by the common theme
of heart disease. A 24 minute Navy video entitled "Weight
and fat control/nutrition education" was then shown.
A question and answer period followed the movie. The
class was concluded by a statement about the Navy's
commitment to a healthy workforce and the fact that recruits
should try to make healthy choices in all aspects of their
lives.
Booster
Two companies were given a booster class at the end of
recruit training to reinforce key points of the education
intervention, and to further motivate them not to use tobacco
after graduation. This class was presented on the Friday
before the recruits' departure from RTC. Their formal
graduation ceremony (Pass and Review) was held Friday morning
and the recruits were allowed to go on uncontrolled off-base
liberty starting that evening. The booster class lasted
approximately 45 minutes and was presented mid-afternoon to
both companies in this treatment group.
The booster class incorporated several strategies to
reinforce prior training and increase motivation. Two
pamphlets were distributed to each recruit:
Smart Move: A Stop Smoking Guide ACS #2515LE


59
Instruments
Smoking history and relapse information were collected
via pencil and paper survey. Surveys were conducted during
the recruits first week of training (P-4 day), after
graduation (8-3 day), and 3 months after graduation. The
surveys used were modified versions of those by the Naval
Health Research Center for their "new accession tobacco use
survey".
Surveys
The Horn-Waingrow Smoking Motives Questionnaire (Girdano
& Dusek, 1988) was added to the intake survey (see Appendix
A) to examine type of smokers who are best helped by this
program. The Fagerstrom nicotine tolerance questionnaire
(Fagerstrom, 1978) was also added to examine nicotine
addiction. Questions were added to assess knowledge of and
attitudes toward tobacco use.
The graduation survey (see Appendix B) was much shorter
than the intake survey. Most of the questions were repeats
from the first survey with only a few added to assess change
in knowledge and attitudes. The 3 month follow-up survey
(see Appendix C) was a modified version of the Naval Health
Research Center's 12 month follow-up survey with questions
added to measure change in attitude and knowledge.


3
smoking in the military, living conditions, demographic
population makeup, low cigarette cost in military exchanges,
and advertising targeted to young military members represent
factors hypothesized as causes for high military smoking
prevalence.
Smoking prevalence in the Navy (44%) slightly exceeded
the military average in a 1988 survey (Bray et al., 1988).
It has been estimated smoking costs the Navy nearly $25
million a year in higher health care and insurance costs, and
an additional $140 million in lost wages due to absenteeism
(Zolton, 1992). Efforts are underway in the Navy to reduce
the smoking prevalence and the Navy Surgeon General has set a
goal of a smoke-free Navy by the year 2000 (Nelson & Roth,
1991). Surveys of incoming Navy recruits, though, show a
smoking prevalence of between 28% and 40% (Cronan & Conway,
1988; Grochmal, 1990). If the Navy wishes to attain the goal
of being smoke-free not only will current smoking members
need assistance stopping, but the number of new smoking
members must be reduced and eventually eliminated. Current
Navy smoking policies have not yet proven effective in
lowering smoking prevalence to civilian levels. Policy
efforts thus far have only reduced smoking rates from 54% in
1980 to 44% in 1988 (Bray et al., 1988).
A smoking ban at all Recruit Training Commands (RTCs)
seems effective in stopping smoking temporarily for recruits
who enter as smokers (Commander E. Reeves, personal
communication, May 14, 1991). This policy stemmed from study


85
Relapse
rate
Cigarettes smoked
Note: 1 = no smoking
2 = <1 per day
3 = 1-5 per day
4 = 6-20 per day
5 = >20 per day
Figure 1. Percent relapse for corresponding entry smoking
levels
Some relapses are found in cigarette consumption
category "none" because those indicating they quit within two
months prior to recruit entry were considered current
smokers. An obvious trend is seen in that relapse increases
with an increase in cigarette consumption. The differences
seen in relapse rate by prior cigarette consumption were
found to be significant (x2 = 35.85, pc.001). Analysis of
age smokers started and their AFQT scores did not reveal any
significant results.
To determine if relapse was affected by increased
knowledge scores an analysis of variance (ANOVA) was
conducted modeling relapse with knowledge gain. Possible


104
the findings of the Grochmal (1990) study of 40% current
smoking at entry. Most disturbing is the fact that the
overall rate of 43% is in sharp contrast to the 29% thirty
day prevalence reported for high school seniors by Johnston
et al. (1991). Clearly the recruit population taken in by
the Navy have a much higher smoking prevalence than their
peers, and this serves only to perpetuate the Navy smoking
problem.
The present study finding of smoking by gender (41% male
and 50% female) were also similar to the Grochmal (1990)
study. These findings are in contrast to Johnston et al.
(1991) who report males and females are equally likely to
smoke and Bray et al. (1988) who found smoking was not
predicted by gender.
The 1989 Surgeon General report on smoking (USDHHS,
1989) placed smoking prevalence for whites at 29%, blacks at
34%, and Hispanics somewhere around 40%. The present finding
of 45% white, 21% black, and 39% Hispanic are in contrast to
the general population findings. The Surgeon General
(USDHHS, 1989) reported a decline in smoking prevalence as
education level increases; from 36% with less than high
school education to 16% for college graduates. The present
study found a decrease as well but college graduates still
reported a 41% smoking prevalence which was the same
prevalence reported by high school graduates (the small
number of college graduates included in the present study may
have affected the observed percentage).


70
Thomas J. Glynn, Ph D
Chief, Cancer Prevention and Control
Extramural Research Branch
National Institutes of Health
National Cancer Institute
Terry L. Conway, Ph D
Health Psychology Department
Naval Health Research Center
All reviewers stated they believed the program to be a sound
design. Many suggestions were given, and most were
incorporated into the existing plan.
Sham treatment
A sham (placebo) treatment was conducted for one company
to analyze the effect of any intervention on the study
population. The idea was to present an educational
intervention, irrelevant to smoking prevention/cessation, but
prefaced by an explanation that the class is part of an
overall program designed to help recruits remain tobacco-free
after graduation from RTC.
This intervention was accomplished on the company's 2.2
day of training, but only for a 40 minute period. The
curriculum (see Appendix G) consisted of a short lecture
about the Navy's commitment to maintain a healthy, productive
workforce, Navy smoking policy, and goals for tobacco use.


51
Without use of a 24 hour urine sample though, normalization
using creatine excretion is often used (Haley, Colosimo,
Axelrad, Harris, & Sepkovic, 1989). This normalization
requires additional analysis and thus higher costs. Haley et
al. (1989) concluded the additional analyses may not be
necessary when simple validation of nonsmoking status in a
smoking cessation program is the endpoint.
Several analytical techniques have been used to
determine cotinine concentration in biological fluids. The
most frequent used are radioimmunoassay, liquid
chromatography, and gas chromatography (Skarping, Willers, &
Dalene, 1988). The choice depends on the biological fluid to
be assayed; the need for sensitivity, precision, and
accuracy; and economic considerations (USDHHS, 1988).
Immunoassay techniques are simpler, generally require smaller
samples, and may be less expensive. They have been
determined to be best suited for smoking/non-smoking
determinations.
Non-smokers can show low levels of cotinine from
nicotine exposure to environmental tobacco smoke (eg. car,
home, restaurants). Studies have shown passive cotinine
concentrations as high as 32 ng/ml, and active cotinine
concentrations as low as 44 ng/ml (Wall, Johnson, Jacob, &
Benowitz, 1988). Sensitivity for non-smoker analysis is
generally set in the range of 1-25 ng/ml (Thompson et al.,
1990), however cutoff sensitivity and specificity set for
discriminating true has also been set at 50 ng/ml (Jarvis et


TOBACCO USE SURVEY
Dear Participant:
You and several hundred other new members of the U S. Navy have been selected to participate in this
survey. Your answers will assist researcners at the Naval Health Research Center study tobacco use among
new Navy members and evaluate current tobacco use policies. Your participation is very important because
the information you provide will help guide future program policy regarding tobacco use.
Please answer all the questions honestly and to the best of your ability. Your responses are for
research use only and will be kept strictly confidential. Data will be reported so that no individual
participant can oe identified. If you have any questions about this survey, please contact Dr. Terry L.
Conway, Naval Health Research Center. San Diego, CA 92186-5l22,Autovon: 553-8465: Commercial: (619)
553-8466.
Thank you very much for your cooperation in this project!
DEPARTMENT OF THE NAVY
NAVAL HEALTH RESEARCH CENTER
P.O. BOX 85122
SAN DIEGO, CA 92186-5122
PRIVACY ACT STATEMENT
CONSENT STATEMENT
1. Authority S USC 301
2. Parpase. Medical mearen information will be
collected to enhance basic medical knowledge,
or to develop tests, procedures, and equipment
to unprove the diagnosis. treatment, or
prevention of illness, injury or performance
impairment.
3. Use Medical research information will be used
Tor statistical analysts and reporu by the
Departments of Navy. Defense and other U
Government sgenaes. provided this use is
compatible with the purpose for which the in
formation was collected^ L'se of the informa
tion may be granted to non-Govern mem agen-
nes for individuals by the Chief. Bureau of
Medicine and Surgery, in accordance with the
provisions of the Freedom of Information Act.
4. Disclose re I understand that ail information
untamed in the Consent Statement or derived
from the study described therein will be
retained at the Naval Health Research ('enter.
San Diego, and that my anonymity will be
maintained, i voluntarily agree to its disclosure
ui agencies or individuals identified in the
preceding pa rag rapo, and I have been iniormed
that (ailure u> agree to such dug insure mav
negate the purposes for which the tudv is
being conducted.
UU1Y9
This research is part of an evaluation of the tobacco use prevention and cessation component of the Navy's
Health and Physical Readiness Program. Your participation in this study involves completing the followti^ i
survey, which should take aoout 15 minutes and asks about your tobacco use. In addition we will be ,
administering two simitar follow-up surveys: one at the end of your current training and one in approximately
one year. 1
Your peruapaimn is strictly voluntary. Refusal to participate will involve no penalty or loss of any benefits
to which you are otherwise entitled. All data from this research will be kept at the Naval Health Research
Center and used for research purposes only. Primarily, the data will be summarised in reports for (
professional audiences interested irr health and nutrition, la all caaes, the data will be reported so that .
no ladlvtdaal respondent can be Identified. The information gathered will not be cows port of ywwr
Mb hope that you will consent to participate, because your input ts needed for program evaluation. By
ugning this consent form, you stale that your participation is voluntary, without force or duress of any
kind. You also acknowledge that you understand the purpose of this study and that you are free to withdraw
your consent at anv time without prejudice to yourself or your military or civilian career.
Should question* an*e. feet free to contact Terry L Conway, \avai Health Research Center. San Diego, CA
92186-SI 22/Autovo: XWWIi- Commercial: llt) t>J-84bS ,
Stgnsturm
7^1
ffcOS*fCT MASK
O' QwCOftftfCT MAJOCS '''
Use a NO. 2 PENCIL only.
Do not use ink or ballpoint pen.
Pill in the circle completely.
Cleanly erase any marks you wish to change.
Do not make arty stray marks on this form.
2301
IOOOOOOOOOOOO
116
111111111111 JJ


73
in the tobacco prevention program (see Appendix I), but
signing the pledge was voluntary. It was stressed that
signing was not necessarily a promise never to use tobacco,
but rather a promise to do whatever they can to help reach
the goal. The recruits were told the Navy hoped part of this
assistance would be a choice to remain tobacco-free. The
certificate was signed by the researcher, as the program
director, and the Commanding Officer of Recruit Training
Center, Orlando.
All recruits in the booster companies received a T-shirt
courtesy of the American Cancer Society. The T-shirts were
yellow and carried the logo of "Smoke-free class of 2000".
These shirts are being used in the national "Smoke-free class
of 2000" campaign. The recruits were told they are part of
the Navy's smoke-free class of 2000. The recruits were
thanked for their participation, congratulated on graduation,
and reminded of the upcoming follow-up surveys.
Follow-up surveys
Follow-up surveys were administered just before the
participants left RTC, then again 3 months after graduation.
These surveys were designed to measure current tobacco use
habits, knowledge, and attitudes.
The graduation survey (see Appendix B) was administered
by the company commanders after the uncontrolled liberty
weekend. Because some of the questions dealt with possible


APPENDIX C
THREE MONTH FOLLOW-UP SURVEY


91
Table 15. Knowledge scores at each measurement period and
differences observed
Treatment
qroup
1
2
3
4
Total
4.01
4.06
4.07
3.93
4.03
Pre
(1.08)
4.29
(1.17)
4.59
(1.02)
4.57
(1.13)
4.25
(1.10)
4.48
Post
(0.83)
4.14
(0.85)
4.39
(0.85)
4.56
(1.00)
4.05
(0.89)
4.35
F/U
--L1.02L
(1.00)
(0.93)
(0.39)
(0.98)
Diff.**
0.19
0.54
0.45
0.29
0.41
post-pre
(1.21)
a-09)
(1.11) _
(1.12)
(1.13)
Diff.***
-0.22
-0.25
-0.07
-0.35
-0.19
f/u-post
-(1-24)
(1.04)
(1-10)
.. (0.70)
d-07)
Note: Standard deviations are in parentheses.
Differences reflect only subjects completing both pre and post
tests
**Differences reflect only subjects completing both pre and
follow-up.
Repeated measures ANOVA were performed to determine if
time, treatment group, or interaction effects were present.
A significant time effect was seen for the entire population
(F = 8.46, df = 6, 398, p<.l). Treatment effect was also
significant (F = 2.27, df = 3, 199, p<.l) but interaction
effect was not significant (F = 1.31, df = 6, 398, p>.l). A
knowledge difference variable (knowledge gain) was produced
by subtracting the pretest knowledge score from the posttest
knowledge score. An ANOVA (SAS PROC GLM) was conducted
modeling knowledge gain with treatment level. Post-hoc tests
revealed a significant difference only between treatment
Groups 1 and 2. A knowledge difference variable (knowledge
retention) was produced by subtracting pretest scores from
follow-up. Results of knowledge retention show the booster


CHAPTER 2
REVIEW OF LITERATURE
WHEN loves grows cool, thy fire still warms me;
When friends are fled, thy presence charms me,
If thou art full, though purse be bare,
I smoke, and cast away all my carel
-German Smoking Song
Introduction
The purpose of this chapter is to provide a summary of
what has been learned from other studies regarding smoking
prevention and smoking relapse prevention. Insight as to how
the current study will contribute to a fuller understanding
of the issues is also presented. The chapter starts with a
look at ill effects of tobacco, and tobacco use prevalence
rates in the U.S. population, and military sub-groups.
Several theories of smoking relapse are then reviewed
followed by an examination of how these theories have been
used in the past as basis for research in relapse prevention.
Research on the effects of smoking policy and miscellaneous
relapse research are then examined. Research on smoking
prevention, as it relates to this study, is then reviewed.
Prevention methods which current research has shown effective
16


44
people smoke. Horn states that, the greater the role played
by these superficial and inaccurate beliefs about the
behavior, the more difficult it becomes for an individual to
develop a sound decision-making process. These stereotypes
are perpetuated by cigarette advertisements. Horn's third
group of factors contains a variety of patterns for
psychological forces which may help determine personal
choices for health behavior, particularly behaviors which
reflect a conflict engendered in individuals between the
demands of society and their own inner desires.
The population entering the Navy consists of current
smokers, former smokers, occasional smokers, and non-smokers
(Cronan & Conway, 1988; Cronan et al. 1989). Studies have
found nearly all smokers start smoking in their teenage years
(USDHHS, 1987; USDHHS, 1989). However, the National Cancer
Institute (NCI) now feel there is a second period where
individuals are at risk for starting smoking. Recent
research indicates there may be another smoking uptake period
in the early 20's as employment transition takes place (T. J.
Glynn, personal communication, September 16, 1991). Cronan
et al. (1989) found that some recruits were starting to smoke
during recruit training (this study was done before the
current no-smoking policy was instituted). It is possible,
since the institution of the no-smoking policy in recruit
training, that smoking initiation may now be taking place in
the training environment after recruit graduation. Because
of possible smoking uptake during employment transition, it


103
present study, was seen in the education only treatment group
(Treatment 2). This group also showed the highest smoking
knowledge gain and highest smoking attitudes increase. These
results suggest the education intervention, though not
significantly affecting relapse, may have affected the number
of cigarettes smoked by relapsers. Results of the present
study and others clearly show cigarette consumption affects
successful cessation. The reduction seen with relapsers
should then positively affect cessation success in subsequent
quit attempts by study participants.
Smoking habits
The no-smoking policy currently in effect at RTC,
Orlando seems to be effective, not only in reducing smoking
in boot camp, but also in preventing smoking initiation
immediately after graduation. The present study shows the
utility of combining a smoking education program with the
policy.
Forty-three percent of recruits reported current smoking
status upon entry. This number is not in agreement with the
study of Cronan and Conway (1988) of 28% or the study by
Cronan et al. (1989) of 24%. The discrepancies may be partly
found in that the present study considered former smoker of
less than two months to be current smokers. Further
differences obviously lie in the fact that the present study
included female recruits. The present results did agree with


118
Please indicate tobacco use at entry into the Navy by
marking one answer for each tobacco product.
sEvtn i
ORMER I
UGHT
MOOCIUTE!
HEAW 1
JSEO l
JSER 1
USER
1 JSER 1
JSER I
16. Cigarettes
O :
0 1
0
1 0 I
0 !
17 Cigars
o
c i
o
0
O !
18. Pipe Tobacco
0 !
0 1
o
1 O 1
0 1
19. Chewing Tobacco
O
0
0
0
0 i
20. Snuff/Dip
.O'
0 ]
Q
i 0 1
Ail
.Birr
MOUNT OF TOBACCO
BEaBooucrs used
21.When was the most recent time you smoked a cigarette?
O Never smoked a cigarette
O 10 or more vears ago
Q6 9 vears
Q3-5 vears
O 1 2 vears
Q7-11 months ago
O 4 6 months ago
02-3 months aqo
05-7 a eeks ago
O During tne oast 30 davs
O Today
22.During the last 30 days iust prior to entering the Navy,
how many cigarettes did vou usually smoke on a
typical day when vou smoked cigarettes?
OOd not smoke any cigarettes O 21 25 cigarettes
in the last 30 davs
O Fewer than 1 cigarette.
on the average
O 1 5 cigarettes
06-10 cigarettes
Oil 15 cigarettes
O 16 20 cigarettes
026 30 cigarettes
031 35 cigarettes
O 36 40 cigarettes
041 45 cigarettes
0 46 55 cigarettes
O 56 or more cigarettes
DURING THE MONTH BEFORE ENTERING THE NAVY...
23. On the average, how manv days per month aid you
use chewing tobacco?
O Never m tne oast 12 months/ G 2-3 davs a month
Don t use chewmg tobacco O 1 *2 davs a week
OOnce or twice m tne oast 12 months 03-4 davs a week
O 3-6 davs m the Dast 12 months O 5-6 davs a week
07-11 davs in the oast 12 months Q About every dav
O About once a month
24. On the davs vou used chewing tobacco, how many
timas per day did you use it?
OnA 02 04 06 03
Ol 03 05 07 09-
25. On the average, how many days per month did you
use snuff/dip?
O Never m the oast 12 monins/ 02*3 oavs a month
Dont use snutt o¡c 0 '*2 davs a week
0 Once cf ".vice n me oast months O 3*4 davs j wh**k
3 3-6 davs in tne cas* *2 months O 5-6 days a ween
0:*r JjvS *n *re c'.is! 2 nonths 0 ^oout every oav
O About once 3 mor tn
26. On the days you used snutt/dip. how many times per
day did vou use it? m
O NA 02 04 06 03 m
03
^ 7
09+
27. On the average, how manv days par month did vou
smoke a pipe?
O Never m tne Dast 12 months/ 02-3 davs a monfl
Don t smoKe a oipe Q 1-2 davs a week
0 Once or twice m the nast 12 months 03-4 davs a week
03-6 davs m me oast 12 months 05*6 davs a week
O 7* 11 davs m the oast 2 montns Q About every dav
O About once a month
28. On the days you smoked a pipe, how manv pipefuls of
tobacco did vou smoke?
ONA 02 Q4 06 08
Q1 0 3 05 07 09*
29. On the average, how many days per month did you
smoke cigars? i
O Never in the oast 12 rrcmns/ 02*3 davs a month i
Don t smoite cigars Ol2 d?vs a week i
OOnce or twice in the Dast 12 months 03*4 davs a week i
03-6 davs m the past 12 months Q5-6 davs a week i
07-11 davs m the past 12 months Q About every oav
O About once a month i
30. On the days you smoked cigars, how many did you i
smoke? i
CNA 02 O4 06 Q8 i
01 03 05 07 09*
IF YOU HAVE NEVER USED CIGARETTES. ,
CIGARS. OR PIPES. PLEASE MARK HERE C AND ,
GO TO *32. ,
31 Below is a list of reasons people give for START i
ING to use CIGARETTES. CIGARS, and/or i
PIPES. For each possible reason, mark NO or i
YES to indicate whether ft was a reason why you
started to use any of these tobacco products. a
a) I was bored
b) Most of my friends did.
cl I wanted to be "coot"
d) I liked the image.
el I liked the taste
f) It gave me a kick,
gi I wanted to show that I was tough,
hi I wanted to take a oare.
n It calmed me.
j) I wanted to lose weight,
kl I wanted to look and feel like an adult.
O I wanted to oe masculine,
mi I didn't want to feet left out of a group.
I wanted to show I vvasn t afraid,
or Mv parents smoked,
p) I was curious.
NO
s'
O
O
o
o
0
o
; O
0
i O 1
! O
C 1
o
0 1
o
O I
0 i
O i
o ¡
i o
0 !
! C
O !
, 0!
o;
- O !
o 1
o
J2
O .
I O I
SL
Pag* 3


112
pressures (subjective norm). Attitude is a function of an
individuals belief that the outcome of performing a given
behavior will be positive or negative. Knowledge of
smoking's adverse effects play a key role in changing
attitudes.
The present study results show smoking education
affected smoking knowledge and attitudes. The booster group
showed a trend toward increased intention to not smoke in the
future. Changing beliefs during recruit training by changing
smoking knowledge, attitudes, and intentions can assist
smokers in changing perception that smoking leads to more
negative than positive outcomes. The current Recruit
Training Command no-smoking policy, especially when fully
supported by recruit company commanders, increases social
pressure on the recruits not to engage in smoking behavior
after recruit training. The recruit experience, combined
with continued smoking education, stricter smoking policies,
and increased negative social acceptance of tobacco use, can
accelerate the cycle of smoking behavior change. This may
make new Naval personnel who remain smokers more receptive to
smoking cessation efforts encountered through their Naval
career. A recruit smoking education program can accelerate
the drop in Navy smoking prevalence and assist the Navy of
reaching its goal of being smoke free by the year 2000.


80
pretest survey). Seventy-four percent of this total
completed surveys at graduation (only 50% were completed in
treatment Group 1 due to an administering error in one
company).
Follow-up surveys were mailed to 516 individuals. Of
these surveys 320 were returned completed for a response rate
of 62%. Table 7 summarizes survey completion at each
occasion.
Table 7. Percent survey completion at each measurement
period
Treatment qroup
1
2
3
4
Total
Pre
(140)
(151)
(136)
(69)
(496)
Post
50% (70)
85% (128)
82% (112)
81% (56)
74% (366)
F/U
57% (80)
64% (97)
60% (82)
29% (20)
56% (279) |
Notes:Actual numbers are in parentheses.
Treatment: 1 = Policy only
2 = Policy + education
3 = Policy + education + booster
4 = Policy + sham treatment
Treatment Group 4 consisted of only one recruit company and a
poor follow-up return rate of 20 should be noted.
Ten percent of the surveys were reported lost or
undeliverable to participants, and 28% were not returned (not
accounted for) at all. Forty-two of the surveys not returned
had been sent to 13 commands who did not respond to the
initial letter or the reminder, and could not be reached by


8
Hypotheses
The null hypotheses relating to Navy recruits after
eight weeks in a smoking restricted environment are that no
differences will be observed among treatment conditions for
(1) smoking relapse rate,
(2) smoking attitudes,
(3) smoking knowledge,
(4) smoking intentions,
(5) cigarette consumption, and
(6) smoking initiation after graduation (for
never/former smokers prior to recruit training).
Significance of the Study
Results of this study should assist Navy smoking
cessation efforts by finding effective means of reducing
smoking prevalence in personnel entering the service. This
study was unique in that it was the first to examine smoking
intervention while including the Navy female recruit
population. Secondarily the study was designed to contribute
to literature information on: a) successful techniques to
prevent relapse in young ex-smokers, and b) successful
techniques to prevent smoking initiation in non-smokers
during employment transition.
This study will provide further evidence to support or
refute the theory that policy alone is insufficient to effect


58
demographic data were obtained from Naval Technical Training
Command data bases (CNTECHTRA, 1991b). Table 2 is a
comparison of the study group to 6 months of all recruits
going through RTC Orlando, and all 3 Navy RTCs for several
variables.
Table 2. Study group comparison
Education
level
Average
AFQT*
score
Average
Age
Percent
Minority
All RTCs 6 mo
RTC Orlando
6mo
11.69
12.07
61.04
67.89
19.51
19.42
19.37
17.8
T-l
12.05
66.07
19.48
19.12
T-2
12.09
68.48
19.41
14.94
T-3
12.02
64.78
19.40
23.48
Sham
11.95
60.57
20.10
26.58
*Armed Forces Qualification Test
to all services
(AFQT) is
required for
enlisted entry
This table shows the companies chosen for the study were
fairly representative of all companies going through RTC
Orlando, and the rest of Navy Recruit Training Centers.


129
26.How do you think that a smoke-free work
environment would (or does) influence your
tobacco use?
0 NA-I am not a tobacco user
0 It would help me STOP using tobacco
0 It would help me REDUCE my tobacco use
0 It would NOT CHANGE my tobacco use
0 It PROBABLY would INCREASE mv tobacco use
ORIENTATIONS
36.Do you plan to make the Navy a career?
0 No 0 Yes
INTENTIONS
For questions 37-40 circle answer:
NA if Not Applicable
1 if No Chance At All
2 if Slight Chance
3 if Somewhat Likely
4 if Quite likely
5 if Extremely likely
27. Does it bother you when someone is
smoking around you?
0 No 0 Yes
28. when you are inside public areas that
have no rules about smoking and someone
lights up a cigarette, wnat are you most
likely to do?
0 Just do nothing
O Move away from the
person
0 Ask the person not to
smoke
0 Something
else( specify) -*
Over the next year...
37. If you currently smoke cigarettes,
cigars, or a pipe, how likely it is that you
will stop smoking?
NA 1 2 3 4 5
38. If you currently use chewing tobacco,
snuff, or dip, how likely it is that you
will stop using these tobacco products?
NA 1 2 3 4 5
39. If you do not saoke cigarettes,
cigars, or a pipe now, how likely is it that
you will remain a non-smoker?
NA 1 2 3 4 5
29. Do you believe smoking...
a) is related to heart disease
is related to cancer
is related to emphysema
is addictive
b)
c)
No
Yes
0
0
0
0
0
0
0
0
40.If you currently do not use chewing
tobacco, snuff, or dip now, how likely is it
that you will remain a non user?
NA
1
In the future, do you
N
Y
N
30. Are you concerned about the
No
Yes
see yourself as...
o
e
A
health effects of...
s
a) Cigarettes
0
0
41. Someone who smokes?
0
0
b) Cigars/Pipes
0
0
42. Someone who uses
0
0
c) Chewing Tobacco
0
0
smokeless tobacco
d) Snuff/Dip
0
0
In the future are you
31. How important is it to you to
not use
likely to be a non
tobacco products?
user of tobacco.
0 Not at all important 0 Very important
43. Out of concern for
0
0
0
0 Somewhat important 0 Extremely
your health?
0 Moderately important important
44. Because a medical
0
0
0
professional has told you
32. What percent of the U. S. population do
to quit?
you think currently smoke cigarettes?
45. Because of the cost of
0
0
0
0 20% 0 30% 0 40%
tobacco products?
0 50% 0 60% 0 75%
46. Because of social
0
0
0
pressures not to use
33. What percent of all Navy members do you
tobacco?
think currently smoke cigarettes?
47. Because of hassles
0
0
0
0.20% 0 30% 0 40%
related to smoking
0 50% 0 60% 0 75%
restrictive areas?
48. Because few of your
0
0
0
34. Should tobacco companies be allowed to
peers/friends use tobacco?
direct advertising toward certain groups in
order to recruit new customers?
0 No 0 Yes
35. Do you expect to complete a college
degree sometime in the future?
O No O Yes
THAWK-YOU VERY MUCH
COOPERATION
POR YOUR


UNIVERSITY OF FLORIDA
institutional review board
114 PSYCHOLOGY BUILDING
GAINESVILLE. FL 32611-2065
(904) 392 0433
August 6, 1991
TO:
Mr. Thomas L. Pokorski
5 FLG
FROM: C. Michael Levy, Chair,
lional
University of Florida Insi
Review Board
SUBJECT: Approval of Project #91.241
The effect of an education intervention program on smoking
relapse for Navy recruits in a smoking restrictive environment
I am pleased to advise you that the University of Florida Institutional
Review Board has recommended the approval of this project. The Board
concluded that your subjects will not be placed at risk in this research.
Given your protocol it is essential that you obtain written informed consent
from each participant.
If you wish to make any changes in this protocol, you must disclose your
plans before you implement them so that the Board can assess their impact
on your project. In addition, you must report to the Board any unexpected
complications arising from the project which affect your subjects.
If you have not completed this project by August 6,1992, please telephone
our office (392-0433) and we will tell you how to obtain a renewal.
By a copy of this memorandum, your Chair is reminded of the importance of
being fully informed about the status of all projects involving human subjects
in your department, and for reviewing these projects as often as necessary
to insure that each project is being conducted in the manner approved by this
memorandum.
CML/her
cc: Vice President for Research Unfunded
College Dean
R. Morgan Pigg
Dr. W. William Chen
rilliam Chen
EQUAL EMPLOYMENT OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
131


92
group exhibited the best retention but post-hoc tests (PROC
GLM) revealed the group differences were not significant.
Smoking Intentions
Changes in smoking intentions were measured by analyzing
responses to the question "In the future, do you see yourself
as someone who smokes?" on all three surveys. Table 16
summarizes the percent of respondents indicating a future
intention not to smoke, by treatment group.
Table 16. Percent of respondents indicating intention not to
smoke in the future
Treatment
qroup
Total
1
2
3
4
Pre
74.6%
88.6%
70.9%
80.9%
79.5%
Post
68.6%
83.1%
73.9%
72.4%
77.7%
F/U
65.4%
86.6%
77.8%
90.0%
79.0%
A categorical data modeling procedure was conducted
using responses given on the pretest and the follow-up. A
significant treatment effect was seen between treatment
levels (x2 = 11.12, p<.l), but no significant time effect was
observed over the entire population (x2 = 0.9, p>.l). Only
treatment Group 3 showed a continual increase in the percent
indicating an intention not to smoke but the difference
observed was not significant (x2 = 0.681, p>.l).