Perceived risks and benefits of smoking cessation: Gender-specific predictors of motivation and treatment outcome

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1 Addictive Behaviors 30 (2005) Perceived risks and benefits of smoking cessation: Gender-specific predictors of motivation and treatment outcome Sherry A. McKee a, *, Stephanie S. O Malley a, Peter Salovey b, Suchitra Krishnan-Sarin a, Carolyn M. Mazure a a Department of Psychiatry, Yale University School of Medicine, Substance Abuse Center-CMHC, 34 Park Street, #S-211, New Haven, CT 06519, USA b Department of Psychology, Yale University, USA Abstract The primary aim of this study was to examine gender differences in perceived risks and benefits of smoking cessation and their relationship to pretreatment motivation and treatment outcome. No validated measures that comprehensively assess perceived risks and benefits associated with smoking cessation were available in the literature; consequently, we developed a self-report instrument [Perceived Risks and Benefits Questionnaire (PRBQ)] for this purpose. A sample of 573 treatmentseeking smokers (48% female) entering smoking cessation trials completed the PRBQ, and its association with treatment outcome was assessed in a subsample of 93 participants. Overall, the PRBQ demonstrated good psychometric properties. Females indicated greater likelihood ratings of perceived risks and benefits than males. For women and men, perceived benefits were positively associated with motivation, and perceived risks were negatively associated with motivation and treatment outcome. Women evidenced stronger associations between perceived risks and pretreatment motivation, and treatment outcome. Knowledge of perceived risks and benefits associated with smoking cessation is critical for public education campaigns and could inform intervention strategies designed to modify sex-specific beliefs associated with lowered behavioral intentions to quit smoking. D 2004 Elsevier Ltd. All rights reserved. Keywords: Smoking cessation; Gender differences; Perceived risks; Perceived benefits; Motivation; Treatment outcome * Corresponding author. Tel.: ; fax: address: sherry.mckee@yale.edu (S.A. McKee) /$ see front matter D 2004 Elsevier Ltd. All rights reserved. doi: /j.addbeh

2 424 S.A. McKee et al. / Addictive Behaviors 30 (2005) Introduction Most investigations examining perceived risks and benefits with regard to smoking have focused on risks of continued smoking and benefits of quitting. The Agency for Health Care Policy and Research (Fiore et al., 2000) suggests that clinicians should address the negative consequences of continued smoking (e.g., heart attacks and strokes, lung and other cancers) and highlight the benefits of quitting (e.g., improved health, feel better about yourself) to help motivate patients to quit smoking. Although much work has been done investigating risk perceptions associated with continued smoking (e.g., Weinstein, 2001), there has been relatively little work examining risk perceptions associated with quitting. Independent investigations examining single risk perceptions associated with quitting have focused on gender differences to help explain why women have poorer smoking cessation treatment outcomes compared to men (see Perkins, 2001 for review). For example, women are more likely than men to be concerned about postcessation weight gain (Pirie, Murray, & Luepker, 1991), and to identify weight gain as the cause for relapse to smoking (Swan et al., 1993). Furthermore, women who are concerned about postcessation weight gain are less likely to be motivated to quit smoking (Weekley, Klesges, & Relyea, 1992). Women are also more concerned that smoking cessation will result in increased levels of stress and negative affect (Sorensen & Pachacek, 1987). Women have greater expectations that smoking will reduce negative affect (Brandon & Baker, 1991) and are more likely to report smoking in response to negative affect or stress (e.g., Livson & Leino, 1988). Moreover, in situations involving negative affect, women report lower selfefficacy in their ability to resist smoking (Abrams et al., 1987). Additionally, anticipated negative withdrawal symptoms have been identified as a risk for failed smoking cessation. Retrospective assessments of withdrawal symptoms find that women report greater withdrawal distress compared to men (Pomerleau et al., 1994), although this finding is not generally supported in prospective studies (Pomerleau, 1996; Svikis et al., 1986). It has been suggested that women accurately remember past withdrawal, but men tend to minimize symptoms (Pomerleau et al., 1994). There also are gender differences in perceived benefits of quitting. Women are less likely to acknowledge the health benefits of smoking cessation (Sorensen & Pachacek, 1987) than men, and less likely to be motivated to quit to gain health benefits (Curry, Grothaus, & McBride, 1997). In a large epidemiological survey, women who had experienced health events were less likely than men to quit smoking (McKee, Maciejewski, Falba, & Mazure, 2003). Women are more likely to acknowledge the risks associated with smoking cessation, and less likely to acknowledge the benefits. As perceived benefits and risks of smoking cessation are associated with intentions to quit (e.g., Sutton, Marshet, & Matheson, 1990) and actual treatment response (e.g., Gibbons, McGovern, & Lando, 1991; Halpern & Warner, 1993), it is important to delineate such beliefs and their impact on behavioral intentions and treatment response. Gender-specific differences in perceived risks and benefits of quitting may partially contribute to the finding that women have poorer smoking cessation outcomes as compared to men (Perkins, 2001).

3 S.A. McKee et al. / Addictive Behaviors 30 (2005) Currently, there is no validated measure that comprehensively assesses perceived risks and benefits associated with smoking cessation. Some existing instruments assess perceived benefits associated with quitting (e.g., Reasons for Quitting: Curry, Wagner, & Grothaus, 1990), but there are none available that assess perceived risks associated with quitting. As part of the current investigation, we developed the Perceived Risks and Benefits Questionnaire (PRBQ) to investigate gender differences in anticipated outcomes related to smoking cessation. The development of this 39-item self-report instrument was guided by subjective utility theory (Edwards, 1954). Rather than assessing general attitudes as precursors to behavioral intentions, examining specific beliefs and perceived outcomes (both positive and negative) associated with a particular behavior should provide a better understanding of the behavior in question. Sutton et al. (1990) found that individuals who had strong intentions to quit smoking rated the perceived benefits of smoking cessation (health, financial, social, and self-esteem) as more likely, and rated the risks associated with smoking cessation (negative affect and loss of enjoyment) as less likely than individuals with weak intentions to quit smoking. The primary aim of this study was to examine gender differences in perceived risks and benefits of cessation and their relationship to pretreatment motivation and treatment outcome. We predicted that women would anticipate greater risks and fewer benefits of quitting, compared to men. Furthermore, we predicted that perceived risks would be negatively associated with motivation to quit and positively associated with treatment failure for women. For men, we predicted that perceived benefits would be positively associated with motivation to quit and negatively associated with treatment failure. As perceived risks and benefits associated with smoking cessation have been found to vary on the basis of education (Manfredi, Lacey, Warnecke, & Buis, 1992), age (Kviz et al., 1994), length of nicotine dependence (Orleans et al., 1991), and race (Palinkas et al., 1993), we assessed these variables as potential covariates when examining gender differences. 2. Method 2.1. Data source Data from two ongoing smoking cessation trials were used for this study. Study 1 (n = 172) involved a detailed examination of acute withdrawal effects using counseling and contingency management to bolster abstinence rates (Torello, Franco, Cooney, & Krishnan-Sarin, 2002). Only baseline data were used from Study 1. Study 2 (n = 401) was a double-blind, randomized, dose-ranging clinical trial examining whether naltrexone augments the effects of nicotine patch (O Malley, 2003). All participants received 21 mg nicotine patch daily and were randomized to placebo or 25, 50, or 100 mg of naltrexone for a 6-week period. Participants also received weekly counseling. Baseline and treatment outcome data (for the naltrexone placebo + 21 mg patch group only, n = 93) were used from Study 2. For both studies, participants provided informed consent prior to data collection. Inclusion criteria included smoking at least 10 cigarettes per day for Study 1, and 20 cigarettes per day for

4 426 S.A. McKee et al. / Addictive Behaviors 30 (2005) Study 2. Participants were also required to be medically stable and have no major psychiatric disorders Baseline sample For the current study, a combined sample of 573 participants (47.6% female) was used to examine the psychometric properties of the PRBQ and its association with pretreatment motivation. Baseline characteristics of this sample by gender are presented in Table 1. Males were found to smoke more cigarettes per day [t(571) = 4.43, P <.0005], have higher Fagerstrom nicotine dependence scores [t(571) = 2.76, P=.006], have more lifetime quit attempts [t(571) = 2.27, P=.02], and demonstrate a trend towards being able to quit smoking for a longer period of time [t(571) = 1.94, P=.06] compared to females Treatment sample Analyses examining the association of the PRBQ to treatment outcome were based on a sample of 93 (50.5% female) from Study 2. This sample was primarily Caucasian (89.2%) and college educated (49.4%). The mean age was (S.D. = 11.40) years old, and participants smoked 26.9 (S.D. = 10.47) cigarettes per day, had smoked for (S.D. = 14.64) years, and had Fagerstrom nicotine dependence scores of 4.87 (S.D. = 1.42). Participants had also engaged in 7.61 (S.D. = 15.85) lifetime quit attempts, and their longest prior quit attempt had lasted for an average of 0.53 (S.D. = 1.8) years. The only difference across gender was cigarettes per day [t(92) = 2.80, P <.01]. Males smoked more cigarettes per day (29.95, S.D. = 13.09) than females (23.91, S.D. = 5.79) PRBQ items Items were pooled from prior studies assessing perceived risks and benefits associated with smoking cessation (Curry et al., 1990; Sorensen & Pachacek, 1987; Sutton et al., 1990). Table 1 Characteristics of baseline sample by gender Variable Female (n = 273) Male (n = 300) Age (m, S.D.) (11.52) (12.59) Race (% Caucasian) Education (% college) Cigarettes per day (m, S.D.) (9.15)** (11.87) Years smoking (m, S.D.) (13.16) (13.26) FTND scores (m, S.D.) 4.75 (1.53)** 5.12 (1.66) Lifetime quit attempts (m, S.D.) 5.32 (9.50)* 8.01 (17.35) Length (years) of longest quit attempt (m, S.D.) 0.75 (1.88) # 1.49 (6.52) *P <.05. **P <.01. P <.10.

5 Additionally, new items were written and then all items were evaluated by a panel of five experts in tobacco research. Forty items were then grouped into scales assessing perceived benefits (health, well-being, finances, self-esteem, social approval, and physical attraction), or risks (weight gain, increases in negative affect, reduced ability to attend or concentrate, social ostracism, loss of enjoyment, and craving) of smoking cessation. Participants responded to the stem Use the scale below to rate how likely each item would be if you were to stop smoking. Items were rated on a Likert scale, which assessed the likelihood of the item (1 = no chance, 7= certain to happen). This seven-point Likert response scale has demonstrated superior reliability and validity when compared to other self-report formats assessing perceptions of personal health risk (Diefenbach, Weinstein, & O Reilly, 1993). Items were averaged to create the 12 individual scale scores. Perceived risk and benefit scales were calculated by averaging risk and benefit items, respectively. Refer to Appendix A for a copy of the instrument Other measures At the first intake appointment for the smoking cessation trials, participants completed questionnaires that assessed age, race, education, smoking behavior (including cigarettes per day, number of lifetime quit attempts lasting longer than 24 h, and length of longest quit attempt), and nicotine dependence (Fagerstrom Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991). Additionally, participants completed self-report measures that assessed pros and cons of smoking and pretreatment motivation. The Decisional Balance Scale (Velicer, Prochaska, Prochaska, DiClemente, & Brandenburg, 1985) was used to assess the pros and cons of smoking. The Thoughts About Abstinence Scale (Hall et al., 1991) was used to assess the patient s level of commitment to an abstinence goal, desire to quit, expectations of success in quitting smoking, level of confidence, and anticipated difficulty in maintaining abstinence. Commitment to abstinence was assessed by asking the client to endorse one of six goals ranging from no goal to total abstinence never use cigarettes again. The remaining four items on the Thoughts About Abstinence Scale were rated from 1 to 10 (e.g., no desire to quit =1;extremely high desire to quit = 10) Statistical analysis S.A. McKee et al. / Addictive Behaviors 30 (2005) To evaluate the psychometric properties of the PRBQ, the baseline sample of 573 participants was used. Structural equation modeling (Amos 5.0, 2003) using maximum likelihood discrepancy functions was used for confirmatory factor analysis and fit indices were reported (GFI, CFI, and RMSEA). Scale reliability analyses (internal consistency and test retest reliability) and intercorrelations were also performed. Construct validity was assessed by examining the association of the PRBQ with the Decisional Balance Scale. To examine gender differences in the perceived risks and benefits of cessation, multivariate analysis of variance was used to determine if perceived risks and benefits of smoking cessation varied by gender. Linear and logistic hierarchical regression analyses were used to examine gender interactions of perceived risk and benefit scales predicting pretreatment

6 428 S.A. McKee et al. / Addictive Behaviors 30 (2005) motivation and treatment outcome. Baseline variables demonstrating gender differences (cigarettes per day, FNTD scores, number of lifetime quit attempts, and length of longest quit attempt) were used as covariates in these analyses. 3. Results 3.1. Perceived Risks and Benefits Questionnaire Confirmatory factor analysis The a priori model that guided our scale development consisted of two higher order factors (perceived risks and benefits), each with six separate scales (see Appendix A). To examine the fit of this a priori model, we first examined separate models for perceived risks and benefits. These models examined how well items loaded on their respective scales (assessed as latent variables) and how latent scales loaded onto a higher order latent variable (perceived risks or benefits). For the Perceived Risk model, the fit was good [v 2 (125, N = 573) = , P <.05, GFI=.95, CFI=.97, RMSEA=.05]. For the Perceived Benefit model, the fit was adequate, although not as good [v 2 (181, N = 573) = , P <.05, GFI=.90, CFI=.89, RMSEA=.07]. For both of these models, all standardized parameter estimates for individuals items and latent scales were greater than 0.4. We then examined a structural model, which loaded scale scores onto their respective latent variable (perceived risk or benefit). The fit for this model was best of all [v 2 (50, N = 573) = , P <.05, GFI=.96, CFI=.97, RMSEA=.05] Internal consistency Cronbach a ranged from.61 to.90 for individual scales, and.90 for Perceived Risk Scale and.93 for Perceived Benefit Scale, as reported in Appendix A. Only one item I will be more attractive to others was deleted based on internal consistency analysis. We also calculated test retest reliability for a subsample of 45 participants. Average time between PRBQ administrations was 1 2 weeks, and the second administration occurred prior to participants engaging in their quit attempt. There was a test retest correlation of r(45)=.82 for Perceived Risk Scale and r(45)=.61 for Perceived Benefit Scale. Lower correlations for the Perceived Benefit Scale may be a result of this scale s reduced variability (S.D. = 0.49) when compared to the Perceived Risk Scale (S.D. = 0.93). Additionally, there were no mean differences on Perceived Risk and Perceived Benefit across the two test retest administrations. All intercorrelations of scale scores were below.62, indicating that the scales represent separate variance. The higher order factors of perceived risks and benefits were correlated [r(573)=.25, P <.001] Construct validity To assess construct validity, we examined associations between the PRBQ and the Decisional Balance Scale. As expected, there were significant associations between the pros of smoking and perceived risks of quitting [r(570)=.32, P <.0005], and the cons of smoking and perceived benefits of quitting [r(570)=.41, P <.0005].

7 S.A. McKee et al. / Addictive Behaviors 30 (2005) Gender differences Multivariate analysis of variance examining mean differences in perceived risks and benefits, controlling for baseline gender differences, demonstrated a significant effect of gender [ F(2,556) = 13.15, P <.0005]. Females reported greater perceived risks (m = 5.11) and benefits (m = 6.61), compared to males (m = 4.76, m = 6.47, respectively). The comparison of individual scale means in Table 2 demonstrated that females had significantly higher scores on all scales except loss of enjoyment and craving, where they did not differ from males Pretreatment motivation Hierarchical regression analysis was conducted to examine gender interactions between perceived risks and benefits and pretreatment motivation. The four Likert scale items of the TAAS were averaged for the criterion variable. There were no baseline gender differences for this TAAS variable. Control variables were entered on the first step (cigarettes per day, FTND scores, number of lifetime quit attempts, and length of longest quit attempt), and on the second step, gender and perceived risk and benefit scales were entered. The final step assessed interactions between gender and perceived risk and benefit scales. The regression fit a linear model [ F(9,562) = 7.58, P <.0005] with 11% of the variance accounted for in TAAS scores. There were significant main effects for both the risk (b =.29, P <.0005) and benefit (b=.30, P <.0005) scales. Perceived risk was negatively associated with pretreatment motivation, whereas perceived benefit demonstrated a positive association. There was a significant interaction between risk and gender (b =.24, P <.005) in predicting pretreatment motivation to quit. Examination of partial correlations reported in Table 3 revealed that females had a stronger association between pretreatment motivation and perceived risks of Table 2 Mean (S.E.) scale scores of PRBQ by gender Scale Female (n = 273) Male (n = 300) Perceived risk 5.11 (.06)*** 4.76 (.05) Weight gain 5.60 (.08)*** 4.77 (.08) Negative affect 5.05 (.08)** 4.72 (.08) Attend/concentrate 4.29 (.08)* 4.01 (.08) Social ostracism 4.69 (.09)* 4.29 (.08) Loss of enjoyment 5.49 (.09) 5.35 (.09) Craving 6.08 (.07) 6.01 (.07) Perceived benefit 6.62 (.03)*** 6.47 (.03) Health 6.77 (.04)** 6.64 (.03) Well-being 6.56 (.04)** 6.42 (.04) Self-esteem 6.65 (.04)*** 6.43 (.04) Finances 6.77 (.04)** 6.58 (.04) Physical appeal 6.87 (.03)** 6.76 (.03) Social approval 6.51 (.04)* 6.36 (.04) *P <.05. **P <.01. ***P <.001.

8 430 S.A. McKee et al. / Addictive Behaviors 30 (2005) Table 3 Partial correlations of PRBQ and TAAS scores by gender Scale Female (n = 273) Male (n = 300) Perceived risk.35***.16** Weight gain.17**.00 Negative affect.24***.21*** Attend/concentrate.25***.17** Social ostracism.17**.00 Loss of enjoyment.29***.17** Craving.31***.11 Perceived benefit.02.16** Health Well-being.03.14* Self-esteem.13*.21*** Finances.07.17** Physical appeal.00.15* Social approval *P <.05. **P <.01. ***P <.001. cessation (r =.35, P <.0005), compared to males (r =.16, P <.01). Secondary analyses examining correlations of individual risk scales and TAAS scores for females demonstrated significant negative associations for all scales. For males, correlations of TAAS scores were not significant for weight gain, social ostracism, and craving scales. For the TAAS item measuring treatment goal, we dichotomized the variable into total abstinence versus other goal (Hall, Havassy, & Wasserman, 1991). A chi-square analysis demonstrated a trend toward an effect of gender on abstinence goal [v 2 (1,559) = 2.57, P=.11]. Fewer females (57.89%) had a total abstinence goal compared to males (64.51%). We then performed logistic regression with treatment goal as the criterion. Variables were entered into the model in the same manner as the prior analysis. Results demonstrated a significant main effect of perceived benefits on treatment goal (Wald = 4.10, P <.05, OR = 1.47). As perceived benefits increased by one unit, participants were 1.47 times more likely to have a total abstinence goal Treatment outcome Treatment outcome was calculated as continuous abstinence over the 6-week treatment phase, which was determined from self-report (i.e., not even a puff) and weekly carbon monoxide readings (less than 10 ppm). For the placebo naltrexone + 21 mg nicotine patch group (n = 93), 39% were continuously abstinent for 6 weeks and there was no significant gender difference in abstinence rates (females = 34%; males = 44%). A hierarchical logistic regression was performed with treatment outcome (total abstinence yes or no) and variables were entered into the model in the same manner as the prior analyses. The analyses demonstrated a trend for a main effect of perceived risks on treatment outcome ( P=.08); however, the interaction of perceived risk and gender was significant (Wald = 4.70, P <.05, OR = 4.04). The slope for

9 S.A. McKee et al. / Addictive Behaviors 30 (2005) perceived risks and treatment failure was steeper for women than men. Perceived risks had four times the impact on relapse among women compared to men. Secondary logistic regression analyses, examining the relationship between individual risk scales and treatment outcome in females, revealed trend effects ( P <.10) for negative affect, attention and concentration, social ostracism, and loss of enjoyment increasing the likelihood of relapse. 4. Discussion The current findings support prior research indicating that perceived risks and benefits of smoking are associated with intentions to quit (e.g., Sutton et al., 1990) and actual treatment response (e.g., Gibbons et al., 1991). For both women and men, perceived risks were found to be negatively associated with pretreatment motivation and somewhat positively associated with treatment outcome in a subsample of smokers who had received 6 weeks of placebo naltrexone+ 21 mg patch. Conversely, perceived benefits were positively associated with pretreatment motivation and total abstinence goals. Our results also support and extend prior research examining how perceived risks and benefits vary by gender (Curry et al., 1997; Lando, Pirie, Hellerstedt, & McGovern, 1991; Sorensen & Pachacek, 1987). Women reported that anticipated negative outcomes associated with smoking cessation (i.e., weight gain, increases in negative affect, reduced ability to attend or concentrate, social ostracism, loss of enjoyment, and craving) were more likely compared to men. Women also evidenced stronger associations between perceived risks and pretreatment motivation, and this association remained significant across all risk categories. Finally, perceived risk was significantly associated with treatment outcome in females. As likelihood ratings of perceived risk increased, women were four times more likely than men to relapse to smoking. This finding appears to be associated with the specific perceived risks of increased negative affect, reduced ability to attend or concentrate, social ostracism from smoking acquaintances, and the loss of enjoyment. Although perceived benefits were associated with pretreatment motivation for both women and men, we did not find any gender-specific effects for this relationship. In prior work, men were more likely than women to acknowledge the health benefits of smoking cessation (Sorensen & Pachacek, 1987), and we had hypothesized that perceived benefits would be more strongly associated with motivation and treatment outcome in men. Overall, we found that women indicated that perceived benefits from smoking cessation were more likely than did men, although the magnitude of these differences was small. When examining the partial correlations in Table 3, there appears to be a more consistent relationship between perceived benefits and motivation to quit for men compared to women. However, there was no significant interaction between perceived benefits and gender, predicting pretreatment motivation. It is possible that lack of findings may be due to the reduced variability demonstrated on the Perceived Benefit Scale. As can be seen in Table 2, both male and female smokers indicated a high likelihood of perceived benefits of smoking cessation. This finding may be related to the nature of this sample, which consisted of smokers who had volunteered to participate in a smoking cessation trial. In a community sample of smokers, there would likely be greater variability in perceived benefits of smoking cessation, which may then result in a different pattern of findings.

10 432 S.A. McKee et al. / Addictive Behaviors 30 (2005) Another aim of this investigation was to develop a measure that could be used to comprehensively assess perceived risks and benefits associated with smoking cessation. In this initial investigation, the PRBQ demonstrated acceptable psychometric properties. Confirmatory factor analysis supported a two-factor higher order model of perceived risks and benefits. Although measures of internal consistency on some of the subscales were moderate, we decided not to eliminate these scales as we have yet to investigate psychometric properties of the PRBQ in a community sample of smokers, which may demonstrate different patterns of variability. This preliminary investigation examining perceived risk and benefits of smoking cessation demonstrated gender-specific predictors of motivation and treatment outcome in a sample of treatment-seeking smokers. Further investigations examining perceived risks and benefits should examine gender-specific associations with motivation to quit and quit behavior in a community sample of smokers. Ultimately, such knowledge could inform public health campaigns designed to increase motivation to quit and intervention strategies designed to modify beliefs associated with lowered treatment response. Acknowledgements Supported by NIH grant P50DA Appendix A. The 39-item Perceived Risk and Benefits Questionnaire by subscale with Cronbach A Instructions: Use the scale below to rate how likely each item would be if you were to stop smoking. Scale Item a No chance Very unlikely Unlikely Moderate chance Likely Very likely Certain to happen Perceived risk.90 Weight gain I will eat more..83 I will gain weight. I won t be able to lose weight as easily. Negative affect I will be more irritable..79 I will be less able to deal with stress. I will feel less calm. Attend/concentrate I will have a shorter attention span..89 I will be less able to concentrate. I will be less able to focus my attention. My thoughts will be more likely to wander. I will be more inattentive.

11 S.A. McKee et al. / Addictive Behaviors 30 (2005) Appendix A (continued) Scale Item a Social ostracism I will be less welcome around my friends.61 who smoke. I will feel uncomfortable around smokers. Loss of enjoyment I will miss the taste of cigarettes..84 I will miss the pleasure I get from cigarettes. Craving I will experience intense cravings for a.90 cigarette. I will have strong urges for a cigarette. I will desire a cigarette. Perceived benefit.93 Health benefits I will lower my chances of developing.85 bronchitis. I will lower my changes of developing lung cancer. I will lower my chances of developing heart problems. I will avoid health problems down the road. I will live longer. General well-being I will get instant health benefits..74 I will breathe easier. I will feel more energetic. I will be healthier. Self-esteem I will feel proud that I was able to quit..75 I will be more in control of my life. I will feel a sense of achievement. I will prove I can achieve abstinence from cigarettes. Finances I will have more money for items besides.73 cigarettes. I will be able to save more money. Physical appeal I will smell cleaner..75 My breath will be fresher. I will be more attractive to others (deleted item). Social approval The people who care most about me will.67 approve. I will have the respect of my friends. I will set a good example for others (e.g., children). I will no longer offend others by smoking.

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