Journal o f Behavioral Medicine, VoL 12, No. 3, 1989

Perceptions of Immunity to Disease in Adult Smokers

Christina Lee ~

Accepted for publication: October 27, 1988

Public education has ensured smokers' awareness o f the health risks of smok- ing. It has been suggested that engaging in a behavior (e.g., smoking) which one knows to be dangerous will result in an unpleasant state o f "cognitive dissonance." Smokers may deal with such a state by denying the dangers o f smoking. In this study, 97 smokers and 95 nonsmokers (age range, 15-65 years) rated the risk to themselves and to the average Australian smoker o f contracting three smoking-related diseases. Evidence supportive o f denial o f risk was found: smokers'ratings o f the risk to the average smoker were lower than nonsmokers" ratings, and smokers" ratings o f their own risk were lower still. Such denial o f risk may undermine the effectiveness o f stop-smoking campaigns which focus on health aspects o f smoking, and methods o f deal- ing with this problem are discussed.

KEY WORDS: denial; immunity; risk; smoking.

I N T R O D U C T I O N

Cigarette smoking has been identified as the major cause of disease and ill health in developed countries (USDHEW, 1979); in Australia, an estimated 16,000 people die each year as a direct result of cigarette smoking (Armstrong, 1987). Every cigarette packet carries a government health warning, and yet people continue to smoke. It has been suggested (e.g., Tagliacozzo, 1981) that this state of affairs may produce a condition of cognitive dissonance among smokers. Cognitive dissonance arises when there is a perceived in- consistency between a number of beliefs held or behaviors engaged in by the

~Department of Psychology, University of Newcastle, Newcastle, NSW 2308, Australia.

267

0160-7715/89/0600-0267506.00/0 �9 1989 Plenum Publishing Corporation

268 Lee

one person (Festinger, 1957). This is argued to be an unpleasant state which the individual will attempt to reduce by changing incompatible beliefs or be- haviors or by avoiding situations which increase dissonance or make it more salient. Smokers experience a conflict between the knowledge that smoking causes a range of serious diseases and the fact that they smoke. Given the great difficulties experienced in attempting to give up smoking (Leventhal and Cleary, 1980), smokers may use some form of denial of the health risk in order to reduce this dissonance.

For example, Tagliacozzo (1981) had students read a list of statements about smoking and health and mark those which they considered were im- portant for the public to know about. Smokers marked significantly fewer items than nonsmokers, and she argued that this suggested an avoidance by smokers of exposure to information which could produce dissonance.

Similar conclusions have been drawn by other researchers. There is some evidence to indicate that smokers do perceive themselves, and smoking, in a way which differs from nonsmokers. Dawley et al. (1985), for example, surveyed adult smokers and nonsmokers concerning their beliefs about smok- ing and disease. They found that nonsmokers were more willing than smokers to agree that smoking was associated with risks to health and that the more their respondents smoked, the less likely they were to accept the existence of health risks. Again a cognitive-dissonance model can be used to explain these results.

Smokers may also cope with the known dangers of smoking by deny- ing that it can affect them personally. Fishbein (1977) has argued that peo- ple may accept that information is true in a general sense, while still not accepting that it may have any personal relevance. Hansen and Malotte (1986) examined this proposal in a study of the beliefs of school students (aged 10 to 18 years) concerning the probability of several consequences of smoking. They were asked to rate the risk of suffering each consequence to themselves, to a person who began smoking at school and smoked regularly for his/her entire life, and to themselves if they were to smoke regularly. Students rated the risk to themselves as significantly lower than the risk to themselves as lifelong smoker and the risk to another smoker. Students who smoked did give higher probabilities of risk for themselves than did nonsmokers. These results suggest some realistic judgment of the risk of smoking but also sig- nificant denial that it could affect them personally. It is always possible that these descriptive findings result from preexisting differences in perceived sus- ceptibility; that is, people who believe that they are less at risk may be those who take up smoking.

However, the tendency to perceive oneself as somehow immune, at least in part, to health risks is not restricted to smokers. Weinstein (1982, 1987), for example, asked college students and community members to rate their own chances of developing various health- and life-threatening problems.

Perceived Risk from Smoking 269

Subjects rated their own chances lower than those of their peers. This gener- al tendency becomes important in a group, such as smokers, who are already engaging in a known risky behavior. The perception of personal immunity makes it more difficult to motivate risk-takers to change their behavior.

The possibility that such attitudes might undermine a smoker's willing- ness to attempt cessation is supported by evidence from Velicer et al. (1985). They found that smokers who were contemplating cessation rated negative aspects of smoking, such as ill health, as more important to themselves than did smokers with no intention of stopping. This suggests that a denial of the negative aspects may be important in maintaining smoking.

The aim of the present study was to assess the extent of such tenden- cies among adult smokers. Most investigations to date have used students, and it may be that older persons do not show this effect. One could hypothe- size that by the age of 40 or 50 years a smoker was already beginning to see the effects of a lifetime of smoking, either in him- or herself or in acquain- tances, and therefore might be less likely to show denial.

In this investigation, both smokers and nonsmokers assessed their own risk of developing (a) lung cancer, (b) heart disease, and (c) a chronic lung disease other than cancer (e.g., emphysema, bronchitis) at some stage in their life. They also assessed the same three risks for the "average Australian smoker." It was hypothesized that

(1) smokers' ratings of their own risk would be higher than nonsmokers' ratings of their own risk, reflecting some acceptance by smokers of their risk;

(2) smokers' ratings of the risk to the average Australian smoker would be lower than nonsmokers' ratings of the risk to the average Aus- tralian smoker, reflecting generalized psychological denial;

(3) smokers' ratings of their own risk would be lower than their ratings of the risk to the average Australian smoker, reflecting a sense of "personal immunity";

(4) younger smokers would perceive a lower risk than older smokers; and (5) smokers who did not wish to stop smoking would perceive a lower

risk than those who did wish to stop.

METHOD

Respondents

One hundred ninety-two individuals provided information for this in- vestigation. Sixteen psychology students each surveyed 12 persons as part of a practical research exercise. Each selected three smokers and three non-

270 Lee

smokers in each of the age groups 15-35 and 36-65 years. Students were in- structed not to use psychology students as subjects but otherwise selected a convenience sample which met the requirements of age and smoking status. The sample consisted of 97 women and 95 men, with 97 current smokers and 95 nonsmokers. Males and females were equally distributed between the two age groups (x 2 = .04) and between smoker and nonsmoker status (x 2 < .01). The smokers smoked an average of 17.3 cigarettes per day ( S D =

9.7) and had been regular smokers for an average of 14.7 years. Twelve (12.4%) smoked pipes or cigars as well as cigarettes. Ages ranged from 15 to 65 years, with a mean of 34 years.

Apparatus and Procedure

A questionnaire was developed to assess respondents' perceptions of health risk. For the first three items, they were asked to consider "an aver- age Australian smoker" and give percentage ratings of that person's risk of developing each of lung cancer, heart disease, and a chronic lung disease other than cancer at some stage during his/her life. A scale was provided for each rating, anchored at 0 with "no chance" and at 100 with "certain to happen," and marked in units of 10. The second three items were identical but asked the respondent to "think about what is likely to happen to your- self" and rate the chance of themselves developing each of the three diseases at some stage during their lives. The third section of the questionnaire asked for details on smoking status, intention to give up, and age and sex.

RESULTS

A five-way analysis of variance with two repeated and three nonrepeated variables was conducted, using data from the 171 respondents who provided all relevant information. Ratings of risk were used as the dependent vari- able. The five independent variables were current smoking status (smoking or not), age group (15-35 or 36-65 years), sex of respondent, orientation of question to self or "average smoker," and disease rated (lung cancer, heart disease, or noncancerous lung disease).

Main Effects

There was no significant main effect for smoking status (F = .39) or for age group (F -- 1.82) on overall ratings of risk (combining ratings across all diseases and both orientations). The main effect for sex was significant

Perceived Risk from Smoking 271

(F = 5.80, df = 1,163, p = .017), with women giving an overall mean risk rating (combined across diseases and orientations) of 46.1 and men 40.6. There was a significant effect for disease rated (F = 5.63, df = 2,326, p = .004), with perceived risk of lung cancer (mean = 40.8) significantly lower than perceived risk of heart disease (mean = 44.0) or noncancerous lung diseases (mean = 45.1). However, by far the largest main effect was for orien- tation of question to self or "average smoker" (F = 276.08, df = 1,163, p < .00001). The mean risk rating (average across smoking status and disease rated) was 30.7 for self and 56.4 for the average Australian smoker.

Two-Way Interaction Effects

Of the 10 two-way interactions, 5 reached statistical significance. Smoking status interacted significantly with orientation of question (F = 91.63, df -- 1,163, p < .001). Averaged across the three diseases, nonsmokers saw their own risk as 21.8~ and the risk for the average smoker as 62.907o. Smokers saw their own risk as 39.307o and the risk to others as 49.8070 (see Fig. 1). Post hoc tests indicated significant differences among all four means.

Smoking status also interacted significantly with type of disease rated (F = 9.04, df = 2,326, p < .01). Averaged across "self" and "average smoker" ratings, smokers and nonsmokers did not differ on their ratings for lung cancer and noncancerous lung diseases, but smokers rated the risk of heart disease higher than did nonsmokers.

Perceived Risk of Disease smoking stetus by question orientation

perceived risk 70 - -

IL>2~1 smoker s 60 - - ~ n o n - s m o k e r s

50

40

2O

10

0 1 2

or ientat ion of quest ion

Fig. 1. Mean perception of lifetime risk (averaged across all diseases) for smokers and nonsmokers, rating (1) themselves and (2) the average smoker.

272 Lee

Orientation of question also interacted significantly with age group (F = 10.83, df = 1,163, p = .001). Younger respondents gave significantly lower ratings of risk than older respondents when rating themselves (27.0 versus 35.5) but the two age groups did not differ on their ratings of the average smoker (57.5 and 55.0, respectively). Both age groups (combined across smokers and nonsmokers) rated the average smoker's risk as signifi- cantly higher than their own.

Orientation of question interacted with type of disease rated (F = 18.95, df = 2,326, p < .001). Although respondents rated the average smoker's risk as higher than their own for all three diseases, heart disease was seen as significantly more probable than the other diseases when the self was rated, but noncancerous lung diseases were seen as more probable when rating the average smoker.

There was also a significant interaction between age group and disease rated (F = 3.43, df = 2,326, p = .033). Younger and older groups did not differ on their average ratings for lung cancer and noncancerous lung dis- eases, but the older group saw a significantly greater risk of heart disease than did the younger group.

Higher-Order Interaction Effects

Only 1 of the 10 three-way interactions and 1 of the 5 four-way inter- actions reached statistical significance.

The three-way interaction which reached statistical significance was smoking status x orientation of question • disease rated (F = 8.11, df = 2,326, p < .001). Figure 2 depicts this interaction. For all three diseases, risk ratings differed significantly among all four categories of judgment. Nonsmokers also saw their own risk of heart disease as higher than their risk of the other diseases, while smokers did not differ on their ratings of risk of the different diseases. Concerning risk to the average smoker, non- smokers saw the risk of each disease as similar, while smokers rated the risk of noncancerous lung diseases as significantly higher than the others.

The four-way interaction to reach significance was smoking status x age group x orientation of question x disease rated (F = 4.48, df = 2,326, p = .012). Figures 3 and 4 illustrate this interaction. In the younger age group, nonsmokers rated their own risk of each disease significantly lower than did smokers and, also, rated the average smoker's risk of each disease signifi- cantly higher than did smokers. Both nonsmokers and smokers saw them- selves as significantly more likely to develop heart disease than the other diseases, while they rated the average smoker's risk as the same for all diseases.

In the older age group, smokers and nonsmokers did not differ in their ratings of their own risk of heart disease, but nonsmokers rated themselves

Perceived Risk from Smoking 273

Perceived perceived risk

7O

60

50

40

30

20

10

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~lung cancer E~ heart disease 1:7-71other lung diseose

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Risk of Disease

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3 4 smoking statuS/ question orientation

Fig. 2. Mean perception of lifetime risk for each disease, for (1) smokers rating themselves, (2) smokers rating the aver- age smoker, (3) nonsmokers rating themselves, and (4) non- smokers rating the average smoker.

lower than smokers for the other two diseases. In rating the average smoker, nonsmokers rated their risk of lung cancer as significantly higher but the two groups gave equal ratings for heart disease and noncancerous lung disease.

Perceived Risk of Disecse a g e s 1 5 - .55

perceived risk 70--

E~a lung cancer 60 -- E~.~heart disease

[7-~other lung disease

3O

20

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smoking status/ question orientation

Fig. 3. Mean perception of lifetime risk for each disease, 15- to 35-year age group only. (t) Smokers rating themselves, (2) smokers rating the average smoker, (3) nonsmokers rating themgelves, and (4) nonsmokers rating the average smoker.

274 Lee

perceived risk 70

60 - -

5 0 - -

40 - -

3 0 - -

20 - -

1 0 - -

0

Perceived Risk of Disease a g e s 3 6 - 6 5

E ~ l u n g cancer r disease [ 7 - T t o t h e r lung disease

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/ / P - f / ~ / ~_. / .#f/IM/. /

~ . . r / / I / ~ / / / . f r ~ / / : ~ / /

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Y. / r

F./'.,~/f.../~l// : / J f / / ~ / . / ~ / /

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Fig. 4. Mean perception of lifetime risk for each disease, 36- to 65-year age group only. (1) Smokers rating themselves, (2) smokers rating the average smoker, (3) nonsmokers rating themselves, and (4) nonsmokers rating the average smoker.

Older and younger smokers did not differ significantly in their percep- tions of risk for any disease, either for themselves or for the average smoker. Among older and younger nonsmokers, the older group rated their own risk of heart disease significantly higher than did the younger group.

Comparisons Among Subgroups of Smokers

The smokers were divided into those who stated they wished to give up (N = 47) and those who did not (N = 50). A multivariate analysis of variance was performed to assess differences in perceptions of risk between the two groups. The obtained multivariate F was not statistically significant ( F = 2.01, df = 1,89, p = .07). Smokers were then split into two groups at the median of smoking rate, to form light and heavy smoking groups. Again, the multivariate F, across all six ratings of risk, was not statistically significant (F = 0.95, df = 1,89, p = 0.7).

DISCUSSION

These results suggest that, compared to nonsmokers, smokers underes- timate the risk of a smoker developing each of the diseases rated. Further, they minimize their own risk even more than they do that of the "average

Perceived Risk from Smoking 275

smoker." This effect seems to be more pronounced among younger adult smokers than it is among older smokers.

The interaction between smoking status and orientation of question sup- ports the first three hypotheses of this investigation: that smokers will ac- cept that their own risk is higher than that of nonsmokers; that smokers will minimize the risk of disease to the average smoker, by comparison with non- smokers; and that smokers will minimize the risk to themselves, by compar- ison with their own ratings of the average Australian smoker.

The fourth hypothesis was that this effect would be greater in younger than in older smokers. Again, this hypothesis was supported by the data. Older respondents, both smokers and nonsmokers, rated the risk to them- selves higher than did the younger respondents and, also, rated the risk to the average smoker lower.

The fifth hypothesis, that smokers who wish to stop will give higher risk ratings than those who do not, was not supported. This is in contrast to the results of Velicer et al. (1985), who found that smokers intending to stop endorsed more negative items about smoking than did those who in- tended to continue. However, procedural differences mean that the two studies are not directly comparable. In particular, the definition of the two subgroups of smokers differed between the two studies. It is also possible that, in this particular sample, health was not the prime reason for wanting to stop. Issues such as expense and social acceptability may be more immedi- ately salient to some than the risk of developing a serious disease at some unspecified time in the future.

Overall, heart disease is rated as having a higher risk than the other diseases. This accords with data indicating that heart disease is the most fre- quent cause of death in Australia (Dobson, 1987). In the older age group, nonsmokers and smokers saw their own risk of heart disease as equal to each other, with nonsmokers rating their own risk of heart disease as considera- bly higher than their own risk of the lung diseases. This accords with the fact that smoking is not the preeminent risk factor for heart disease as it is for the lung diseases. Nonsmokers are also at some risk through hyperten- sion and other behavioral factors such as sedentariness, inappropriate diet, and excess levels of psychological stress (Booth-Kewley and Friedman, 1987; Herd, 1984).

Some of the significant findings are difficult to interpret, as they in- corporate data averaged across smokers and nonsmokers, or across ratings for self and ratings for the average smoker, or both. The main effect for sex, for example, appears to indicate that women give higher risk ratings than men, regardless of what disease they are rating, whether they are rating their own risk or the risk to the average smoker or whether they themselves smoke. Sex of respondent did not interact with any other variable, which suggests that this is simply some form of response bias.

276 Lee

Overall, perceived probabilities are considerably higher than actual ~isks. For example, the overall mean ratings for "average smoker's" risk were 54% for lung cancer, 54% for heart disease, and 60% for noncancerous lung dis- eases. Doll and Peto's (1976) study of British doctors indicates that 6% of smokers' deaths were due to lung cancer and 30% to heart disease. It is quite likely that this overestimation is a result of the rating scales employed. A scale numbered in tens probably promotes responses in units of 10, and there may be a tendency to spread responses across the scale rather than cluster them at the low end, resulting in inflated estimates.

In interpreting these results, it must be acknowledged that the sampling strategy was open to bias. Most of the subjects were relatives or acquain- tances of the students who collected the data and are, therefore, highly un- likely to be representative in terms of education or socioeconomic status. However, if the results are found to generalize more widely, they have im- portant implications for the design of smoking cessation interventions.

Denial or minimization of risk may well help smokers to deal with the cognitive dissonance arising from their smoking; however, it is likely that it interferes with efforts to reduce smoking rates. Hansen and Malotte (1986) suggest that educational interventions with smokers should focus on immedi- ately observable effects, such as breathlessness on exertion or expired air car- bon monoxide; they argue that demonstrations of these effects provide information which is harder to ignore than general education focusing on cancer or other long-term risks.

Reed and Janis (1974) suggested that smokers might be helped to reduce their resistance to information about health risk by presenting them with in- formation that directly challenged rationalizations for continuing to smoke. They attempted this approach with a group of smokers and found that it increased people's belief in their personal susceptibility to lung cancer and emphysema and their belief that smoking is generally harmful to health. There was little, if any, effect on actual smoking behavior. However, it might be that such an approach could be incorporated into a behavioral smoking- cessation program and evaluated more thoroughly.

A problem which arises is that people who deny or minimize their own risk of disease may be unlikely to attend stop-smoking programs. Therefore, if the results from this sample generalize to a wider population of smokers, it may be important that media and educational campaigns also attempt to confront issues such as denial of risk, rationalization of continued smoking, and perception of personal immunity. Further research would be needed to identify beliefs held by smokers which might effectively be challenged in educational campaigns, but it may be that this approach could encourage more smokers to attempt cessation or to persist longer with cessation efforts.

Perceived Risk from Smoking 277

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