ORI GI NAL ARTI CLE

Applying Lessons Learned from Obsessions:

Metacognitive Processes in Smoking Cessation
Elizabeth Nosen Sheila R. Woody
Published online: 29 December 2007
Springer Science+Business Media, LLC 2009
Abstract Cognitive theories of obsessions propose that
unwanted thoughts become frequent, intense and persistent
when people interpret them in personally meaningful ways
and attempt to control themthrough thought suppression. The
present study examined the generalizability of this model to
another form of unwanted, actively resisted intrusionnico-
tine cravings. In this investigation, 180 individuals attempting
to quit smoking completed several online questionnaires. In
line with cognitive theories, individuals who appraised their
cravings as more catastrophic and personally signicant
experienced more severe craving-related thoughts and were
more likely to be smoking one month later; these effects
remainedafter accountingfor several establishedpredictors of
cessation difculty. Contrary to expectation, tendency to
suppress unwanted thoughts was not a signicant factor.
Overall, ndings complement existing work on the role of
anxiety sensitivity in smoking behaviour and implicate per-
sonally meaningful appraisals of smoking-related thoughts,
images and impulses in cessation difculty.
Keywords Obsessions Metacognition Appraisals
Thought suppression Smoking cessation
Nicotine dependence
Introduction
Researchers have identied a strong cognitive component
to nicotine cravings, characterized by a thought, thought
process, or an expectation of the consequences of smoking
(Shadel et al. 2001). Smokers are more likely to lapse after
experiencing intense, persistent and distressing cravings
(Shiffman et al. 1997a; Shiffman et al. 1996; Shiffman
et al. 1997b). As such, identifying factors that inuence the
severity of smoking-related thoughts, images and impulses
is critical for understanding and preventing cessation
relapse. Recent research from the study of obsessions may
provide a fresh perspective on this issue.
For some time, anxiety researchers have been investigat-
ing the development of another type of distressing and
recurrent cognitive phenomenonobsessions. Current cog-
nitive models of obsessivecompulsive disorder propose that
metacognition plays a pivotal role in determining how
problematic unwanted thoughts become: individuals who
interpret their thoughts as meaning something overly
important tend to be more disturbed by unwanted thoughts
and tend to experience more frequent, intense and persistent
intrusions (Clark et al. 2000; Rachman 1997, 1998; Sal-
kovskis 1985). In addition, some individuals attempt to avoid
the discomfort associated with unwanted thoughts by sup-
pressing them. Unfortunately, this strategy can paradoxically
make the thoughts recur with greater frequency, which in
theory, propels an escalating cycle of recurrence, over-
interpretation and distress (Abramowitz et al. 2001; Purdon
1999; Rachman 1997, 1998; Salkovskis 1985; Wegner et al.
1987). These models have been gaining empirical support in
recent years and have led to the development of new inter-
ventions designed to reduce the persistence and distress
associated with obsessions (Abramowitz et al. 2007; Clark
et al. 2000; Clark et al. 2003; Purdon and Clark 1994a,
1994b; Rachman 2003; Teachman et al. 2006).
The key element in these theories is appraisal of the
meaning of an intrusive thought, irrespective of thought
content. As such, the same processes that are proposed to
occur for obsessions may also occur for other types of
E. Nosen (&) S. R. Woody
Department of Psychology, University of British Columbia,
2136 West Mall, Vancouver, BC, Canada V6T 1Z4
e-mail: lnosen@psych.ubc.ca
1 3
Cogn Ther Res (2009) 33:241254
DOI 10.1007/s10608-007-9180-8
unwanted, distressing and actively resisted thoughts, like
the craving-related thoughts experienced by people trying
to quit smoking. To the extent that this is true, personally
meaningful interpretations of cravings and use of thought
suppression may promote the development of more fre-
quent, intense and persistent cravings, which may in turn
increase risk for future smoking behaviour. The present
study represents an initial investigation of this hypothesis.
Maladaptive Interpretations of Unwanted
Intrusive Thoughts
The Obsessive Compulsive Cognitions Working Group
(OCCWG) has highlighted three types of appraisals that
are important in obsessions: overestimation of the personal
signicance of the thought (e.g., this thought means I am a
bad person), thoughtaction fusion or awed beliefs
about the perceived consequences of having an unwanted
intrusive thought (e.g., having this thought means I will
undoubtedly act on it), and an unrealistic desire to maintain
perfect thought control (e.g., I must control this thought)
(OCCWG 1997, 2001, 2003). Research on obsessive
thoughts suggests that these personally meaningful inter-
pretations of unwanted thoughts encourage negative self-
evaluation, are associated with intrusion frequency, con-
trollability and discomfort with thought recurrence and
prospectively predict obsessivecompulsive symptoms
(Abramowitz et al. 2007; Clark et al. 2000; Clark et al.
2003; Purdon 2001; Purdon and Clark 1994a, b; Teachman
et al. 2006). In other forms of psychopathology, the ten-
dency to assume equivalence between thoughts and action
(i.e., thoughtaction fusion) has been found at elevated
levels in individuals with depression, generalized anxiety,
and eating disorders (Abramowitz et al. 2003; Hazlett-
Stevens et al. 2002; Muris et al. 2001; Shafran et al. 1999).
Negative interpretations of the personal meaning of
unwanted intrusive cognition have also been associated
with distress in PTSD, hypochondriasis, psychosis and
depression (Bouman and Meijer 1999; Morrison 2001;
Starr and Moulds 2006; Steil and Ehlers 2000).
In the area of nicotine addiction, little research has
investigated how individuals who are attempting to quit
smoking appraise the personal meaning of cravings. While
many people likely view cravings as a mundane or natural
consequence of smoking cessation, others may interpret
them in similarly overly personal and signicant ways (e.g.,
as meaning that they are weak, going crazy, out of control or
destined to fail). Shiffman (1984) showed that individuals
who face a relapse crisis, in which they are tempted to, but
do not, smoke, experience declines in their abstinence self-
efcacy and feelings of failure similar to those who actually
do lapse. This suggests that a form of thoughtaction fusion
may occur in some individuals whereby cravings are
appraised as similar to actual smoking and an indication of
likely failure in the quit attempt.
Thought Suppression
According to cognitive theories of obsessions, disturbing
interpretations of unwanted thoughts motivate people to
watch apprehensively for reappearance of the original
intrusion and to try to prevent its recurrence (Clark and
Purdon 1993). Unfortunately, actively trying not to think a
thought can produce a paradoxical increase in the frequency
of the intrusion (Abramowitz et al. 2001; Wegner et al.
1987). In theory, reappearance of the original thought con-
rms initial beliefs in the importance and personal meaning
of the thought and strengthens desire for control, which in
turn begins an escalating cycle of distress, vigilance, and
unsuccessful suppression (Clark and Purdon 1993). Imply-
ing a mediational model, several correlational studies have
conrmed that the relationship between personally mean-
ingful appraisals of unwanted thoughts and OCD symptoms
declines when thought suppression is controlled (Rassin
et al. 2000; Smari and Holmsteinsson 2001). Consistent with
a broader, transdiagnostic effect, thought suppression has
also been correlated with symptoms of PTSD, agoraphobia,
depression, and insomnia (Ehlers et al. 1998; Fehm and
Margraf 2002; Harvey 2001; Wenzlaff and Luxton 2003).
The role of thought suppression in addictive behaviours
is unclear. Salkovskis and Reynolds (1994) examined the
effects of suppression in a sample of individuals attempting
to quit smoking. They found that individuals instructed to
suppress intrusive thoughts about smoking subsequently
experienced more frequent intrusions than individuals
instructed to either monitor their thoughts or monitor and
relax. However, Reynolds et al. (2005) failed to replicate
this nding in a study of drug-related thoughts among
individuals recovering from opiate or multi-substance
dependence in an inpatient treatment center. Palfai and
colleagues found that suppression of alcohol-related urges
increased the accessibility of alcohol outcome expectancies
(Palfai et al. 1997). They also observed a cross-substance
effect whereby suppressing alcohol-related urges increased
the intensity of cigarette smoking in current smokers
(Palfai et al. 1997). While this suggests that urge sup-
pression may have important behavioural consequences,
the mechanisms driving this effect are unclear.
Correlational studies designed to determine whether and
to what effect smokers actually use thought suppression
while quitting have also produced mixed results. Based on
the idea that using thought suppression techniques may make
quitting smoking more difcult, Toll et al. (2001) found that
current smokers (termed unsuccessful quitters) scored
higher on a general measure of thought suppression than ex-
smokers (i.e., successful quitters). This study used the
242 Cogn Ther Res (2009) 33:241254
1 3
full-scale White Bear Suppression Inventory (WBSI) as an
index of thought suppression. However, researchers have
recently found that this measure actually contains two sub-
scales, only one of which assesses suppression (Hoping and
de Jong-Meyer 2003; Rassin 2003). Use of the other scale,
which reects problems with intrusive thoughts, may arti-
cially inate apparent relationships with psychopathology
(Hoping and de Jong-Meyer 2003). Indeed Haaga and Alli-
son (1994) assessed suppression by coding thoughts
articulated in response to various stimulus situations and
found no association between the use of thought suppression
strategies and maintenance of non-smoking over a one-year
period. At present, it is unknown whether similar results
would be observed using self-report measures of chronic
tendencies towards thought suppression (such as the WBSI
suppression subscale).
Current Study
The present study is an exploratory investigation of the
extent to which the cognitive model of obsessions may help
explain problems with nicotine craving-related cognitions
among individuals attempting to quit smoking. We hypoth-
esized that interpretations of smoking-related thoughts as
personally meaningful or relevant to the probability of ces-
sation success would correlate with concurrent problems
with cravings (in terms of smoking-related thought fre-
quency, intensity, distress, etc.), partly as a function of
thought suppression efforts. We anticipated that this rela-
tionship would remain signicant even after accounting for
other established predictors of craving severity, including
nicotine dependence, negative affect, expectations about
smoking, and cessation self-efcacy beliefs (Droungas et al.
1995; Field and Duka 2001; Gwaltney et al. 2005; Killen
et al. 1992; Willner and Jones 1996). Because of the critical
role that craving severity appears to play in cessation dif-
culty, we further hypothesized that personally meaningful
appraisals and suppression would prospectively predict
future smoking behaviour. We anticipated that this rela-
tionship would remain after taking both concurrent (time
one) severity of craving-related thoughts and other previ-
ously established predictors of cessation success into
account. These hypotheses were investigated in an online,
questionnaire-based study of individuals quitting smoking.
Method
Participants
Participants were 180 English-speaking adults currently
engaged in a serious effort to quit smoking. Participants
were included if they reported having reduced their
smoking by at least ve cigarettes per day. Participants
were excluded if they had smoked for less than one year
prior to the current attempt to quit, smoked fewer than 10
cigarettes per day (on average) before quitting, or had
initiated their current quit attempt more than six months
ago. Most participants were female (70.6%), Caucasian
(93.9%), and employed full-time (55.0%). The average age
of participants was 39.0 years (SD = 10.3). Most partici-
pants had completed a post-secondary degree (45.6%), and
resided in Canada (36.7%), the United States (32.2%) or
the United Kingdom (24.4%).
Prior to their current attempt to quit smoking, partici-
pants had smoked fairly heavily (Mdn = 20 cigarettes per
day, range = 1080 cigarettes) for many years
(Mdn = 19.5 years, range = 148 years). Nearly everyone
(97.2%) had seriously attempted to quit smoking at least
once before (Mdn = four times, range = 0100 times),
with their longest previous quit attempt lasting a median of
3 months (range =\1 day14 years). Participants repor-
ted having initiated their current attempt to quit smoking a
median of 21 days before participation (range = 1
190 days) and had reduced their smoking by an average of
21.1 cigarettes per day (SD = 9.3, range = 580 ciga-
rettes). At the time they enrolled in the study and
completed the questionnaires, most participants (80.4%)
were fully abstinent from smoking (Mdn = 0 cigarettes per
day, range = 017).
Procedure
Participants completed all questionnaires over the internet,
facilitated by http://www.SurveyMonkey.com, a web-
based survey development and hosting service. Participants
were recruited through links placed on smoking cessation
websites and postings in online discussion forums, and
through advertisements placed in the Vancouver area. In
the early stages of data collection, participants received an
entry into a gift certicate lottery as an incentive (n = 86;
additional draw entry received for completing one-month
follow-up). These participants were screened online for
eligibility; qualied participants were automatically direc-
ted to the informed consent page of the survey. Participants
recruited in the later stages of data collection received an
honorarium in the form of a CDN$20 cheque (n = 94;
CDN$15 for completion of main study questionnaires,
CDN$5 for follow-up).
1
Researchers personally screened
these participants by email or phone using the same
questions as those screened online; eligible participants
received a link to the informed consent page via email.
1
Incentive was increased to speed data collection and ensure
adequate survey completion rates.
Cogn Ther Res (2009) 33:241254 243
1 3
Aside from screening, procedure was identical for draw
and cheque incentive participants.
The study questionnaires, presented in one of three
counterbalanced orders, followed the informed consent.
Questionnaires at time one assessed metacognition (per-
sonally meaningful appraisals and thought suppression),
craving severity and previously established predictors
(depression, cessation self-efcacy, expectancies about
smoking, nicotine dependence and other characteristics of
quit attempt). The survey program neither permitted
missing responses nor allowed participants to return to
previous pages. Upon completion of the survey, all par-
ticipants were asked to re-afrm that they wanted their data
to be used in study analyses; remuneration was explicitly
not dependent on their answer. One month after completing
the bulk of the questionnaires, participants received an
email link to a brief follow-up survey assessing recent
smoking behaviour. All procedures were approved by an
institutional research review board.
Under the draw incentive, 156 individuals completed the
rst page of the questionnaires, among whom 100 (64%)
completed the full survey and asked that we use their data.
Eighty-six of these cases were used in analyses (details on
case exclusion are presented below); one-month follow-up
data were available for 67% (n = 58) of this sample. Under
the $20 incentive, 115 individuals completed the rst page
of the questionnaires, and 110 (96%) completed the ques-
tionnaires and asked that we use their data. Ninety-four of
these cases were used in nal analyses; follow-up data
were available for 90 individuals (96%).
Thirty cases were excluded prior to analyses. Cases were
excluded for the following reasons: not meeting study
inclusion criteria (n = 18), repeat participation (based on
duplicate IP addresses; n = 5)
2
and questionnaire com-
pletion under 25 min (5th percentile of all participants;
n = 7). The survey program did not record individual page
completion times. Thus, long completion times could
reect something innocuous, such as a participant opening
the rst information page of the survey and then deciding
to complete it later on, or something more problematic,
such as taking an extended break mid-way through the
survey. As long completers (i.e., 20 cases completing in
over 2 h) did not differ from the rest of the sample on
questionnaires (including craving severity) and one-month
cessation status (Ps [.05), these cases were retained for
analyses. After case exclusions, 180 cases remained for
analyses. Average survey completion time was 46.3 min-
utes (SD = 15.3).
3
Measures
Appraisals of Cravings Questionnaire (ACQ)
The ACQ assesses how individuals interpret the occurrence
of nicotine craving-related thoughts, images or impulses,
with an emphasis on the types of appraisals researchers
have identied to be problematic in studies of obsessions
(OCCWG 1997, 2001, 2003). Respondents are provided
with a denition of craving-related cognitions and are
asked to provide examples of two smoking-related
thoughts, images or impulses they have recently experi-
enced. Respondents then rate their level of belief (0100%)
in each of 17 interpretations with reference to their per-
sonalized smoking-related thoughts. Appraisals include
beliefs that craving-related thoughts are personally signif-
icant (e.g., These thoughts reveal something important
about me), directly tied to the success of ones attempt to
quit smoking (e.g., Having this unwanted thought means I
will act on it) and need to be controlled (e.g., It is
important for me to cancel out or block the craving-related
thoughts).
The ACQ was developed for the current study by
modifying a commonly used measure of obsessional types
of appraisals, the Interpretations of Intrusions Inventory
(III; OCCWG 1997, 2001, 2003). Obsessional themes and
content provided in the III instructions were replaced with
nicotine craving content generated through pilot testing and
past research results (Salkovskis and Reynolds 1994).
Several minor wording modications were also made (e.g.,
replacing intrusive thought with intrusive craving-
related thought). Participants completed 21 of the original
31 items on the III.
4
To ensure that items covered an
adequate range of appraisals, 11 items drawn from the
unpublished Personal Signicance Scale (Rachman 2001)
and eight items with smoking specic content were also
added. From the initial pool of ACQ items, 18 items were
removed because of restricted variability or extreme skew.
Six items were removed because they did not correlate
strongly with total scale score. Further information on the
psychometric properties of the ACQ is available in the
results section.
Catastrophic Appraisals Index (CAI)
The CAI is an empirically derived scale comprised of 10
items that were initially included as part of the ACQ but
are analyzed separately due to infrequent endorsement.
2
Indicative of possible repeat participation.
3
Not including 20 individuals with completion times over two hours.
4
Piloting suggested that several III items were confusing and unclear
when applied to typical nicotine craving related thoughts (e.g., this
thought could harm people). These items were removed from the
scale.
244 Cogn Ther Res (2009) 33:241254
1 3
Compared to the items of the ACQ, CAI items reect more
extreme, catastrophic interpretations of cravings (e.g., I
will go crazy if I do not stop thinking these thoughts).
Although participants rated these items on the same scale
as the rest of the ACQ items, CAI items were rendered
dichotomous for analysis (0 = did not believe this idea at
all, 1 = some degree of belief in this idea) because of the
highly skewed distribution of responses and the nature of
the questions. Total scale scores reect frequency of
endorsement of extreme appraisals of craving-related
thoughts, such as, Having this intrusive thought means
that I could lose control of my mind, Having this
intrusive thought means I am a bad person, If I dont
control this thought, Ill be punished and These thoughts
mean that I am really an impostor or a phony. Both
measures are available on request from the authors.
Obsessional Beliefs Questionnaire
(OBQ; OCCWG 1997, 2003)
Included to examine the convergent validity of the ACQ
and CAI, the OBQ is a 44-item self-report measure of
characteristic obsessive beliefs regarding the importance of
controlling thoughts, perfectionism, and inated responsi-
bility. Participants rate the agreement with beliefs on a 7-
point Likert scale. The OBQ has demonstrated excellent
internal consistency, test-retest reliability and convergent
validity (OCCWG 2003; Woods et al. 2004). Cronbachs
alpha in the current sample was .94.
ThoughtAction Fusion Scale-Revised
(TAF-R; Shafran et al. 1996)
This 19-item self-report measure was also included to
examine the convergent validity of the ACQ and CAI.
Rated on a 5-point Likert-type scale, items reect beliefs
that thoughts are morally equivalent to action and directly
increase the likelihood of events occurring. The TAF-R has
demonstrated good reliability and validity in both obses-
sional and non-obsessional samples (Rassin et al. 2001;
Shafran et al., 1996). Cronbachs alpha was .92 in the
current sample.
White Bear Suppression Inventory
(WBSI; Wegner and Zanakos 1994)
The WBSI is a 15-item self-report measure of general
tendency to suppress intrusive thoughts. The WBSI is
comprised of two factorsthought suppression and intru-
sive thought experience (Hoping and de Jong-Meyer 2003;
Luciano et al. 2006; Rassin 2003). As use of the intrusion
subscale can inate correlations with measures of psy-
chological distress (Hoping and de Jong-Meyer 2003;
Rassin 2003), only the six items loading on the thought
suppression factor as identied in Hoping and de Jong-
Meyers (2003) study were used in the current analyses.
The suppression subscale had demonstrated acceptable
internal consistency and convergent validity with other
measures of problematic thought control (Luciano et al.,
2006). Cronbachs alpha was .83 in the current sample.
Obsessive Compulsive Drinking Scale-Revised,
Smoking Version (OCDS-RS; Morgan et al. 2004;
Anton et al. 1995)
Originally based on the Yale-Brown Obsessive Compul-
sive Scale (YBOCS; Goodman et al. 1989), the OCDS-R is
a 10-item self-report measure assessing obsessivecom-
pulsive dimensions of alcohol and drug craving.
Participants answered questions on a 04 Likert-type scale
in reference to their experience with cigarette craving-
related ideas, thoughts, impulses, or images; minor word-
ing modications were made (e.g., substituted smoking
for drinking/using). Like the YBOCS, the OCDS-R
includes both obsessive and compulsive subscales
(Anton et al. 1995). Because it is more applicable to cur-
rent study hypotheses, only the ve-item obsessive
subscale was used in analyses. Items assess the frequency,
distress, controllability, persistence, and interference
associated with smoking-related thoughts and impulses.
The obsessional subscale has demonstrated excellent
internal consistency, test-retest reliability and concurrent
validity (Anton et al. 1995). Cronbachs alpha in the cur-
rent sample was .85.
Center for Epidemiological Studies Depression
ScaleShort Form (CES-DS; Kohout et al. 1993)
The short formof the CES-Dis an 11-itemmeasure designed
to assess depressive symptoms in non-psychiatric commu-
nity samples. Participants rate frequency of depressive
symptoms during the past week on a three-point scale. This
version of the CES-D has obtained stable and desirable
psychometric properties across multiple samples (Carpenter
et al., 1998). Cronbachs alpha was .84 in this sample.
The Smoking Self-Efcacy Questionnaire
(SSEQ; Etter et al. 2000)
The SSEQ is a 12-item instrument used to estimate an
individuals condence in his or her ability to abstain from
smoking in a variety of potentially high-risk situations.
Higher scores represent greater self-efcacy. This measure
has demonstrated good content, construct and predictive
validity (Etter et al. 2000). Cronbachs alpha in the current
sample was .95.
Cogn Ther Res (2009) 33:241254 245
1 3
The Smoking Effects Questionnaire
(SEQ; Rohsenow et al. 2003)
This 33-item measure assesses participants positive and
negative expectancies about smoking cigarettes. Respon-
dents rate their belief that smoking will have a particular
effect on a scale of 0 (false), 1 (true and not at all
important), 2 (true and moderately important), or 3 (true
and very important). Subscales are calculated by averaging
relevant item ratings. The SEQ shows good psychometric
properties among adults attempting to quit (Rohsenow
et al. 2003). Only the subscale assessing positive expec-
tancies about smoking (e.g., will relieve negative affect)
was used in analyses. Cronbachs alpha was .88.
The Fagerstrom Test for Nicotine Dependence
(FTND; Heatherton et al. 1991)
This widely used measure assesses nicotine dependence on
a six-item scale. Participants completed the FTND with
reference to their pattern of smoking prior to quitting. The
FTND has demonstrated satisfactory internal consistency,
retest reliability, and convergent validity (Heatherton et al.
1991; Pomerleau et al. 1994). Cronbachs alpha in the
current sample was .65.
Follow-up Questionnaire
One month after completing the questionnaires, partici-
pants were sent a follow-up email asking a couple of
questions. One of these was pertinent to the current study:
Over the past week, how many cigarettes have you
smoked (in total)?. Participants were classied as
smoking if they reported smoking any cigarettes over
the past week and abstinent if they reported not
smoking.
Data Analysis Overview
The psychometric properties of the ACQ and CAI were
examined rst, followed by tests of primary study
hypotheses. Prior to analyses, variables were screened for
outliers and t with the assumptions of multivariate anal-
ysis. The inuence of study methodology (e.g., differing
incentives, questionnaire orders and follow-up survey
completion rates) was also explored. In the next stage of
analysis, previously established predictor variables were
examined to determine relevance for tests of main
hypotheses. Partial correlations were then calculated to test
the hypothesis that metacognitive factors (personally
meaningful appraisals and thought suppression) would be
associated with concurrent severity of craving-related
cognition after accounting for previously established
predictors. Finally, the hypothesis that metacognition
would also predict future smoking behaviour (i.e., status as
abstinent or smoking at follow-up) was examined
through two hierarchical logistic regression analyses. At
the rst level in the model, relevant previously established
predictors were added as covariates. Thought suppression
(WBSI scores) was introduced in the second level of the
model. Because of the strong correlation between
appraisals as measured by the ACQ and CAI (r = 0.61),
we entered appraisals in the third level of the model in
separate analyses (ACQ scores in the rst analysis, CAI
scores in the second).
5
Overall, this model facilitates
examination of the unique inuence of metacognitive
factors on future smoking behaviour over and above
established predictors.
Results
ACQ and CAI Psychometrics
An exploratory factor analysis (principal component anal-
ysis) was performed on the 17 ACQ items to examine the
structure of the ACQ. Although three factors with eigen-
values greater than one were extracted, the scree plot
suggested a unifactorial structure. Examination of rotated
factors revealed multiple complex loadings in multi-fac-
torial solutions. All items loaded highly ([.55) on the rst
factor, which accounted for 45.6% of the measure variance.
As such, we elected to use the ACQ as a unidimensional
scale. Cronbachs alphas for the ACQ and CAI were .92
and .88, respectively, suggesting excellent internal con-
sistency. CAI and ACQ scores were moderately correlated
(r = .61).
As measures of obsessional types of appraisals (applied
to smoking cessation), one would expect the ACQ and CAI
to be moderately correlated with other measures of
obsessional beliefs. Consistent with this, the ACQ corre-
lated with the OBQ and TAF at .42 and .31 respectively,
Ps \.01. The CAI correlated with the OBQ and TAF at
.36 and .39, respectively, Ps \.01.
Preliminary Analyses
No cases had missing data. Four outliers for the number of
times a participant had previously attempted to quit
smoking were replaced with adjacent scores. Three
smoking history variables were transformed to reduce the
number of outliers and improve their distributions. This
5
Interpretation of logistic regression results is problematic when
individual predictors are strongly correlated and expected to be
related to the criterion in similar ways (Tabachnick and Fidell 2001).
246 Cogn Ther Res (2009) 33:241254
1 3
procedure affected duration of current and longest previous
quit attempt (both log transformations) and number of
previous quit attempts (square root transformation). Based
on Mahalanobis distances at P\.01, two cases were
identied as multivariate outliers and removed from the
sample, leaving 178 cases available for analysis.
As there were no signicant differences on study ques-
tionnaires between individuals participating under the draw
or $20 incentive, ts (176) \1.82, Ps [.05, the samples
were combined for analyses. Participants not completing the
one-month follow-up had quit smoking more recently than
individuals completing the follow-up (Ms = 0.45 months
ago vs. 1.26 months ago; t (47.37) = 3.87, P\.01). These
groups did not differ on any other demographics, smoking
history variables or on study questionnaires, ts (176) \1.59,
Ps [.05. Analysis of questionnaire order showed no sig-
nicant effects, F (12, 342) = 1,71, P[.05, so this factor
was not considered further. Demographics and smoking
histories did not differ for individuals completely vs. par-
tially abstinent at the time of completing questionnaires,
aside from amount currently smoking (0.0 vs. 3.4 cigarettes
per day), t (47) = 5.90, P\.05. Table 1 provides descrip-
tive statistics for study questionnaires, calculated using both
the full sample (N = 178) and only participants completing
the follow-up, classied as abstinent (n = 78) or smoking
(n = 70). All statistical analyses were conducted at a two-
tailed alpha of .05.
Previously Established Predictors
The relevance of previously established predictor variables
for subsequent analyses was determined by examining for
signicant relationships with the criterion variables (craving
severity and one-month smoking status). The frequency,
distress, and intensity of craving-related thoughts (OCDS-
RS scores) correlated signicantly with two smoking history
variables: (log of) the number of days since a participant
began the current quit attempt, r = -.36, and (square root
of) frequency of previous quit attempts, r = .19, Ps \.05.
Severity of craving-related thoughts was also signicantly
associated with positive smoking expectations (SEQ-pos),
r = .33, depression (CES-DS), r = .37, and poorer cessa-
tion self-efcacy (SSEQ), r = -.50, Ps \.05. OCDS-RS
scores did not show signicant correlations with gender,
years of education, use of antidepressant medication, dura-
tion of regular smoking, current cessation status (completely
vs. partially abstinent), pre-quit nicotine dependence
(FTND), or (log of) duration of longest previous quit
attempt, r s B .14, Ps [.05.
Table 1 shows statistics comparing smoking and absti-
nent individuals at follow-up. Means and SDs are based on
raw scores, although some variables (as noted) were
transformed for analysis. Compared to abstinent individu-
als, participants who were smoking at the one-month
follow-up had been regular smokers for fewer years before
Table 1 Means and Standard Deviation for smoking history variables and questionnaires
Measure One-month follow-up status
Full sample
(N = 178)
Smoking
(n = 70)
Abstinent
(n = 78)
Smoking versus
Abstinent
M SD M SD M SD t d
Smoking History and Other Established Predictors
Years smoking before quit 20.09 10.78 18.60 10.29 22.66 11.41 -2.26* -0.37
Number of previous quit attempts
a
6.56 9.82 6.74 4.96 5.39 5.09 2.15* 0.36
Longest previous quit attempt (months)
a
9.62 21.49 11.23 28.38 7.36 14.25 1.17 0.19
Duration of current quit attempt (months)
a
1.12 1.29 1.04 1.47 1.46 1.23 -3.58* -0.59
Fagerstrom Test for Nicotine Dependence (pre-quit) 5.65 2.28 5.69 2.29 5.72 2.20 -0.09 -0.01
Smoking Effects Quest: Positive Expectancies 1.29 0.55 1.33 0.56 1.29 0.56 0.43 0.07
CES-DepressionShort Form 7.96 4.40 8.59 4.74 7.51 3.82 1.52 0.25
Smoking Self-Efcacy Questionnaire 39.84 12.45 33.86 11.01 44.51 12.20 -5.56* -0.92
Metacognition and craving severity
White Bear Suppression Inventory: Suppression 20.81 4.69 21.33 4.81 20.40 4.58 1.21 0.20
Catastrophic Appraisals Index 3.83 3.24 5.17 3.42 2.86 2.86 4.48* 0.74
Appraisals of Craving Questionnaire 71.81 37.27 88.29 33.97 58.69 35.04 5.20* 0.86
OCDS-RS ObsessionalSmoking Version 9.34 4.20 11.21 3.81 8.08 4.02 4.86* 0.80
Note: CES-Depression = Center for Epidemiological Studies Depression Scale, OCDS-RS Obsessional = Obsessional subscale of the Obses-
sive-Compulsive Drinking ScaleRevised, * P\.01.
a
Transformed for analysis, but raw scores presented here
Cogn Ther Res (2009) 33:241254 247
1 3
quitting, had quit smoking more recently, had attempted to
quit more frequently, and were less often completely
abstinent at the time of completing the questionnaires
(48.6% vs. 91.0%; v
2
= 32.26, P\.01). Smokers also
reported less condence in their ability to quit (as measured
by the SSEQ) and more frequent, persistent and intense
cravings (OCDS-RS scores). There were no signicant
differences between groups on other questionnaires or on
other demographic and smoking history variables.
Metacognition and Concurrent Severity
of Craving-related Thoughts
Thought suppression scores were moderately correlated
with appraisals of cravings as measured by both the ACQ
(r = .34, P\.01) and the CAI (r = .27, P\.01). Table 2
shows the relationships between previously established
predictor variables, craving severity and the metacognitive
variables. Partial correlations control for quit attempt
duration, number of previous quit attempts, positive
smoking expectations (SEQ-pos), depression (CES-DS) and
cessation self-efcacy (SSEQ). All variables correlated
\.60. SPSS collinearity diagnostics revealed that while all
condition indices fell\.30, no dimension had more than one
variance proportion [.50. Thus, multicollinearity was not
an issue (Belsey et al. 1980; Tabachnick and Fidell 2001).
Consistent with hypotheses, the frequency, distress, and
intensity of craving-related thoughts (OCDS-RS scores) cor-
related signicantly with both ACQ and CAI scores (i.e.,
personally meaningful appraisals of cravings) after removing
the effects of previously established predictors. Inconsistent
with predictions, use of thought suppression was not related to
craving severity after accounting for previously established
predictors. The possibility that suppression effects were
moderated by personally meaningful appraisals was also tes-
ted. However, the interaction between suppression and
meaningful appraisals (as measured by either the ACQ or
CAI) was not signicantly correlated with craving severity
either before or after partialling out the effects of other pre-
dictors (rs B .12, Ps [.05).
Metacognition in the Prediction
of One-month Smoking Status
At the one-month follow-up, 47.3% of participants reported
smoking over the previous week (leaving 52.7% classied
as abstinent). Two hierarchical logistic regression anal-
yses examined whether metacognitive variables (personally
meaningful appraisals and thought suppression) predicted
smoking behaviour above and beyond previously estab-
lished predictors: initial smoking status (complete vs.
partial abstinence), duration of regular smoking, quit
attempt duration, number of previous quit attempts, craving
severity (OCDS-RS scores) and condence in ability to
quit (SSEQ scores). All predictor variables correlated\.60.
SPSS collinearity diagnostics revealed that while all con-
dition indices fell \.30, no dimension had more than one
variance proportion [.50. Thus, multicollinearity was not
an issue (Belsey et al. 1980; Tebachnick and Fidell 2001).
Table 3 provides details of the model. In the rst level
of the model (previously established predictor variables),
participants were more likely to be smoking at the follow-
up if they had quit smoking more recently, were not
completely abstinent at the time of completing the ques-
tionnaires and were experiencing more frequent, intense
and persistent craving-related thoughts, images and
impulses. Inconsistent with hypotheses, thought suppres-
sion (WBSI scores) did not explain a signicant proportion
of variance in smoking status beyond that accounted for by
previously established predictors, nor was it associated
with a unique change in the odds of future smoking
behaviour above and beyond the covariates.
Table 2 Correlations between metacognitive variables, established predictors and craving severity
Variables White Bear Suppression
Subscale
Catastrophic Appraisals
Index
Appraisals of Craving
Quest
Quit Attempt Duration (log) .20** -.01 -.14
Frequency of Past Attempts (H) -.01 .02 .07
Smoking Effects Quest: Positive .25** .22** .30**
CES-Depression .24** .35** .32**
Smoking Self-Efcacy Quest. -.06 -.38** -.52**
OCDS-RS Obsessional
Zero-Order .16* .37** .55**
Partial
a
.14 .17* .33**
Notes: N = 178, * P\.05. ** P\.01. OCDS-RS Obsessional = Obsessional subscale of the Obsessive Compulsive Drinking ScaleRevised,
Smoking Version, CES-Depression = Center for Epidemiological Studies Depression ScaleShort Form
a
Controlling for time elapsed since beginning quit attempt, frequency of previous quit attempts, positive smoking expectancies, depression, and
cessation self-efcacy
248 Cogn Ther Res (2009) 33:241254
1 3
As predicted, personally meaningful appraisals measured
by the ACQ, introduced in the third step of the model,
explained a signicant proportion of variance in smoking
status above and beyond that accounted for by previously
established predictors and thought suppression. When all
variables were entered, ACQ scores were also associated
with a small but unique change in the odds of future
smoking. Participants were 1.02 times more likely to be
smoking at follow up for each additional increment of belief
in the personally meaningful appraisals of cravings assessed
by the ACQ (where scores ranged from 1170). In separate
analysis, catastrophic appraisals also explained a signicant
proportion of variance in smoking status incremental to that
accounted for by previously established predictors and
thought suppression, and were associated with a unique
change in the odds of future smoking behaviour. Partici-
pants were 1.2 times more likely to be smoking at the
follow-up for each catastrophic interpretation of cravings in
which they endorsed some degree of belief.
The possibility that suppression effects were moderated
by personally meaningful appraisals was tested by intro-
ducing an interaction term (suppression 9 appraisals) in
the fourth step of each model. This step did not contribute
signicantly to the prediction of smoking status, regardless
of whether appraisals were assessed by the ACQ or CAI,
Step v
2
s (148) B 1.95, Ps [.05, nor did it affect the
signicance of individual predictors.
Discussion
The present study investigated the applicability of cognitive
theories of obsessions to the nicotine craving-related
thoughts, images and impulses experienced by people
attempting to quit smoking. Results support the generaliz-
ability of key aspects of the model. Specically, like
obsessions, personally meaningful appraisals of intrusive
craving-related thoughts correlated signicantly with the
severity of these thoughts. Participants experienced more
problematic cravings, in terms of frequency, distress, con-
trollability, persistence, and interference, if they held a
concurrent view of their cravings as more catastrophic,
personally signicant and important to control. Importantly,
these appraisals prospectively predicted whether partici-
pants would be smoking one month later after accounting
for initial smoking status, years of regular smoking, recency
of the quit attempt, craving severity and condence about
being able to successfully abstain. Contrary to expectation,
tendency to suppress unwanted thoughts did not contribute
signicantly to the prediction of either concurrent craving
severity or one month cessation outcome.
Maladaptive Appraisals of Cravings
To date, very little research has investigated how people
trying to quit smoking interpret their cravings. In the present
study, many participants endorsed beliefs that craving-
related thoughts mean that they are weak, that their attempt
to quit smoking is destined to fail, and that it is important to
cancel out or block the thoughts. On average, participants
expressed a moderate degree of belief in these ideas (average
rating of 4.2 on a scale of 0 = no belief at all to
10 = completely convinced). A substantial minority of
individuals took their appraisals even further, endorsing
beliefs that craving-related thoughts mean that they are out
of control, for example, or that the thoughts will lead to
Table 3 Logistic regression predicting smoking versus abstinent status at one-month follow-up
Variables Step 1 Step 2 Step 3 Step 3
Established predictors Thought suppression Appraisals: ACQ Appraisals: CAI
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Initial abstinence status 9.81 3.2729.45* 10.39 3.3732.01* 10.57 3.3533.32* 11.06 3.4835.16*
Years smoking before quit 1.00 0.991.00 1.00 .991.00 1.00 .991.00 1.00 .991.00
Quit Attempt Duration (log) 0.41 0.170.97* .36 .15.88* .35 .14.85* .33 .13.81*
Frequency of Past Attempts (H) 1.48 0.962.27 1.47 .962.25 1.50 .962.35 1.60 1.022.51*
Smoking Self-Efcacy Quest. 0.98 0.941.02 .98 .941.02 .99 .951.04 .99 .951.03
Craving Severity (OCDS-RS) 1.14 1.011.29* 1.13 1.001.28 1.08 .951.23 1.09 .961.24
White Bear Suppression 1.05 .961.15 1.01 .921.12 1.03 .941.12
Appraisals of Craving Quest. 1.02 1.001.03*
Catastrophic Appraisals Index 1.19 1.021.39*
Step v
2
65.24* 1.31 4.24* 4.90*
Model v
2
65.24* 66.55* 70.79* 71.45*
Note: N = 148, * P\.05. White Bear Suppression refers to the Suppression subscale of the White Bear Suppression Inventory. OCDS-RS
refers to the Obsessive-Compulsive Drinking Scale-Revised Smoking Version, Obsessional Subscale
Cogn Ther Res (2009) 33:241254 249
1 3
insanity, punishment or condemnation. Participants
endorsed some degree of belief in an average of four of these
more catastrophic appraisals. Overall, these ndings are
intriguing because they suggest that some people appraise
craving-related thoughts as powerful signals of the type of
person they are or the likely success of their quit attempt.
Cognitive theories of obsessions suggest a cyclical
relationship between personally meaningful appraisals and
unwanted intrusive thoughts, whereby negative and per-
sonally signicant appraisals give rise to more frequent
intrusions, which seem to reafrm the interpretation that the
intrusions have personal meaning for the individual or the
future (Rachman 1997, 1998; Salkovskis 1985). Results of
the current study are consistent with correlational research
conducted on obsessions in support of this theorized process
(Clark et al. 2000; Clark et al. 2003; Purdon and Clark
1994a, 1994b). That is, we found a strong positive corre-
lation between personally meaningful interpretations of
craving-related thoughts, images and impulses and the
frequency, distress and intensity of the intrusions. Although
the prospective ndings of the current study provide
intriguing support for a causal effect of appraisals on
craving severity and cessation difculty, more longitudinal
and experimental studies are needed to establish the tem-
poral relationship and causal direction. Persistent and
intense craving-related thoughts, for example, would plau-
sibly elicit more catastrophic, personally meaningful
appraisals than would eeting, infrequent thoughts of
smoking. Researchers studying obsessions have noted
similar difculties disentangling the causal actions under-
lying these reciprocal relationships (e.g., Teachman et al.
2006).
Nevertheless, this work complements and extends
existing work on the role of anxiety sensitivity in cessation,
which suggests that tendency to catastrophize about inter-
nal sensations (i.e., score high on anxiety sensitivity
measures) is uniquely associated with smoking to reduce
negative affect, decreased cessation self-efcacy, and
increased risk of early cessation relapse (Brown et al. 2001;
Zvolensky et al. 2006; Zvolensky et al. 2006; Zvolensky
et al. 2007). Consistent with this, the present study found
that individuals who appraised cravings as meaning
something negative about themselves or who believed their
craving-related thoughts needed to be controlled felt more
depressed and less condent in their ability to abstain from
smoking. They also expected that smoking would have
more positive effects. These ndings merit further research
to discover whether personally meaningful appraisals of
smoking-related thoughts exacerbate low mood or damage
self-efcacy. It would also be very useful to know how the
appraisals assessed by the ACQ and CAI relate to anxiety
sensitivity and the extent to which these measures uniquely
contribute to understanding cessation relapse.
Just as cognitive theories of obsessions have inspired
new interventions to specically target maladaptive
appraisals of unwanted thoughts, understanding the role of
metacognition in cravings may open the door to innovative
clinical strategies. Appraisals of the meaning of craving-
related thoughts, as investigated in the current study, are
not explicitly targeted by current cessation treatments. If
personally meaningful appraisals prove to be a robust
predictor of craving severity and cessation outcome, then
some aspects of cognitive therapy for obsessions may be
usefully applied to the cravings experienced during
smoking cessation.
Thought Suppression During Smoking Cessation
Cognitive theories of obsessions predict that individuals
who appraise their unwanted thoughts in negative, overly
signicant ways will try to avoid or control their thoughts
as a means of reducing distress and preventing undesirable
outcomes (OCCWG 1997). Because the effort is doomed to
fail, trying to control unwanted thoughts is believed to be a
central mechanism involved in their persistence (OCCWG
1997; Purdon and Clark 1999). Failure to eliminate the
thoughts seems to strengthen belief in the importance of the
thought and exacerbate distress about having the thought
(Purdon and Clark 2001; Purdon et al. 2005). In the current
study, participants who endorsed a greater tendency to
suppress (general) unwanted thoughts also reported more
negative and personally signicant interpretations of
cravings, a nding that is consistent with research on
obsessions (Rassin et al. 2000; Smari and Holmsteinsson
2001).
Our results, however, did not show a relationship
between thought suppression and either concurrent craving
severity or prospective smoking behaviour. Though this
result differs from research on obsessions, it is consistent
with several studies from the substance dependence liter-
ature, including the Reynolds et al. (2005) experimental
nding that suppression did not increase the frequency of
drug-related thoughts and the Haaga and Allison (1994)
prospective nding that use of thought suppression was
unrelated to maintenance of smoking abstinence. The
addictions literature, however, is not entirely consistent on
this nding, as the Salkovskis and Reynolds (1994) and
Palfai et al. (1997) experimental studies and the Toll et al.
(2001) questionnaire study reported different results. Fac-
tors that may have led to differences among these studies
include the setting of the study (with no effect found in
more naturalistic settings; Reynolds et al. 2005) and
delineation of smoking status (with no effect found in
prospective investigations). An additional issue may be
how thought suppression is measured. Previous research
has indicated that many items on the White Bear
250 Cogn Ther Res (2009) 33:241254
1 3
Suppression Inventory conate thought frequency with
thought suppression (Hoping and de Jong-Meyer 2003). As
such, we used only the thought suppression factor in an
effort to produce clearer results. This may be another
reason our results differ from Toll et al. (2001), who
employed the full scale WBSI.
This ambiguity in the literature may reect different
effects of thought suppression for different individuals or
circumstances. Some evidence, for example, suggests that
suppression of depressive or worry-related thoughts may
actually be benecial under certain conditions, with
expression associated with subsequent dysphoria and
rumination (Borkovec et al. 1983; Roemer and Borkovec
1994). A similar phenomenon may occur for craving-
related thoughts: postponing or redirecting thoughts of
smoking may be adaptive at times when attempting to quit.
Consistent with this idea, current smoking cessation treat-
ments encourage people to use distraction when
experiencing urges to smoke (Abrams et al. 2003). Alter-
natively, thought suppression may become problematic
only when it fails or when individuals appraise failures in
thought control as overly signicant. Indeed, individuals
who believe that they should be able to perfectly control
obsessional types of thoughts are more upset by suppres-
sion failure (Purdon et al. 2005). Finally, the degree to
which thought suppression is adaptive or counterproductive
may also vary with situational variables, such as the rela-
tive salience of smoking cues or the accessibility of
cigarettes. Given the array of possible complicating factors,
it is important to keep in mind that the measure of thought
suppression used in the current study was not specic to
cravings or to particular settings. If the effect of thought
suppression depends on context or thought content, then it
may be important to assess suppression of specic forms of
unwanted intrusive thoughts.
Limitations
Several limitations of the current study are important to
bear in mind when interpreting the results. To begin, all
variables were assessed via self-report. Individuals
undoubtedly vary in the degree to which they are able to
recognize and recall their appraisals of intrusive thoughts.
Momentary, in vivo assessment or the use of implicit
measures of cognition would improve condence in the
ndings. Though research suggests that assessment of
smoking via self-report is generally accurate (Patrick et al.
1994), conrmation with biochemical assessment would
similarly increase certainty in the results.
The measures used in this study also leave some ques-
tions unanswered. Neither the ACQ nor the CAI have been
subjected to rigorous psychometric evaluation, although we
did aim to provide some support for reliability and validity
in this study. Demonstrating convergent validity, the ACQ
and CAI were moderately correlated with measures of both
obsessive beliefs and other forms of problematic cognition
during smoking cessation (e.g., poor cessation self-ef-
cacy, positive beliefs about the effects of smoking).
Discriminant validity was also demonstrated indirectly
though the tests of the main study hypotheses. That is,
these measures correlated in expected ways with craving
severity even after accounting for several other relevant
predictors (like depressed mood and cessation self-ef-
cacy). The ACQ and CAI also predicted smoking
behaviour after controlling for these established predictors.
The ACQ and CAI were derived from measures of
appraisals relevant to obsessions, which is both a strength,
in that some of those measures were carefully developed,
and a weakness: these measures may not cover all content
areas relevant to smoking cessation. Future research
investigating the clinical utility of the ACQ and CAI may
wish to broaden their scope to include other types of
smoking-specic appraisals.
We also assessed craving severity with the OCDS-RS.
We chose this measure because it is analogous to a com-
monly used index of obsessivecompulsive symptoms (the
Y-BOCS), because it assesses several facets of craving
severity (unlike traditional single item 0100 urge scales)
and because it has demonstrated strong psychometric
properties. Nevertheless, it is not widely used and it is not
clear how it relates to traditional single item measures of
craving or to other symptoms of nicotine withdrawal.
Similarly, we assessed future smoking behaviour via
self-reported recent (i.e., past week) smoking at a one-
month follow-up. Other conceptualizations of cessation
success (e.g., continued abstinence over the entire month,
abstinence at six months or a year) may present different
and meaningful information. Replication with alternative
measurement of both craving severity and cessation out-
come is warranted.
The sample also has strengths and weaknesses.
Although all participants reported actively trying to quit
smoking, they represent a particular slice of the population.
Specically, the results may not generalize well to indi-
viduals without regular computer or internet access (e.g.,
people with low socioeconomic status or older individuals).
Cultural diversity of the current sample was also limited;
participants in the current study were mainly of a Cauca-
sian or Western European ethnic background. Finally,
participation was restricted to individuals with a fairly
specic smoking history.
In summary, the current study provides some of the rst
indications of how people who are trying to quit smoking
appraise the occurrence of cravings. The types of appraisals
that have been found to be important in obsessions (per-
sonal signicance of the thoughts, responsibility arising
Cogn Ther Res (2009) 33:241254 251
1 3
from the thoughts, and the importance of controlling the
thoughts) were related to craving severity. More cata-
strophic appraisals of the meaning of craving-related
thoughts, although endorsed less frequently, were also
predictive of craving severity. Both types of appraisals
predicted cessation status one month later. In contrast to
theories about obsessions, thought suppression did not
appear to play a role in craving severity in this sample.
Clearly these results need to be replicated and further
investigated, but they provide evidence that cognitive
theories of obsessions generalize to other types of
unwanted thoughts and suggest fruitful directions for
research and clinical strategies in smoking cessation.
Acknowledgements This research was funded through the strategic
initiative Advancing the Science to Reduce Tobacco Abuse and
Nicotine Addiction, which is a partnership of government and non-
prot organizations under the coordination of the Canadian Tobacco
Control Research Initiative (CTCRI), http://www.ctcri.ca. This study
was also supported by a Social Science and Humanities Research
Council Scholarship awarded to the rst author. We thank Scott
Carlson and Charlotte Johnston for their helpful contributions to this
project.
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