Validation of the support provided measure among spouses of smokers
receiving a clinical smoking cessation intervention
Janet L. Thomasa*, Christi A. Pattenb, Jonathan D. Mahnkenc, Kenneth P. Offordd,
Qingjiang Houc, Ian M. Lyname, Betty A. Wirtfand Ivana T. Croghanf
aDepartment of Medicine, Division of General Internal Medicine, University of Minnesota,
Minneapolis, Minnesota, USA;bDepartment of Psychology and Psychiatry, Cancer Center,
Mayo Clinic, Rochester, Minnesota, USA;cDepartment of Biostatistics, University of Kansas
Medical Center, Kansas City, Kansas, USA;dSurvey Research Center, Mayo Clinic, Rochester,
Minnesota, USA;eDepartment of Psychology, University of Missouri, Kansas City, Missouri,
USA;fNicotine Dependence Center, Mayo Clinic, Rochester, Minnesota, USA
(Received 26 February 2008; final version received 1 May 2009)
Studies indicate a positive association between social support and smoking
cessation. However, clinic-based interventions designed to increase social support
delivered. Understanding supportive interactions between support providers and
current investigation examined the perceptions of smoking-specific support
provided by the spouse of a partner who smokes and was seen for a nicotine
dependence consultation. Specifically, we examined spouse reported willingness to
help their spouse quit, interest in learning ways to help their spouse quit, and
characteristics associated with the provision of smoking-specific supportive
behaviors (as assessed via the Support Provided Measure, SPM), in the 2-weeks
prior to the consultation. The current investigation also examined the concurrent
validity of the SPM with a validated measure of support provided to a smoker, the
smoker readiness to change. The sample comprised 84 adult cigarette smokers seen
for a clinical smoking cessation intervention and their spouses (N ¼ 84). Results
indicate that a high percentage of spouses are willing to help their partner who
smokes and interested in learning way to help. As expected, spouses who were
femalesand had never smokedhad higher scores on the SPM than males or current
smokers. The SPM was significantly correlated with the PIQ positive (r ¼ 0.50,
p 5 0.01) and negative (r ¼ 0.44, p 50.01) item scales overall and for spouses
whose partners reported higher levels of readiness to quit smoking (r ¼ 0.54,
p 5 0.01; r ¼ 0.50, p 5 0.01, respectively). Suggestions for future research are
Keywords: social support; smoking; measurement
A substantial body of literature indicates that the support provided to a smoker
by others, predicts successful smoking cessation (Fiore, 2000). Further, the
*Corresponding author. Email: firstname.lastname@example.org
This study was conducted at the Nicotine Dependence Center, Mayo Clinic, Rochester, MN.
Psychology, Health & Medicine
Vol. 14, No. 4, August 2009, 443–453
ISSN 1354-8506 print/ISSN 1465-3966 online
? 2009 Taylor & Francis
literature on social relationships and health suggests the effectiveness of boosting
natural support networks versus social support groups (Cohen, 2004). Social support
provided by family members, friends, and concerned others is a key factor in
successful smoking cessation (Hanson, Isacsson, Janzon, & Lindell, 1990; Roski,
Schmid, & Lando, 1996). However, literature reviews indicate that interventions
attempting to manipulate partner support to achieve better abstinence outcomes
have generally not been successfully (May & West, 2000; Park, Tudiver, Schultz, &
Campbell, 2004). Interventions provided to those who smoke by family and friends
in their natural environment may have wider reach and greater population impact
(Cohen, 2004; Patten et al., 2004a,b). A recent study (Christakis & Fowler, 2008)
highlighted the role of social networks on smoking among adults, indicating that
health promotion efforts targeted to people who are socially connected to the person
who smokes might be effective.
There is considerable interest among the lay public in supporting those who
smoke, as indicated by the increasingly available self-help materials and Web sites
dedicated to this topic (e.g. American Lung Association). The California Smoker’s
Helpline documented that 7% of the 349,110 calls received over a 13-year period
were from proxies (i.e. nonsmokers calling to seek help for someone else) (Zhu,
Nguyen, Cummins, Wong, & Wightman, 2006). Because many nonsmokers in the
population seek assistance on behalf of those who smoke (Zhu et al., 2006), it is of
considerable clinical interest to establish whether social support can be harnessed in
an intervention to optimally tap the potential role of spouses and supportive others
in smoking cessation (May, West, Hajek, McEwen, & McRobbie, 2006).
Despite evidence that smoking-specific social support might influence the
likelihood of smoking behavior change, the question of what partner behaviors
might influence outcomes remains largely unanswered. Understanding supportive
interactions surrounding smoking behavior change is a complex issue (Falba &
Sindelar, 2008; Rohrbaugh et al., 2001). Although the perception of support received
by the person who smokes is important, one methodological limitation of prior
studies is that most assessments of smoking-specific supportive behaviors have relied
only on the perceptions of support received from others and few (Lichtenstein,
Andrews, Barckley, Akers, & Severson, 2002; Pollak et al., 2001) have assessed the
support provider’s report of support delivered. Relying on one perspective alone
may not accurately represent the amount of support given. Earlier studies indicate
that reports of shared experiences may not be highly correlated and could be
influenced by the individuals’ satisfaction with the relationship and their current
mood state (Elwood & Jacobson, 1988). This emphasizes the importance of
clarifying the intended or actual, as opposed to perceived supportive behaviors,
associated with successful smoking behavior change attempts. Only then, can we
adequately develop programs to teach these behaviors to spouses and other
concerned others, design ways to involve them in treatment or follow-up, and
identify those in need of additional social support to quit smoking. Further, a valid
method to measure the perception of support provided, is needed to assess whether
interventions are effective in changing spouse behaviors.
Toward this end, we developed and examined the preliminary psychometric
properties of the Support Provided Measure (SPM), a measure of supportive
behaviors provided to a person who smokes. The current investigation examines the
concurrent validity of the SPM with the Partner Interaction Questionnaire, PIQ
(Cohen & Lichtenstein, 1990; Roski et al., 1996), a widely used measure of perceived
444 J.L. Thomas et al.
support for smoking cessation. The PIQ captures both positive and negative
behaviors and taps the perceptions of support received by spouses or partners. More
recently, the PIQ has been utilized to assess support provided by spouses and
partners to a smoker (McBride et al., 2004). The PIQ items only tap support
provided to smokers who are taking action or preparing to quit. In contrast, the
SPM was developed to assess support provided to a smoker irrespective of the
smoker’s level of motivation to quit. Most smokers do not seek treatment for
smoking cessation and report low levels of motivation to quit (Abrams, Herzog,
Emmons, & Linnan, 2000). The SPM was found to have good internal consistency
(a ¼ 0.83) in a sample of college students (Thomas et al., 2005). In the current
study, we examine the association of the SPM and PIQ among spouses of
persons who smoke and are receiving treatment for smoking cessation. Because the
PIQ has been validated among those reporting high levels of readiness to quit
smoking, we hypothesized that the SPM would be significantly correlated with the
PIQ among spouses of whose partners report high, but not lower, levels of readiness
It is possible that reports of support provided to or received by a person who
smokes could be influenced by the tendency to respond in a socially desirable
manner. A limitation with prior studies is that none have taken into account
potential response biases. Thus, we examine the association of the SPM with the
Marlowe–Crowne Social Desirability Scale (Crowne & Marlowe, 1960), a widely
used measure of social desirability. Earlier research indicates that persons who
smoke are less effective at providing support (based on the smoker’s report) than
are those who do not smoke (McBride, Lozano, Curry, Rosner, & Grothaus,
1998b; Murray, Johnston, Dolce, Lee, & O’Hara, 1995). Furthermore, recent
studies suggest that females are more likely than males to endorse willingness to
help a smoker quit (Thomas et al., 2008) or to seek help for a smoker (Zhu et al.,
2006). Thus, we also examined the association of the SPM score with gender and
spouse smoking status. Finally, on the basis of these prior reports, we
investigated the hypothesis that there would be a high level of spouse interest
and willingness to help their partner who is being seen for a smoking cessation
This study was approved by the Mayo Clinic Institutional Review Board. We
utilized a cross-sectional survey design.
The Mayo Clinic Nicotine Dependence Center Treatment Program is operated under
the direction of a physician with most of the intervention services provided by
masters trained counselors. Intervention services include: initial inpatient and
outpatient consultation and individual counseling, an outpatient group program, a
residential treatment program, a structured relapse prevention program based on
telephone follow-up and patient contact via letter and the Minnesota state tobacco
quitline. To date, over 25,000 patients have been treated. Most patients are physician
referred (85%), and the counseling is provided in conjunction with services provided
by the referring physician.
Psychology, Health & Medicine 445
The sample included 84 adults seen for a clinical nicotine dependence consultation in
2003 by the Mayo Clinic Nicotine Dependence Center and their spouses. Only 8% of
persons seen for the consultation were hospitalized.
Eligibility criteria were: (1) adults who smoked one or more cigarettes per day in
the past 7 days. For hospitalized smokers, we asked whether they were smoking
during the 7 days before entering the hospital. That is, those who were abstinent
since their hospitalization were eligible only if they were smoking prior to being
hospitalized, (2) the spouse was present with the person seen for the consultation, (3)
both the person who smoked (‘patient’) and their spouse were at least 18 years of
age, (4) both provided written informed consent, and (5) both were willing to
complete study questionnaires.
Of the 84 spouses, 49% were female, 88% were Caucasian, and 91% completed at
least a high school education. With respect to smoking status, 39% had never
smoked, 39% currently smoked, and 22% had smoked but not in the past 6 months
(‘former smoker’). Table 1 shows the mean scores for the spouse completed SPM,
PIQ, and Marlowe–Crowne measures.
Of the 84 person who smoked and received the nicotine dependence intervention,
50% were female, 88% were Caucasian, 90.4% completed at least a high school
education and the average age was 52+12 years (range 20–76). The mean FTND
Marlowe social desirability scale scores among spouses of smokers seen for a clinical cessation
intervention (N ¼ 84)a
Spouse support provided measure, partner interaction questionnaire, and Crowne–
% (n) or mean+SD
Support provided measure
Partner interaction questionnaire
Positive items score
Negative items score
Ratio (positive/negative item scores)
Crowne–Marlowe social desirability scale
aData were missing for six participants for the support provided measure and for eight participants for the
Crowne–Marlowe and for the partner interaction questionnaire.
446 J.L. Thomas et al.
score was 5.82+2.05 (medium level of dependence); 51.4% started smoking before
the age of 18; the vast majority (99.5%) had made at least one lifetime quit attempt
and the mean cigarettes smoked per day was 24.8+12.8, (range 0–60; 5/6 inpatients
endorsed smoking no cigarettes in the past 7 days).
Adults who met the inclusion criteria were provided with a survey packet containing
one informed consent form for the person receiving the consultation and a separate
consent for their spouse. Questionnaires specific to both the person who smoked and
their spouse were also included and the couple was encouraged to complete their
respective questionnaires separately and without discussion between them.
Spouse survey measures
Demographics and tobacco use
Demographic items assessed included gender, ethnicity, and education. Spouses were
asked about their use of cigarettes using standard questions (Royce, Hymowitz,
Corbett, Hartwell, & Orlandi, 1993). Those who had not smoked at least 100
cigarettes in their lifetime were classified as never smokers and those who reported
smoking 100 or more cigarettes in their lifetime, but spouses who had not smoked
within the last 6 months, were categorized as former smokers. Current cigarette use
was defined as smoking 100 or more cigarettes during their lifetime and use during
the past 7 days (i.e. ‘Over your entire lifetime, have you smoked 100 or more
cigarettes? If yes, in the past 7 days, have you smoked any cigarettes [yes or no])’.
Motivation and interest in helping spouse quit
Participants were asked to rate on a 5-point likert scale ‘How motivated are you to
help your spouse quit smoking?’ (‘not motivated at all’ to ‘extremely motivated’) and
‘How interested are you in learning about ways to help your spouse to stop
smoking?’ (‘little or no interest’ to ‘extremely interested’).
Support provide measure. Participants completed the 22-item SPM (Thomas, Patten,
Offord, & Decker, 2004; Thomas et al., 2005) at baseline, before cessation
counseling. The SPM asks that respondents indicate whether or not the item
occurred (i.e. yes or no) during the prior 2 week period (e.g. During the past 2 weeks
have you ...). Eleven of the items ask about positive supportive behaviors
(‘... praised or encouraged your spouse for his/her efforts to quit smoking?’) and
11 of the items assess negative (i.e. non supportive) behaviors (‘ ... attempted to hide
or keep cigarettes away from your spouse?’). SPM items pertain to support provided
to a smoker irrespective of their level of readiness to quit smoking and were derived
base on theoretical model of social support (Cohen, 2004). The SPM was shown to
have high internal consistency (a ¼ 0.83) in a sample of 771 adults (Thomas et al.,
2005). The total score is calculated by summing the number of items endorsed in the
Psychology, Health & Medicine447
direction of supportive behaviors and can range from 0 to 22. The internal
consistency reliability of the SPM for the current sample, as assessed using
Cronbach’s a coefficient, was 0.72.
Partner interaction questionnaire. A modified version of the 10-item PIQ (Cohen &
Lichtenstein, 1990; Roski et al., 1996; Thomas et al., 2005) was used to assess
spouses’ reported delivered support to the smoker (Lichtenstein et al., 2002). The 10-
item PIQ includes five items addressing positive behaviors (e.g. complimenting the
spouse on not smoking) and five items assessing negative behaviors (e.g. commenting
that smoking is a dirty habit). Item responses are never (1), once (2), a few times (3),
and often (4). For this study, the PIQ was modified from the original, 10-item PIQ
(Roski et al., 1996) by: (1) changing the time period assessed from the ‘past week’ to
the ‘past 2 weeks’ and (2) adjusting the wording of the items to ask the spouse
whether they provided each behavior versus the original wording of the PIQ which is
directed to the smoker (e.g. ‘During the past week, how often did your
spouse ... compliment your not smoking?’ was changed to ‘During the past 2
weeks, how often did you ... compliment your spouse for not smoking?’). The
Cronbach’s a coefficient for this sample was 0.83.
Social desirability. The Marlowe–Crowne Social Desirability Scale (MCSD; (Crowne
& Marlowe, 1960) was developed to measure one form of response bias, social
desirability or ‘faking good’. Respondents report whether a list of 33 statements
concerning personal attitudes or traits are either ‘true’ or ‘false’ as it pertains to them
personally (e.g. ‘I like to gossip at times.’). The MCSD scale has been widely used and
the current study, the Cronbach’s a coefficient for this sample was 0.68.
Patient survey measures
The Mayo Clinic Nicotine Dependence Center patient questionnaire included
measures of demographic information and smoking behaviors. The principal source
for the smoking items was the COMMIT Smoking Prevalence Survey (Royce et al.,
1993). All items have established validity and reliability, and have been used in
clinical and research samples. Demographic items used in the current study include
gender, age, and education.
Tobacco-related items included current number of cigarettes smoked per day (i.e.
‘During the past 7 days, on average, how many cigarettes did you smoke per day?’),
age first started smoking regularly (i.e. ‘How old were you when you first started
smoking on a regular basis?’, and number of lifetime quit attempts (i.e. ‘How many
serious attempts have you made at stopping smoking?’ [‘none’, ‘one’, ‘two to five’,
‘six to ten’, and ‘more than ten’]).
Nicotine Dependence was measured using the Fagerstro ¨ m Test for Nicotine
Dependence (FTND) (Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991),
448 J.L. Thomas et al.
a widely-used, 6-item scale (score range 0–10) with scores of low (0–3), medium (4–6)
and high (47). The FTND has adequate internal consistency and reliability
(Cronbach’s a ¼ 0.61). Scores on the FTND are classified as low (0–3) medium (4–6)
and high (47).
Readiness to quit
to quit (Biener & Abrams, 1991) (i.e. 0 ¼ ‘No thought of quitting’ to 10 ¼ ‘taking
action to quit’). Following previous work (Zhu et al., 2006), the contemplation ladder
score was grouped into three categories: low (0–3), medium (4–6) or high (7–10).
Because of the small number of smokers reporting low (n ¼ 4) or medium (n ¼ 11)
levels of readiness to quit, these two categories were combined for analysis purposes.
Categorical baseline variables were summarized by frequencies and percentages
while quantitative baseline variables were summarized by means and standard
deviations. To assess the concurrent validity of the SPM, Spearman correlation
coefficients were estimated between the SPM and the PIQ. Subgroup analyses were
also performed investigating this bivariate relationship within Contemplation
Ladder score categories low/medium (0–6) or high (7–10). Bivariate relationships
of the SPM with spouse gender and smoking status (never, former, current) were
examined using the Wilcoxon rank sum test and the Kruskal-Wallis test,
Willingness and interest in learning ways to help their spouse quit smoking
Results indicate that 84% of spouses were ‘very’ or ‘extremely’ motivated to help
their spouse to quit and *90% were ‘very’ or ‘extremely’ interested in learning ways
to help their spouse to quit.
Association of SPM and PIQ
The SPM score was significantly correlated with the PIQ positive and negative item
scores, but not with the PIQ ratio of positive to negative items score. Table 2 shows
the association of the SPM and PIQ scores by the smokers’ level of readiness
(combined low and medium vs. high) to quit.
scores among all smokers and by smoker’s level of readiness to quit.
Correlation of support provided measure and partner interaction questionnaire
Readiness to quit
All smokers Low/medium High
pr (N)pr (N)
Psychology, Health & Medicine449
Association of SPM score with socially desirable responding
No significant association was detected between the SPM or the PIQ scores and the
Marlowe–Crowne score (r ¼ 0.12, p ¼ 0.31 and r ¼ 0.02, p ¼ 0.85).
Association of SPM score with spouse characteristics
The SPM was significantly higher for female vs. male spouses (mean 11.5+3.2 vs.
9.9+3.5, p ¼ 0.03). Smoking status also approached significance (p ¼ 0.08) with
never smokers (5100 lifetime cigarettes) reporting more supportive behaviors (mean
11.6+3.7) than former (mean 9.3+2.7) or current smokers (?100 lifetime cigarettes)
This is the first study to assess the willingness of the spouse of an adult seen for a
smoking cessation consultation to help their partner to quit. Results indicate that
80% of the sample reported that they were ‘very’ or ‘definitely’ willing to help their
partner to quit. Also consistent with our previous study of adolescents (Patten et al.,
2004a), and young adults (Thomas et al., 2008), over 90% of the spouses of adults
who smoke and are being seen for a cessation consultation were also interested in
learning ways they could help. Thus, it appears that spouses might be an important
target group. If the potential role of the spouse in assisting their partner to make a
quit attempt could be tapped, the public health benefit could be substantial. These
findings may indicate that the clinic setting may be an important venue to engage the
spouse to teach them skills to help their smoker. Future research might also examine
training needs among spouses.
This study also provides new information on the concurrent validity of the SPM
among spouses of adults who smoke who received a nicotine dependence
intervention. The main findings were that the SPM was significantly correlated
with the PIQ positive and negative item scales overall and for spouses whose smokers
reported higher levels of readiness to quit smoking. The PIQ ratio score was not
associated with the SPM score, but this may reflect the fact that the SPM does not
have a comparable ratio score. Moreover, the SPM was not significantly associated
with the Marlowe–Crowne indicating that for this sample, a response bias related to
social desirability did not appear to be operating. No previous study has examined
the relationship between reports of support provided or received with potential
response biases. As expected, and consistent with prior research (McBride et al.,
1998a,b; Murray et al., 1995), females and never and former smokers were found to
have higher scores on the SPM than males or current smokers.
This study has several limitations that should be considered when interpreting the
results. First, we included a self-selected and possibly unrepresentative sample of
smokers and their spouses. Most smokers do not seek assistance in quitting (Zhu
et al., 2006). All spouses were present with their partner at the intervention, which in
itself could be construed as a supportive action. It is not known whether or not the
spouses may have been a motivating factor in the smoker’s decision to seek
treatment, or in the case of a hospitalized patient, agree to be seen for an
intervention (Lichtenstein et al., 2002). However, the range of SPM scores (6–20) was
not restricted to the high end of the scale, indicating variability in level of support
450 J.L. Thomas et al.
provided. Nevertheless, spouses who do not attend treatment and/or whose partner
does not receive professional assistance may differ in provided support. Further, we
did not assess the reason for the patient’s visit to the Mayo Clinic (inpatient or
outpatient). It is likely that those seen for symptoms associated with a tobacco-
related illness may have been more likely to attend the nicotine dependence
consultation. Future research might investigate the association between willingness
to support and medical diagnosis. Second, because the PIQ was developed for
completion by spouses or partners, we restricted our sample to couples, which limits
generalizability of our findings to other potential supporters. Nonetheless, a meta-
analysis indicated that interventions to increase support for smoking cessation
showed the most promise when implemented with live-in, married or equivalent to
married partners (Park et al., 2004). Moreover, being married has been found to be a
good predictor of quitting (Sorensen, Emmons, Stoddard, Linnan, & Avrunin,
2002). Third, we did not assess the smoking patient’s’s perception of support
received, thus it is not known how the spouse support efforts were experienced by the
patient. Our study aimed to understand the perception of support provided by the
spouse of a patient being seen for a clinical consultation. Thus, we designed the study
so as to minimize the burden posed to the patient (smoker) reporting to the clinic for
the nicotine dependence consultation. Therefore, we asked them to complete a
minimal number of questions. We suggest that future research might examine the
correlation of support provided and support received among spouses.
This study suggests several directions for future research. The psychometric
properties of the SPM, including its factor structure and test–test reliability, need
examination in a larger sample of spouses. Moreover, a key question is how effective
the support was to the smoker at quitting smoking or maintaining abstinence. Future
studies should therefore examine the external validity of the SPM. An advantage of
the SPM over the PIQ is that it is not limited to completion by spouses or partners or
support provided to smokers with higher levels of readiness to quit smoking. Indeed,
most studies focus solely on the spouse as a support provider. Research is emerging
however, indicating that a substantial number of other family members (e.g.
children, siblings), as well as friends and co-workers, express interest in assisting a
smoker (Patten et al., 2004b). Among 2143 nonsmokers who called the California
Helpline to request assistance for someone who smokes, only 43% were spouses
(Zhu et al., 2006). Thus, the SPM could be validated among non-spouses. Moreover,
research is needed to validate the SPM in a sample of spouses and non-spouses
whose partnerss are at varying levels of readiness to quit smoking. Furthermore,
knowing how assessments of support behaviors differ between the provider and
receiver could help in designing interventions to account for these gaps. Such
research should also account for satisfaction with the marital relationship as the
quality of the relationship may affect reports of delivered and/or received support
(Cohen & Wills, 1985; Coriell & Cohen, 1995).
A novel and exciting avenue for tobacco control would be to engage family
members to reach the smoker using the SPM to guide intervention development and
monitor behavioral change. To date, family based smoking behavior change
interventions have received limited attention (Rohrbaugh et al., 2001; Shoham,
Rohrbaugh, Trost, & Muramoto, 2006). Our findings indicate that spouses who are
both female and nonsmokers may be appropriate targets for future couple-based
support interventions for smoking cessation. Further, social support interventions
could be designed for the nonsmoking spouse alone with the goal of increasing
Psychology, Health & Medicine451
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Meyers, 2004), where a spouse concerned about substance use in their partner are
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