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TRANSCRIPT
How effective are physical appearance interventions in changing smoking
perceptions, attitudes and behaviours? A systematic review
Keira Flett, David Clark-Carter, Sarah Grogan
Staffordshire University, Stoke on Trent, UK
Rachel Davey
University of Canberra, Australia
Word Count: 2,846
Address correspondence to:
Keira Flett
Psychology Department
Staffordshire University
Stoke on Trent
STAFFORDSHIRE
ST4 2DE
Phone: 07837633710
E-mail: [email protected]
Key Words: Smoking Cessation, Physical Appearance, Intervention, Behaviour.
1
ABSTRACT
Objective
A systematic review was conducted in order to identify physical appearance
interventions related to smoking cessation, and to evaluate their effectiveness in order
to inform smoking cessation practice.
Data Sources
Articles were only included if they focused on an appearance intervention related to
changing smoking attitudes, intentions or behaviour. Seventeen online databases were
searched using date restrictions (1980 to 2011) revealing 4356 articles. After
screening 11 articles were identified that met the review criteria. Seven articles
investigated the impacts of facial age-progression software on smoking cessation.
Three articles focused on reducing weight concerns in order to improve smoking
abstinence rates. One oral health article was identified which focused on physical
appearance in order to prevent or reduce smoking.
Data Synthesis
Few studies have focused on physical appearance interventions in smoking cessation
however the identified studies report positive impacts on smoking related cognitions
and cessation behaviours. Two different methods of quality analysis were conducted
for quantitative and qualitative papers. The consensus was that the quality of the
articles was generally weak. Of the 10 quantitative articles, nine were rated weak and
one was rated moderate. The one qualitative study provided clear, in-depth
information.
Conclusions
Questions still remain as to whether physical appearance interventions have an impact
on smoking attitudes, intentions or behaviours, particularly in British samples. To
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inform practice, additional, well-designed, studies are needed. They should include
control groups, use robust randomised allocation to conditions, measures with
established reliability and validity and take measures pre and post intervention.
Key Words: Smoking Cessation, Physical Appearance, Intervention, Behaviour.
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What this paper adds: This is the first review to investigate physical appearance interventions and
smoking. The review found that physical appearance interventions impacted positively
on smoking outcomes. Study quality analyses illustrated that evidence needs to be interpreted with
caution. Future well-designed studies are needed to understand fully factors
influencing the effectiveness of physical appearance interventions.
INTRODUCTION
One of the biggest challenges for smoking cessation practices includes engaging
young people with smoking cessation services. The health problems associated with
smoking are well known[1] and have been highlighted in various smoking cessation
campaigns however success has been debatable. One promising motivational factor
which may impact on smoking behaviours is concern about physical appearance.
Physical appearance in Western societies is valued highly, as illustrated in beauty-
related expenditure on procedures such as cosmetic surgery[2]. Research has
suggested that reducing cessation related weight concerns[3], emphasising facial
wrinkling[4] and making people aware of the oral health impacts of smoking[5] may
be effective ways to enable people to quit smoking, but it is unclear how effective
these interventions are. One study found that smokers said that they would quit if skin
ageing and other negative effects on appearance became evident[4]. It has also been
suggested that reducing weight gain concerns in contrast to managing weight may
prove to be an effective smoking cessation intervention[6-11]. In addition the impact
of teeth discolouration on physical appearance may act as an effective technique to
combat smoking[12- 14].
In order to determine what is known about the effectiveness of physical appearance
interventions on smoking cessation for individual smokers, a systematic review of
available published literature was conducted. The research question for this
systematic review is:
What is the current evidence on the effectiveness of physical appearance
interventions in changing smoking perceptions, attitudes and behaviours?
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METHOD
A systematic search was conducted in December 2011 in order to identify smoking
and appearance intervention research. Methods included searching 17 online
databases including PsychARTICLES, CINAHL, Cochrane Database, Web of
Knowledge, Ingenta Connect, PsycINFO, Science Direct, Swetwise, Wiley
Interscience, Sage Journals, Springer Link, PubMED, PubCentral, British Medical
Journal (BMJ), BBNet, Australasian Medical Journal (AMJ) and Narcis. The
University library and smoking-related text books were further searched. In addition,
manual searches were conducted using search engines and reference lists of relevant
articles were reviewed.
The search keywords were chosen in order to cover terms for smoking, physical
appearance and intervention. The following key words were used to search for
relevant articles: '(smok* OR cigarette* OR nicotine OR tobacco) AND (intervention
OR cessation OR program OR quit*) AND (appearance OR beauty OR looks OR
attractive OR skin OR ageing OR wrinkl* OR fac*) OR (weight OR thin* OR
exercise OR physical activity) OR (yellow* OR stain* OR discolour* OR teeth OR
oral OR dental OR dentist) OR (morph* OR ag* OR software OR computer OR
electronic OR technology) OR (hair OR eye*). Main terms were searched using
‘AND’ and similar terms were searched using ‘OR’. Existing reviews were searched
with ‘review’ in the heading. Manual searches included viewing the titles within
selected journal volumes. If there were a large number of studies identified then
advanced search was used including selecting the limit: ‘search in article titles’. In
advanced search articles were requested from 1980 to 2011 and the population group
was specified. Exclusion of articles before 1980 was based on the rationale that body
image research was developing from 1980’s onwards[2].
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Inclusion and exclusion criteria were applied to all the articles. Articles were included
if they aimed to investigate an appearance intervention related to changing smoking
attitudes, intentions or behaviour.
Articles were excluded if they:
Involved a sample consisting of a specific clinical subgroup (such as
individuals with depression or psychosomatic disorders).
Were dated before 1980.
Involved a meta-analysis or literature review (in contrast to an intervention
design).
Were not written in English.
The combined search revealed 4356 articles. Each article title was reviewed in
relation to the topic relevance, producing a list of 251 articles. The 251 abstracts were
then reviewed. Full text content was accessed for 158 of the 251 articles resulting in
11 articles found to fulfil the inclusion criteria. If abstracts did not contain sufficient
detail to judge their relevance then the full text content was reviewed. Articles were
excluded if they did not fit the inclusion criteria. Eleven articles were found to fulfil
the criteria. A quality rating and summary of the identified articles was conducted
using the McMaster, and Walsh and Downe quality assessments[15, 16].
The stages of the retrieval process are shown in Figure 1[17].
The McMaster quality assessment was conducted on 10 of the quantitative research
articles identified[15]. The assessment involved six quality ratings: selection bias,
study design, blinding, data collection methods, withdrawals and drop-outs. The
process of quality assessment involved selecting appropriate codes including either:
strong (3), moderate (2) or weak (1). Three of the authors independently determined
the quality ratings. Researchers reached a 100% rating agreement for eight of the
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studies[18-25]. On With the two studies where opinions differed[26, 27], consensus
was reached through discussion.
The Walsh and Downe[16] quality assessment was conducted on one qualitative
article identified[28]. The quality assessment was conducted by three of the authors
(reaching 100% agreement) involving commenting on the following eight areas:
Scope and Purpose, Design, Sampling Strategy, Analysis, Interpretation, Reflexivity,
Ethical Dimensions and Relevance/Transferability.
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RESULTS
A total of 11 research articles were identified that met the inclusion criteria. (See Table 1 below for the key features of each study). Study
strengths and limitations are discussed in the following section.
Table 1: Brief Study Checklist. Study Design Participants n Outcome Measures Results
[18]Semer et al. (2005)
Cohort analytic Female / male smokers & non-smokers 64 Smoking behaviours, intentions Individuals reported that the intervention was effective. No statistical significant results.
[19]Pirie et al. (1992)
Cohort analytic Female smokers 417 Weight, carbon monoxide ratings, smoking behaviours
Results are unclear due to various intervention components possibly having an impact. Statistical significant group differences.
[20]Weiss et al. (2010)
Cohort Female students; non-smokers, ex-smokers & occasional smokers
845 Smoking behaviours, intentions, beauty perceptions
Increased motivations to quit smoking, however lack of engagement in smoking cessation course. Significant differences on stages of change variables.
[21]Grogan et al. (2011)
Randomised control trial
Female smokers 70 Carbon monoxide, smoking behaviours, theory of planned behaviour constructs, dependence
Increased intentions to quit smoking. Significant differences on theory of planned behaviour and nicotine dependence variables.
[22]Burford et al. (2009)
Randomised control trial
Female / male smokers 50 Dependence, smoking behaviours Pilot study providing limited information regarding the outcomes measured. No statistical significant results.
[23]Hysert et al. (2008)
Cohort Female / male smokers & non-smokers 792 Attitudes, smoking behaviour, diet, physical activity
Maintenance reported as individuals remembered the intervention, smoking
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behaviour differences. Statistically significant differences for progression to smoking.
[24]Hysert et al. (2003)
Cohort Female / male smokers, non-smokers & ex-smokers
445 Self image, intentions, perceptions Statistically significant results including increased intentions to quit and positive attitudes.
[25]Perkins et al. (2001)
Cohort analytic Female smokers 219 Carbon monoxide, depression, mood weight, dependence
Statistically significant differences between groups for increased smoking cessation rates.
[26]Copeland et al. (2006)
Cohort analytic Female smokers 79 Carbon monoxide, weight, dependence, body concerns, situational factors
Support for tailored appearance interventions due to cessation rates, statistically significant differences between the two groups at a three-month follow up.
[27]Kentala et al. (1999)
Cohort analytic Female / male smokers & non-smokers 2, 586 Smoking abstinence Higher smoking cessation rates in control group, however not statistically significant.
[28]Grogan et al. (2010)
Qualitative Female smokers 47 Semi-structured interviews & one focus group
Demonstrated effectiveness including increasing intentions to quit linked to personal susceptibility. No statistical outcomes as the study included only qualitative investigations.
Quality assessment results for each study are included in Tables 2 and 3.
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Table 2: Quantitative Study Analysis[15].Authors Selection
biasDesign Confound
ersBlinding Data
Collection Methods
Withdrawals & Dropouts
GLOBAL RATING
[18]Semer et al. (2005) Weak (3) Weak (3) Weak (3) Weak (3) Weak (3) Weak (3) Weak (3)
[19]Pirie et al. (1992) Weak (3) Moderate (2) Strong (1) Weak (3) Moderate (2) Strong (1) Weak (3)
[20]Weiss et al. (2010) Weak (3) Moderate (2) Weak (3) Weak (3) Strong (1) Weak (3) Weak (3)
[21]Grogan et al. (2011) Moderate (2) Strong (1) Moderate (2) Moderate (2) Strong (1) Strong (1) Moderate (2)
[22]Burford et al. (2009) Weak (3) Weak (3) Moderate (2) Weak (3) Moderate (2) Weak (3) Weak (3)
[23]Hysert et al. (2008) Weak (3) Weak (3) Weak (3) Weak (3) Weak (3) Weak (3) Weak (3)
[24]Hysert et al. (2003) Weak (3) Moderate (2) Weak (3) Weak (3) Weak (3) Weak (3) Weak (3)
[25]Perkins et al. (2001) Weak (3) Moderate (2) Strong (1) Moderate (2) Weak (3) Weak (3) Weak (3)
[26]Copeland et al. (2006) Weak (3) Moderate (2) Strong (1) Weak (3) Strong (1) Strong (1) Weak (3)
[27]Kentala et al. (1999) Weak (3) Moderate (2) Weak (3) Weak (3) Weak (3) Moderate (2) Weak (3)
Table 3: Qualitative Study Analysis[16].
Authors
Scope & Purpose
Design Sampling Strategy Analysis Interpretation Reflexivity Ethical dimensions
Relevance/ transferability
[28]Grogan et al. (2010)
Clear rationale provided.
Method described in regards to the importance of using grounded theory. Data collection strategies explained.
Description provided. Sample restricted to one geographical area.
Described in detail.
Clear descriptions.
Described in the limitations section.
Basic study procedures explained (e.g. debrief).
Future directions provided and results linked to previous research findings.
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Weiss et al.[20] evaluated the effectiveness of age-progression technology involving
ageing photographs to demonstrate facial wrinkling with female smokers. The
software used to conduct the age-progressions included APRIL Age Progression
Software, Version 2.3. APRIL age-progression software produces ageing algorithms
which are based on a cohort of 2000 individuals and published data of specific effects
of smoking on skin. The software provides images of how an individual will age as a
non-smoker compared to a 1-pack-a-day smoker. Strengths of the research involve a
large sample size, trained professionals implementing the intervention and reliable
measures were administered. Weaknesses of the study included no control group and
no nicotine replacement therapy (NRT) access, and no individuals from the study
attended the smoking cessation group that was available.
Grogan et al.[21] conducted a randomised control trial (RCT) in order to assess the
effectiveness of an age-progression intervention with women smokers. APRIL Age
Progression Software version 2.5 was used in the study. The study strengths included
the study design and reliable outcome measures. Limitations included a lack of
information regarding who had access to nicotine replacement therapies (NRT) at the
start of the study.
Grogan et al.[28] carried out a qualitative study with women smokers who
participated in an age-progression intervention (APRIL Age Progression Software,
version 2.5). Strengths of the study included the in-depth information gained from the
interviews and focus group research. Potential limitations have been identified by the
authors including participants possibly feeling social pressure to report that the
intervention was effective.
Burford et al.[22] conducted a pilot investigation involving assessing the
effectiveness of an age-progression facial-wrinkling intervention (APRIL software)
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with male and female smokers. Strengths included a control group comparison and a
male sample: due to previous studies predominantly assessing female outcomes).
Limitations include the lack of information regarding the study design (as allocation
to groups was not explicit), nicotine replacement therapy access, and the rate of drop-
outs.
Hysert et al.[23] evaluated an age-progression intervention with male and females
using APRIL age-progression software. Strengths involve investigating an age-
progression intervention as a potential preventative method in schools. The main
limitation was the fact that there was no control group as a comparison (alternative
intervention) group was used instead, so it was not possible to identify effects of an
intervention compared with no intervention due to internal validity issues.
Semer et al.[18] assessed the impacts of smoking on facial appearance using
computer ageing technology developed by a technology faculty. A particular strength
included investigating male and female viewpoints. In terms of limitations the study
lacks internal validity due to study design (no control group) and data collection
methods as no outcome differences were reported for the individuals who attended a
motivational event (involving the age-progression software).
Hysert et al.[24] aimed to examineexamined computer ageing technology (APRIL
software) with males and females. Strengths include investigating a limited research
area. Each participant’s photograph was aged by an average of 30 years. Clearly a
decision was made to only age the images by 30 years however the results are not
comparable to other studies that have utilised the full software ageing possibilities (as
APRIL software can age an image to 72 years). In addition, design wise the study did
not include a control group comparison. N.B. Some additional detail on the study by
Hysert et al.[24] has been derived from Mirand, Hysert and Donohue[29].
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Perkins et al.[25] aimed to identify the most effective approach to addressing weight
gain concerns in women quitting smoking. Women were randomised to one of three
treatments. Strengths of the study include evaluating a psychological method to
promote smoking cessation (reducing weight concerns). However a particular
limitation includes monitoring of weight gain among participants which may have led
to increased body image concerns.
Copeland et al.[26] researched a multidisciplinary treatment involving general
psychological, dietary and exercise components with female participants. Participants
were randomly assigned to one of two conditions including an individually tailored
and a non tailored group. Strengths included examining whether or not smoking-
cessation information should be personally tailored or not. No post-treatment
measures were administered to investigate body image differences; therefore
conclusions have to be treated with caution. Further limitations include no control
group and weight monitoring which may have led to body image concerns.
Pirie et al.[19] assessed the effectiveness of two weight reduction strategies including
nicotine gum and a behavioural weight control program. Female participants were
allocated randomly to four groups. Strengths included investigating a nicotine
replacement therapy in conjunction with a psychological intervention. A study
limitation also illustrated in Copeland et al.[26], included the incorporation of
exercise, dietary and weight gain concern reduction components. Concern exists in
terms of reducing weight concerns in contrast to proactively reducing actual weight.
As with Copeland et al.[26] and Perkins et al.[25] the study involved continuous
monitoring of weight gain which may have increased body image concerns.
Kentala et al.[27] conducted a RCT to evaluate a dental health intervention with
adolescent males and females. A particular strength included investigating a limited
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area as this study was the only one identified using oral appearance as a potential
motivator for smoking cessation. A limitation involves dental status not being
reported at each stage of the study. For instance if individuals possess discolouration
already they may be more likely to not initiate smoking or alternatively abstinence
may be encouraged.
DISCUSSION
This review aimed to evaluate the existing research base relating to smoking and
physical appearance interventions in order to inform stop-smoking services. The main
findings suggest some positive impacts on smoking outcomes but there is a lack of
consensus between studies; therefore evidence needs to be dealt with in a cautiously
optimistic way. Of the seven facial wrinkling studies, Grogan et al.[21] and Burford et
al.[22] provided the most convincing claims due to a more robust study design
including a control group comparison. The paper by Perkins et al.[25] provided the
most convincing findings of the weight gain concern articles due to conducting pre
and post measures to assess weight concern. The oral health study findings cannot be
compared to similar research due to limited studies focusing on physical
appearance[27]. Overall, the quality of the articles was generally weak. The facial-
wrinkling studies seemed most promising compared to the oral and weight studies.
This may be due to facial-wrinkling interventions having a personalised impact on
individuals.
Limitations in study design and subsequent reporting were identified. Some of the
studies did not include randomised controlled methods illustrating potential sample
bias and hence limitations of investigating intervention effectiveness. A lack of
measure information such as examples of administered questions or source references
were not provided for some of the studies; therefore the reliability and validity of the
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findings are questioned. We were unable to combine statistical information from the
studies due to variation in outcome measures used in different studies. It is difficult to
recommend principles, specific methods and metrics for future studies due to various
reasons including a) different research objectives, b) different means of investigation
(qualitative/ quantitative) and c) financial reasons (time; sample size recruitment,
access of reliable measures). However, we suggest that future studies attempt to use
similar means of investigation (e.g. reliable measures) and report statistical
information (e.g. effect sizes) in order for future meta-analyses to be conducted.
Lack of consistency in the study environment may have affected the results of many
of the studies, particularly in relation to demand characteristics as it is uncertain
whether participants completed interventions and administered measures alone or in a
group setting. Drop-out rates illustrate an additional generalised limitation among the
studies. A particular problem in smoking research is the assumption that drop-outs are
individuals who have relapsed, whereas they may be effective quitters who have
simply stopped attending and this also suggests problems with Intention to Treat
(ITT) analyses often employed. A further general problem reflected in each study is
the lack of baseline measurement of satisfaction with, and importance of, physical
appearance. Certain individuals may be more susceptible to physical appearance
interventions compared to others who are more satisfied with, or less interested in,
their appearance.
There are a number of questions remaining that can be focused on in future research.
For instance there has not yet been any published qualitative research evaluating how
males experience appearance interventions. Also the majority of studies have not
assessed maintenance tools e.g. taking facial-wrinkling images home or attending
relapse sessions. Although some of the studies investigated nicotine replacement
15
therapies (NRT) we suggest that further studies need to determine whether or not
having NRT available has an impact on effectiveness of these kinds of interventions.
Future studies need to incorporate follow-up time points for the following reasons a)
to investigate whether or not appearance interventions motivate smokers to join a
smoking-cessation service, and b) to examine any short term and long term impacts.
Furthermore future research with other groups (adolescents, non-smokers, older
smokers) may provide informative recommendations in the future. Health orientated
services could provide funding for future research. Also collaboration between people
with complementary expertise is recommended to ensure studies are of high quality
e.g. health orientated services working with academic institutions. There is potential
for linking this work with mass media smoking cessation campaigns. For instance,
launching a shopping centre initiative where large numbers of individuals can be
accessed. Further ideas include having physical appearance information on internet
quit websites. Other ways of disseminating information could include using telephone
and text messaging methods. However a particular limitation of mass media
dissemination (e.g. television advertisements) is lack of personalised impact (the
potential reason why appearance interventions may work); mass media campaigns
need to find ways of personalising their promotion strategies to maximise impact.
In terms of future directions, practitioners will benefit from more high quality,
controlled studies with consistent outcome measures and rigorous methodologies.
Qualitative studies would also be useful. Interviews or focus groups would provide in-
depth information about intervention design and effectiveness. Taking into
consideration the reviewed studies’ designs, future appearance studies need to recruit
large sample sizes. In order to recruit large sample sizes research could be conducted
in collaboration with smoking-cessation services or educational institutes.
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To inform stop-smoking services, studies that address physical appearance related
concerns are long overdue. This review therefore provides a guide to future research
in this area. Additional well-designed studies are required to determine the
effectiveness of physical appearance interventions in terms of smoking attitudes,
intentions and behaviours.
17
* Funding Statement: This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
* Competing Interests Statement: I declare that I have read and understood the
declaration of interest policies. Regarding this review there was no declaration of
interests among the authors.
*Contributorship Statement: Keira Flett conducted the primary data collection and
first draft preparation. Professor Clark Carter provided statistical expertise. Professor
Grogan developed the review design and conception. Professor Davey assisted with
the analysis of studies. All authors contributed to the draft paper and helped devise the
final manuscript.
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