Measuring Cigarette Smoking Risk Perceptions.

Risk perception is an important construct in many health behavior theories. Smoking risk perceptions are thoughts and feelings about the harms associated with cigarette smoking. Wide variation in the terminology, definition, and assessment of this construct makes it difficult to draw conclusions about the associations of risk perceptions with smoking behaviors. To understand optimal methods of assessing adults' cigarette smoking risk perceptions (among both smokers and nonsmokers), we reviewed best practices from the tobacco control literature, and where gaps were identified, we looked more broadly to the research on risk perceptions in other health domains. Based on this review, we suggest assessments of risk perceptions (1) about multiple smoking-related health harms, (2) about harms over a specific timeframe, and (3) for the person affected by the harm. For the measurement of perceived likelihood in particular (ie, the perceived chance of harm from smoking based largely on deliberative thought), we suggest including (4) unconditional and conditional items (stipulating smoking behavior) and (5) absolute and comparative items and including (6) comparisons to specific populations through (7) direct and indirect assessments. We also suggest including (8) experiential (ostensibly automatic, somatic perceptions of vulnerability to a harm) and affective (emotional reactions to a potential harm) risk perception items. We also offer suggestions for (9) response options and (10) the assessment of risk perception at multiple time points. Researchers can use this resource to inform the selection, use, and future development of smoking risk perception measures. IMPLICATIONS: Incorporating the measurement suggestions for cigarette smoking risk perceptions that are presented will help researchers select items most appropriate for their research questions and will contribute to greater consistency in the assessment of smoking risk perceptions among adults.

Perceptions of smokers influence nonsmoker attitudes and preferences for interactions.

In two studies, we examined nonsmokers' perceptions of smokers and consequences of the perceptions. In Study 1, smokers answered questions about their sense of self, dependence on smoking, and motivation to quit. Nonsmokers answered questions about their perceptions of these characteristics. Differences between smokers' self-descriptions and nonsmokers' perceptions were observed. Study 2 asked nonsmokers to judge two types of smokers for which the descriptions were based on Study 1 findings. Results showed that nonsmokers held a more negative attitude about and were less willing to engage in different close relationships with the smoker who was described in terms of nonsmokers' perceptions rather than smokers' reports. Attitude mediated the relationship between type of smoker and willingness to date a smoker.

Self-monitoring effects of ecological momentary assessment on smokers' perceived risk and worry.

Using ecological momentary assessment (EMA), we sought to determine whether differences in reporting would exist for smokers who self-monitored their smoking-related negative thoughts five times daily in comparison to a non-EMA control group. One hundred seventeen smokers were randomly assigned to two conditions. Eighty-eight smokers carried personal digital assistants (PDAs) for 2 weeks and monitored negative thoughts each day, and 29 smokers did not self-monitor their negative thoughts. All smokers completed pretest and posttest assessments reporting their perceived risk and worry associated with smoking consequences. The data revealed evidence of self-monitoring effects, as smokers in the EMA condition reported less worry after 2 weeks of self-monitoring compared to smokers in the control condition. The two conditions did not differ in their reports of perceived risk of smoking consequences. These data suggest that EMA procedures asking respondents to self-monitor their thoughts about smoking may influence feelings about their smoking behavior.

Common-sense beliefs about the prevention of Alzheimer's disease.

OBJECTIVES: Common-sense illness beliefs are important because they influence actions that people take to prevent and treat disease. This research (1) asked younger and older adults about their illness representations of Alzheimer's disease (AD) and (2) manipulated beliefs about AD preventability to determine causal relationships in the data. METHOD: In Study 1, the beliefs of younger (age 18-38; n = 82) and older (age 58-89; n = 57) adults about the causes of and ways to prevent AD were compared. In Study 2, younger adults were randomly assigned to read information stating either that AD can be prevented or not. RESULTS: Compared to younger adults, older adults saw themselves as less at risk, t(137) = 3.03, p = 0.003, d = 0.52, were more likely to believe that AD is preventable, t(137) = 5.01, p < 0.001, d = 0.87 and were more likely to report engaging in behaviors to prevent AD, χ(2)(1, 139) = 19.01, p < 0.001, r = 0.37. Manipulating beliefs in Study 2 caused those told that AD was preventable to see themselves as less at risk, report more prevention behaviors, and hold those with the disease more responsible for their fate. CONCLUSION: These findings highlight the association of illness representations with reports of behavior and show a disconnect between beliefs and what we currently know about AD.

Lay representations of cancer prevention and early detection: associations with prevention behaviors.

INTRODUCTION: The Common Sense Model of illness representations posits that how people think about an illness affects how they try to prevent the illness. The purpose of this study was to determine whether prevention representations vary by cancer type (colon, lung, and skin cancer) and whether representations are associated with relevant behaviors. METHODS: We analyzed data from the Health Information National Trends Survey (HINTS 2005), a nationally representative survey of American adults (N = 5,586) conducted by telephone interview. RESULTS: Respondents reported that all 3 types of cancer can be prevented through healthy behaviors; however, fewer did so for colon cancer. More respondents reported screening as a prevention strategy for colon cancer than did so for lung or skin cancer. Representations were associated with colon cancer screening, smoking status, and sunscreen use. CONCLUSION: Representations of cancer were associated with relevant health behaviors, providing a target for health messages and interventions.

Smokers' thoughts and worries: a study using ecological momentary assessment.

OBJECTIVE: The purpose of this study was to investigate smokers' thoughts and worries about their smoking behavior. Researchers have sometimes asked smokers to make such self-assessments but typically using retrospective summary judgments. DESIGN: Using ecological momentary assessment, community and student smokers reported five times daily during two separate 1-week intervals. MAIN OUTCOME MEASURES: Smokers reported their thoughts about smoking, worries about smoking, and level of contemplation to quit smoking. RESULTS: Smokers reported thinking negatively about their smoking 26.8% of the time they had a cigarette. The most frequent thoughts reported by smokers related to immediate reinforcement of smoking (e.g., "How I smell like cigarettes"). However, smokers reported more intense worry about thoughts related to health concerns (e.g., "Symptoms I'm having because of smoking"). The occurrence of negative thoughts was significantly and positively related to contemplation about quitting, worry about smoking, and risk perceptions. Finally, self-reported worry intensity was more strongly related to contemplation of quitting than negative thought occurrence. CONCLUSION: Our results show that thoughts about smoking (i.e., cognitions) and feelings about smoking (i.e., worry) are loosely connected and it is feelings rather than cognitions that are most related to contemplation to quit.

The effects of warning smokers on perceived risk, worry, and motivation to quit.

BACKGROUND: Research concerning motives for smoking cessation has focused on beliefs (cognitions) that people have, especially risk perceptions, with less attention directed to worry (negative affect) concerning one's smoking. PURPOSE: We tested a manipulation to encourage smokers to think and worry more about their smoking behavior. We contrasted risk perceptions and worry as predictors of contemplation to quit smoking. METHODS: Smokers were randomly assigned to two conditions in which they carried personal digital assistants for 2 weeks. When signaled, smokers read smoking consequence statements or daily hassle statements. RESULTS: After 2 weeks, experimental smokers reported greater perceived risk and worry about developing a medical condition compared to control smokers. Both perceived risk and worry independently mediated the relationship between the experimental manipulation and increased contemplation to quit smoking; however, worry was the strongest mediator in a multiple mediation model. CONCLUSION: Worry may be foremost for motivating smokers to attempt quitting.

Public perceptions of cancer prevention, screening, and survival: comparison with state-of-science evidence for colon, skin, and lung cancer.

BACKGROUND: Lay understanding of cancer prevention, screening, and survival may influence health behavior and health outcomes. METHODS: Data were from the 2005 Health Information National Trends Survey (HINTS). In our analyses, we describe population (N = 5586) beliefs about cancer prevention, detection, and survival for colon, lung, and skin cancer and compare beliefs with state-of-science evidence. We examined differences by sociodemographic subgroups. RESULTS: A majority of respondents responded consistently with state-of-science evidence in prevention for colon (78.2%), lung (81.2%), and skin cancer (83.5%). Respondents' perceptions of screening for colon cancer were generally consistent with state-of-science evidence (89.9%); however, fewer respondents' responded consistently with state-of-science in screening for lung (12.6%) and skin cancer (11.9%). Finally, respondents' estimates of survival/cure of colon (66.2%) and skin cancer (63.6%) were consistent with state-of-the-science evidence in survival; however, a minority of respondents' estimates of lung cancer survival (17.3%) were consistent with state-of-science. Sociodemographic associates of state-of-science consistent responses included younger age, greater education, and White race. CONCLUSIONS: Public knowledge of cancer prevention, screening, and survival varies by type of cancer, levels of evidence, and sociodemographic factors. These findings provide an evidence base for improving public awareness and understanding of cancer prevention, screening, and survival.

Meta-analysis of the relationship between risk perception and health behavior: the example of vaccination.

BACKGROUND: Risk perceptions are central to many health behavior theories. However, the relationship between risk perceptions and behavior, muddied by instances of inappropriate assessment and analysis, often looks weak. METHOD: A meta-analysis of eligible studies assessing the bivariate association between adult vaccination and perceived likelihood, susceptibility, or severity was conducted. RESULTS: Thirty-four studies met inclusion criteria (N = 15,988). Risk likelihood (pooled r = .26), susceptibility (pooled r = .24), and severity (pooled r = .16) significantly predicted vaccination behavior. The risk perception-behavior relationship was larger for studies that were prospective, had higher quality risk measures, or had unskewed risk or behavior measures. CONCLUSIONS: The consistent relationships between risk perceptions and behavior, larger than suggested by prior meta-analyses, suggest that risk perceptions are rightly placed as core concepts in theories of health behavior.

Risk perceptions: assessment and relationship to influenza vaccination.

OBJECTIVE: Accurate measurement of beliefs about risk probability is essential to determine what role these beliefs have in health behavior. This study investigated the ability of several types of risk perception measures and of other constructs from health behavior theories to predict influenza vaccination. DESIGN: Prospective study in which students, faculty, and staff at 3 universities (N = 428) were interviewed in the fall, before influenza vaccine was available, and again early in the next calendar year. MAIN OUTCOME MEASURE: Self-reported influenza vaccination. RESULTS: Two interview questions that asked about feeling at risk and feeling vulnerable predicted subsequent behavior better (r = .44, p = .001) than 2 questions that asked for agreement or disagreement with statements about risk probability (r = .25, p = .001) or 4 questions that asked respondents to estimate the magnitude of the risk probability (r = .30, p = .001). Of the 4 perceived risk magnitude scales, a 7-point verbal scale was the best predictor of behavior. Anticipated regret was the strongest predictor of vaccination (r = .45, p = .001) of all constructs studied, including risk perceptions, worry, and perceived vaccine effectiveness. CONCLUSION: Risk perceptions predicted subsequent vaccination. However, perceived risk phrased in terms of feelings rather than as a purely cognitive probability judgment predicted better. Because neither feeling at risk nor anticipated regret is represented in the most commonly used theories of health behavior, the data suggest that these theories are missing important constructs.

Long-term telephone therapy outcomes for breast cancer patients.

We present the results of a breast cancer clinical trial that tested two therapy interventions delivered by telephone. Women (N = 218) with Stages I, II, or III breast cancer were randomly assigned to breast cancer health education or emotional expression interventions, or to a standard care control condition. Outcome and process measures were obtained at baseline, 6-month and 13-month follow-ups. Oncology certified nurses conducted the therapies in six, 30-minute individual phone sessions. Women in the health education condition reported significantly better knowledge and less perceived stress compared to women in the emotional expression and control conditions. No treatment effects, however, were obtained for quality of life or mood, and all women generally improved on these measures over time. Secondary analyses showed that younger women and women with a more advanced stage of breast cancer reported significantly greater avoidant coping. The data show that telephone therapy is a viable delivery modality and that distress improves with time for most women. Overall, this study showed that neither of the two telephone interventions tested had a meaningful effect on quality of life or mood.

Absolute and comparative risk perceptions as predictors of cancer worry: moderating effects of gender and psychological distress.

Risk perceptions for cancer measured on absolute scales (e.g., "What is the likelihood that you will get cancer?") and on comparative scales (e.g., "How does your risk compare with that of someone similar to you?") are independently associated with worry about cancer. We examined this finding in a large sample across several types of cancer, and explored whether these relationships are moderated by three clinically relevant variables-gender, levels of psychological distress, and cancer experience. Participants were respondents in a national survey who reported risk perceptions and worry regarding colon cancer (923 men, 1,532 women), breast cancer (2,154 women), and prostate cancer (860 men), and completed a validated measure of psychological distress. Analyses showed that absolute and comparative risk perceptions were independent predictors of worry across all cancer sites, but that absolute risk perceptions were significantly more predictive than comparative risk perceptions of worry for women (but not men). Among people who were more highly distressed, comparative risk perceptions were the only significant predictor of worry. Absolute risk and comparative risk were equally predictive of cancer worry among people who previously had been diagnosed with cancer. These findings imply that interventions highlighting the communication of comparative risk information may be differentially effective depending on the audience.

Unrealistic optimism in smokers: implications for smoking myth endorsement and self-protective motivation.

Although some optimists may be accurate in their positive beliefs about the future, others may be unrealistic-their optimism is misplaced. Research shows that some smokers exhibit unrealistic optimism by underestimating their relative chances of experiencing disease. An important question is whether such unrealistic optimism is associated with risk-related attitudes and behavior. We addressed this question by investigating if one's perceived risk of developing lung cancer, over and above one's objective risk, predicted acceptance of myths and other beliefs about smoking. Hierarchical regressions showed that those individuals who were unrealistically optimistic (i.e., whose perceived risk was less than their objective risk) were more likely to endorse beliefs that there is no risk of lung cancer if one only smokes for a few years and that getting lung cancer depends on one's genes. Unrealistic optimists were also more likely to believe that a greater number of lung cancer patients are cured, but they were less likely to identify smoking cessation/avoidance as a way to reduce cancer risk. Most importantly, unrealistic optimists were less likely to plan on quitting smoking. Taken together, these data suggest that in the smoking arena, unrealistic optimism is a potentially costly cognitive strategy.

Lack of acknowledgment of fruit and vegetable recommendations among nonadherent individuals: associations with information processing and cancer cognitions.

Inadequate consumption of fruits and vegetables is regarded as an important behavioral risk factor for multiple types of cancer. Nevertheless, adherence with the National Cancer Institute (NCI) guidelines to eat between five and nine servings of fruits and vegetables per day is remarkably low. The current study explored the extent to which nonadherent respondents in a national survey (N = 5,625) listed fruit and vegetable consumption as a method by which to decrease their own or others' cancer risk. We sought to determine whether respondents who listed fruit and vegetable consumption as a method by which to decrease their own or others' cancer risk (hereafter referred to as "listers") differed from respondents who did not list fruit and vegetable consumption as a method by which to decrease their own or others' cancer risk (hereafter referred to as) "nonlisters" on measures of information processing and cancer cognitions. Nonlisters were more likely than listers to seek out cancer information but less likely to trust the information. The two groups did not differ in the amount of attention they paid to such information. Listers had lower absolute risk perceptions than nonlisters, but listers and nonlisters did not differ on measures of relative breast and colon cancer risk perceptions and worry for cancer in general. Female listers did perceive themselves to be at less relative risk for breast cancer than nonlisters. Respondents were more likely to list fruit and vegetable consumption as a cancer-risk reduction strategy for others than for themselves, suggesting a "double standard" in their beliefs. These findings suggest that communications designed to promote fruit and vegetable consumption need to account for biases in how nonadherent individuals respond to these communications.

Does worry about breast cancer predict screening behaviors? A meta-analysis of the prospective evidence.

OBJECTIVE: Many women worry about the possibility of developing breast cancer, but there is conflicting evidence concerning whether cancer worry acts as a facilitator or inhibitor of breast cancer screening. METHOD: We conducted a meta-analysis of 12 prospective studies that measured worry about breast cancer at baseline and subsequent breast self-examination (BSE) or mammography utilization among 3342 high-risk and general population women. RESULTS: The data consistently show that breast cancer worry has a small but reliable (r = 0.12) association with breast cancer screening behavior, such that greater worry predicts a greater likelihood of screening. We also found that the means for breast cancer worry were consistently in the lower third of the scales, despite differences in measurement approaches, sample utilization, or the date that the study was conducted. CONCLUSION: The meta-analysis supports the contention that breast cancer worry may motivate screening behavior, and that high levels of breast cancer worry are uncommon.

Resisting good news: reactions to breast cancer risk communication.

Many women overestimate their percentage risk of breast cancer, even after they have received careful estimates from health professionals. In 2 experiments with 134 young adult women, 6 variables were explored that might influence such risk perception persistence. In Study 1, each of the following explanations was unrelated to persistence: public commitment, self-consistency, and unique causal risk models. In Study 2, two individual difference measures, pessimism and differences in understanding percentages, were unrelated to risk perception persistence. However, providing a "risk anchor" based on downward social comparison processes resulted in better risk acceptance at posttest that persisted at a 2-week follow-up assessment. This article discusses why comparison anchors might be important in risk feedback situations and concludes with recommendations for professionals who wish to provide accurate risk information and have patients adopt that information.

A heuristics approach to understanding cancer risk perception: contributions from judgment and decision-making research.

BACKGROUND: The likelihood judgments that people make about their risks for cancer have important implications. At the individual level, risk estimates guide protective actions, such as cancer screening. However, at the extremes, exaggerated risk judgments can also lead to anxiety that degrades quality of life or to aggressive self-protective actions that are unwarranted given the objective risks. At the policy level, risk judgments may serve as an indicator of societal perceptions of the "war" against cancer. Using risk judgments, the public expresses its belief about whether we are winning. PURPOSE: We present theoretical perspectives from judgment and decision making, illustrate how they can explain some of the existing empirical findings in the cancer risk literature, and describe additional predictions that have not yet been tested. CONCLUSIONS: Overall, we suggest that theories from the judgment and decision-making perspective offer a potentially powerful view for understanding and improving risk judgments for cancer and other diseases.

Motivation to quit using cigarettes: a review.

This review asks why persons decide to quit using cigarettes. We summarize three literatures from five decades, including over 30 data sets grouped by different methodologies: (a) retrospective reports of ex-smokers (n = 15), (b) cross-sectional surveys of current smokers (n = 14), and (c) prospective studies of smokers in cessation studies (n = 6). Taken together, the data strongly suggest that health concern is the primary motive for quit attempts. These data fit with theoretical reasoning that persons wish to control danger and negative affect. The data also suggest that health professionals should continue emphasizing the negative health consequences of smoking to motivate cessation attempts.

Age differences in treatment decision making for breast cancer in a sample of healthy women: the effects of body image and risk framing.

PURPOSE/OBJECTIVES: To examine the effects of age, body image, and risk framing on treatment decision making for breast cancer using a healthy population. DESIGN: An experimental 2 (younger women, older women) X 2 (survival, mortality frame) between-groups design. SETTING: Midwestern university. SAMPLE: Two groups of healthy women: 56 women ages 18-24 from undergraduate psychology courses and 60 women ages 35-60 from the university community. METHODS: Healthy women imagined that they had been diagnosed with breast cancer and received information regarding lumpectomy versus mastectomy and recurrence rates. Participants indicated whether they would choose lumpectomy or mastectomy and why. MAIN RESEARCH VARIABLES: Age, framing condition, treatment choice, body image, and reasons for treatment decision. FINDINGS: The difference in treatment selection between younger and older women was mediated by concern for appearance. No main effect for risk framing was found; however, older women were somewhat less likely to select lumpectomy when given a mortality frame. CONCLUSIONS: Age, mediated by body image, influences treatment selection of lumpectomy versus mastectomy. Framing has no direct effect on treatment decisions, but younger and older women may be affected by risk information differently. IMPLICATIONS FOR NURSING: Nurses should provide women who recently have been diagnosed with breast cancer with age-appropriate information regarding treatment alternatives to ensure women's active participation in the decision-making process. Women who have different levels of investment in body image also may have different concerns about treatment, and healthcare professionals should be alert to and empathetic of such concerns.

Linking decision-making research and cancer prevention and control: important themes.

This article describes 6 themes underlying the multiple presentations from the Basic and Applied Decision Making in Cancer Control meeting, held February 19-20, 2004. The following themes have important implications for research and practice linking basic decision-making research to cancer prevention and control: (a) Traditional decision-making theories fail to capture real-world decision making, (b) decision makers are often unable to predict future preferences, (c) preferences are often constructed on the spot and thus are influenced by situational cues, (d) decision makers often rely on feelings rather than beliefs when making a decision, (e) the perspective of the decision maker is critical in determining preferences, and (f) informed decision making may--or may not--yield the best decisions.