A Preliminary Study of the Effects of an Innovative Social Cognitive Theory- Driven, Yoga-Based Behavioral Intervention on Smoking Cessation

M. Sharma & D. E. Corbin / Californian Journal of Health Promotion 2006, Volume 4, Issue 4, 63-76


A Preliminary Study of the Effects of an Innovative Social Cognitive Theory-
Driven, Yoga-Based Behavioral Intervention on Smoking Cessation

Manoj Sharma1 & David E. Corbin2

1University of Cincinnati
2University of Nebraska at Omaha

Abstract
The purpose of this study was to develop and test an innovative yoga-based behavioral intervention for
smoking cessation based on social cognitive theory and compare it with an existing self-help based
program. In both the groups, the antecedents of quitting based on social cognitive theory, namely, self-
efficacy for quitting and self-control for quitting were tracked for six months along with self-reported
daily consumption of cigarettes, self-efficacy for yoga, and past week performance of yoga behaviors. A
valid and reliable 23-item instrument was utilized. The study employed an experimental design. Twenty
one participants recruited in this study after informed consent and randomly assigned to the two groups.
Seven (33.3%) participants completed the study protocol and one participant who was in the yoga group
was successful in quitting smoking. Statistically significant improvements occurred in the social
cognitive-theory based yoga group over the self-help group for self-control for quitting (p<0.001) and
performance of yoga behaviors (p<0.05). This pilot study suggested that a social cognitive theory based
yoga intervention was more efficacious in influencing the antecedents of smoking cessation than a self-
help approach. This study lends support for developing and testing future interventions regarding the use
of yoga as a behavioral method for smoking cessation.

© 2006 Californian Journal of Health Promotion. All rights reserved.
Keywords: yoga, complementary and alternative medicine, tobacco


Introduction
A distinct advantage of the behavioral
Smoking remains as the single most important
interventions over pharmacological interventions
preventable cause of death in the United States
in facilitating smoking cessation is the lack of
(Mumford, Levy, Gitchell, & Blackman, 2005;
adverse side effects (Williams, McGregor,
Walsh & McPhee, 2002). Currently there are
Borrelli, Jordan, & Strecher, 2005). However,
over 60 million smokers in our country
there is a need to enhance the efficacy of
(McGinnis & Foege, 1999) that account for
behavioral interventions and, therefore, a need to
438,000 premature deaths and 5.5 million years
utilize innovative approaches. With growing
of potential life lost (YPLL) annually (Centers
interest in the area of complementary and
for Disease Control & Prevention [CDC], 2005).
alternative medical approaches in the United
The total economic costs of tobacco have been
States (National Center for Complementary and
estimated to be well over $100 billion annually
Alternative Medicine (NCCAM, 2000), potential
(Batra, Patkar, Weibel, & Leone, 2002). Most
applications of innovative yoga-based
smokers want to quit, have experimented with
techniques need to be explored in assisting
quitting or are planning to quit within the next
smokers with smoking cessation. The system of
one year but more than two-thirds fail in these
yoga offers a set of such innovative techniques.
attempts (Slovic, 2001). Several pharmaco-

logical and behavioral therapies have been tested
The benefits of yoga techniques have been tested
with varying rates of success for smoking
as complimentary therapy to aid the healing of
cessation (Berrettini & Lerman, 2005; Urso,
numerous ailments such as coronary heart
2003).
disease (Manchanda & Narang, 1998),

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M. Sharma & D. E. Corbin / Californian Journal of Health Promotion 2006, Volume 4, Issue 4, 63-76

hypertension (Labarthe & Ayala, 2002;
cessation. In Kundalini Yoga the meditation
McCaffrey, Ruknui, Hatthakit, & technique involves performing a formless
Kasetsomboon, 2005), depression (Brown, &
contemplation at the pituitary and the
Gerbarg, 2005; Janakiramaiah et al., 2000),
hypothalamus glands. Along with the meditation
anxiety disorders (Kirkwood, Rampes, Tuffrey,
(dhyana), low physical impact postures (asana)
Richardson, Pilkington, & Ramaratnam, 2005;
geared toward muscular strain reduction and
Miller, Fletcher, & Kabat-Zinn, 1995), bronchial
breathing techniques (pranayama) are also
asthma (Lewith & Watkins, 1996), and other
practiced (Maharishi, 1987).
disorders requiring extensive rehabilitation

(Telles & Naveen, 1997). Yoga techniques have
Therefore, the purpose of the study was to
been suggested for smoking cessation but have
develop and test an innovative yoga-based
not yet been systematically tested (McIver,
behavioral intervention for smoking cessation
O'Halloran, & McGartland, 2004; Sahay &
(experimental group) and compare the results
Sahay, 2002).
with an existing self-help based program

(control group). If a smoker can quit smoking
Yoga is an ancient system of physical and
for six months, the chances of relapse are low
psychic practice that originated during the Indus
and the program is considered to be successful
Valley civilization in South Asia. The first
(Prochaska, Redding, & Evers, 2002). Hence,
codified record of this methodology appeared in
the antecedents of quitting based on social
the Yoga Sutra of Patanjali around 3rd or 4th
cognitive theory (Bandura, 1986, 1997, 2004),
Century BC (Singh, 1983). The system consists
namely, self-efficacy for quitting and self
of eight-fold path or asthangayoga. In
control for quitting were also tracked for six
contemporary literature, yoga has been defined
months. Also measured was self- reported daily
in several ways and a more acceptable modern
consumption of cigarettes (normally in a day and
interpretation implies the systematic application
specifically during the past 24 hours) in both the
of techniques to promote harmony in the human
groups. Additionally, self-efficacy for yoga and
body, mind, and environment (Maharishi, 1992).
past week performance of yoga behaviors were
The traditional practice of yoga was quite
also gauged to see if the participants were
rigorous and arduous and entailed lifelong
indeed adhering to the yoga practices.
devoted practice and adherence to strict

austerities. Today many schools of yoga have
Methodology
simplified the techniques making them more
This was a Stage I research study as described
suitable for users in different walks of life. The
by the National Institutes of Health (NIH)
eight conventional steps of asthangayoga consist
(1999) that involves development, modification,
of yama (rules for living in society), niyama
and pilot testing of novel behavioral
(self-restraining rules), asana (low physical
interventions. A purposive sample of smokers
impact postures), pranayama (breathing
from Omaha, Nebraska was recruited after
techniques), pratyahara (detachment of mind
obtaining informed consent. It was planned for
from the senses), dharana (concentration),
the sample size for six levels (two groups x three
dhyana (meditation), and samadhi (union with
times) with the desired significance criterion at
super consciousness). Different schools of yoga
alpha of 0.05, desired power at 0.80, and an
utilize all or some of the above practice steps.
anticipated medium effect size of 0.30, a sample
One well-evolved school of yoga is Kundalini
of six participants per group will be recruited
Yoga or the system of primordial energy
(Polit & Beck, 2003). As such a total of 36
unification (Mahan, 1981, Maharishi, 1992). The
subjects with 18 in each group (experimental
hallmark of this school is that it starts from the
and control) were planned. It was envisaged that
seventh step that of meditation (dhyana) which
over six months a possible attrition of about
can be of particular benefit in combating the
10% in the sample would occur. As a result, 40
negative effects of emotional stress and
subjects were to be recruited with random
enhancing coping among smokers while they
assignment of 20 subjects each into the yoga-
make attempts to quit smoking and remaining in
based experimental group and the self-help

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control group. However, no incentives were
smoked in the past 24 hours; (2) number of
budgeted for enrolling the participants in the
cigarettes normally smoked in a day; (3) self-
study other than providing yoga mats, and a
efficacy for quitting with a range of 0-16 units;
video to the participants in the experimental arm
(4) self-control for quitting with a range of 0-16
of the study. Participants were recruited by
units. In addition, in order to ascertain the
means of an advertisement in the student
adherence of smokers in the experimental group
newspaper of the University, a community
to the yoga practices, the dependent variables of
newspaper, and flyers posted at the University.
self-efficacy and performing of yoga-related

behaviors were also measured.
The inclusion criteria for recruitment in the

study were participants who: were (1) over the
Instrument
age of 18; (2) current smokers and who wanted
A 31-item scale was developed and validated for
to quit smoking; (3) competent and provided
face and content validity by a panel of experts in
voluntary informed consent; (4) had intent and
a two-round process for an earlier yoga study
willingness to adhere to the assigned behavioral
(Sharma, 2001). Internal consistency of this
smoking cessation intervention ? yoga-based or
scale was also found to be acceptable with
self-help ? for a period of six months; (5) who
Cronbach's alpha for each of the components
had intent and willingness to participate in six
being over 0.80 (Sharma, 2001). Since the
sessions to be offered in the evenings at the
purpose of this study was to apply the yoga-
University, if assigned to the yoga group; and
based intervention for smoking cessation, the
(6) who would continue home-based practice of
original instrument was tailored to a 23-item
yoga-related procedures, if assigned to the yoga
scale with five subscales.
group.


The first two items pertained to the number of
People who were excluded from the study were
cigarettes normally smoked in a day and number
those people who had: (1) any major disorder
of cigarettes smoked in the past 24 hours.
that limited performance of activities of daily

living; (2) any overt disorder that limited the
The second subscale of four items measured
participants’ ability to understand and give
self-efficacy for quitting smoking as measured
informed consent; (3) any history of myocardial
by the ability to quit completely, reduce the
infarction within the past six months; (4) history
number of cigarettes, remain smoke free for six
of any major surgery or hospitalization within
months and remain smoke free for six months
the past six months; (5) any active
despite difficulties. The scale uses a rating of not
musculoskeletal disorder that produced pain,
at all sure (0), slightly sure (1), moderately sure
such as uncontrolled rheumatoid arthritis.
(2), very sure (3), and completely sure (4). A

summative score with a range of 0-16 units was
Due to lack of provision for incentives,
calculated. Cronbach’s alpha was found to be
recruitment for the study became very difficult
0.92 and thus acceptable.
and only 21 participants were recruited. The

smokers were randomly assigned into either the
The third subscale of four items measured self-
experimental yoga group (n=11) or the self-help
control for quitting as measured by the ability to
control group (n=10).
manage stress, set a goal for quitting, rewarding

oneself, and exercising self control in remaining
Design
smoke free for six months. The scale used a
The study utilized an experimental design with
rating of not at all sure (0), slightly sure (1),
data collected at: (1) start of the intervention; (2)
moderately sure (2), very sure (3), and
immediately after completion of the intervention
completely sure (4). A summative score with a
at six weeks; and (3) six months after the
range of 0-16 units was calculated. Cronbach’s
intervention. The primary dependent variables
alpha for this subscale was found to be 0.80 and
for comparisons between experimental and
thus acceptable.
control groups were: (1) number of cigarettes


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The fourth subscale of next four items measured
The participants were given a yoga mat and a
self-efficacy for performing yoga-related
video to help them adhere to regular self-
behaviors of strain relieving low physical impact
practice at home. In addition, participants were
postures (asana), relaxation (shava asana),
called by research staff and encouraged to quit
breathing techniques (pranayama) and
smoking. Having the inner potential in the form
meditation (dhyana) on the same rating scale
of self-efficacy for quitting and self-control to
with the summative score ranging from 0-16
quit smoking was reinforced.
units. Cronbach’s alpha for this subscale was

found to be 0.93 and thus acceptable.
The yoga-based intervention was delivered at a

University and a community setting. A video
The fifth subscale of four items measured the
documenting all the techniques was made
past week performance of the above four yoga-
available to all participants in the experimental
related behaviors on a scale of never (0), hardly
group. The control group was provided with
ever (1), sometimes (2), almost always (3), and
self-help reading material in the form of the
always (4) again with a summative score ranging
existing, “You can quit smoking consumer
from 0-16 units. Cronbach’s alpha for this
guide” (United States Department of Health &
subscale was found to be 0.97 and thus
Human Services, 2000). The materials in the
acceptable.
quit smoking consumer guide included

information on reasons for quitting, five keys for
The final four items measured demographic
quitting, questions to think about, and a list of
information about gender, race, education level,
resources. Both groups were encouraged to
age, and smoking cessation efforts undertaken in
make use of the national quit line (1-800-QUIT-
the past.
NOW).


Intervention
Results
As mentioned earlier, the six-week behavioral
A total of 21 participants were recruited for the
yoga intervention has been tested and found to
study of which 11 were randomly assigned to
modify yoga-related behaviors (Sharma, 2001).
the yoga group and 10 were randomly assigned
The intervention consisted of yoga lessons
to the control group. At six weeks, there were
scheduled at the convenience of the participants
five participants in the yoga group and six in the
with the instructions for the participants to
control group. At six months, three participants
practice the techniques taught at home.
(27%) in the yoga group and four participants

(40%) from the control group completed the
In the first lesson, the participants were given an
protocol of the study. The attrition rate was 48%
overview of yoga and taught a set of low
at six weeks and 67% at six months which is
physical impact postures (asanas). These asanas
very high.
included movements of the eyes, neck,

shoulders, fine motor muscles of the hands,
Summary of the distribution of demographic
spinal rotations, spinal rocking with flexion,
variables in the two groups at baseline and at six
extension/ hyperextension of the spine, hip
months is depicted in Appendix A and Appendix
movements, knee movements, and leg postures.
B. No significant differences in the various
Not all participants assigned to the yoga group
categories of variables were observed between
participated in the formal first lesson.
the yoga group and the control group for any of

the demographic variables either at baseline or at
To accommodate the schedules of the
six months.
participants, drop-in yoga lessons were offered

at many sites with many times from which to
The sample was predominantly White (81%),
choose. Participants had the opportunity to be
majority females (71%), and all had completed
introduced to breathing techniques (pranayama),
high school or more. Approximately half of the
and formless meditation.
participants had tried some method of smoking

cessation prior to the study, of which nicotine

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replacement therapy (NRT) was most popular
subjects effects were found to be significant thus
(43%) followed by Bupropion or Zyban (24%).
indicating there were no differences between the
Other methods that were mentioned included
two groups.
cold turkey/own (n=4), Nicorette (n=1),

hypnosis (n=2), and counseling (n=1). The age
Two interactions were found to be significant.
range of the participants at the baseline (n=21)
The interaction between total self control for
was between 19-57 years with a mean of 35.19
quitting at different time intervals and group was
years (s.d. 11.52 years) and the mean for yoga
found to be significant F = 9.563, p = 0.005. A
group being 35.55 years (s.d. 3.12 years) and
cell mean graph has been plotted in Appendix D.
control group 34.80 (s.d. 4.19 years). At six
It is evident from Figure 1 that the mean total
months (n=7) the age range of participants
self-control in the yoga group increased
remaining in the study was between 21-47 years
significantly from base line of 6.33 units to
with a mean of 34.00 years (s.d. 11.03 years)
11.67 units at six months while it decreased in
and the mean for yoga group being 33.00 years
the control group from base line of 11.25 units
(s.d. 7.23 years ) and control group 34.75 years
to 8.75 units at six months. The second
(s.d. 5.85 years).
interaction that was found significant was

between mean of yoga behaviors at different
Table 1 summarizes the distribution of study
time intervals and group (F = 4.192, p = 0.048).
variables at baseline, six weeks, and six months
A cell mean graph is presented in Appendix E. It
for the yoga and the control group. Appendix C
is evident from Appendix E that the mean of
summarizes the analysis of variance (ANOVA)
yoga behaviors increased at six weeks for the
for the study variables. None of the between-
yoga group when compared to the control group.


Table 1
Summary of distribution of study variables at baseline, six weeks,
and six months for yoga group and control group (n=7)

Variable
Baseline
At 6 weeks
At 6 months
(Possible range)
Yoga group
Control
Yoga group
Control
Yoga
Control
Mean (s.d)
group
Mean (s.d)
group
group
group
Mean
Mean
Mean
Mean (s.d)
(s.d)
(s.d)
(s.d)

Total self-efficacy for
5.33
10.00
6.00
8.25
8.67
6.50
quitting (0-16)
(2.52)
(2.00)
(5.20)
(2.99)
(6.66)
(4.04)
Total self-control for
6.33 (2.52)
11.25
9.00
10.00
11.67
8.75
quitting (0-16)
(1.50)
(5.57)
(2.71)
(3.79)
(2.63)
Total self-efficacy for yoga
9.33 (6.35)
12.50
10.67 (2.31)
9.75
8.00
9.75
(0-16)
(1.73)
(4.27)
(6.93)
(2.06)
Total score for yoga
1.33 (2.31)
2.75
4.33 (3.79)
1.50
2.67
3.00
behaviors in past week
(2.22)
(1.91)
(2.31)
(2.00)
(0-16)
Number of cigarettes
14.33
9.50
7.00
7.75
6.00
10.50
smoked normally in a
(6.03)
(2.52)
(2.65)
(3.86)
(7.94)
(3.32)
day
Number of cigarettes in the
11.00
8.00
8.67
5.00
4.67
9.00
past 24 hours
(3.61)
(3.60)
(2.89)
(3.46)
(5.03)
(1.15)






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Discussion
First, the sample size was too small. A much
The purpose of this study was to develop and
larger sample size should have been considered
test an innovative yoga-based behavioral
at the start of the study knowing that the long-
intervention for smoking cessation and compare
term commitments required of the research
it with an existing self-help based program over
participants, without monetary compensation,
a period of six months. From the 21 participants
may lead to a high attrition rate.
who started in this study, seven (33.3%)

completed the protocol and one participant who
Second, the attrition rate was very high (67%),
was in the yoga group was successful in quitting
occurring almost equally in both the groups. The
smoking. The attrition rate in this study is very
attrition rate adversely affected the original
high (66.7%) partly due to the reason that no
sample size further, and reduced power of the
monetary incentives were provided to the
statistical tests conducted. The predicted 10%
participants when others smoking cessation
attrition rate was unrealistic. The inclusion
studies in the same geographical areas were
criteria may need to be revised so that research
offering substantial monetary incentives.
participants can be screened more carefully to

avoid such attrition. Also, monetary or other
Statistically significant improvements occurred
forms of compensation must be made available
in the social cognitive-theory based yoga group
to the research participants in future studies.
over the self-help group for self-control for

quitting (p<0.001) and performance of yoga
Third, the recruitment of research participants
behaviors (p<0.05). Such significant improve-
and the flexibility yoga training scheduling
ments were not observed for self-efficacy for
possibly contributed variability in the protocol
quitting, self-efficacy for yoga, or the mean
used in both groups. The recruitment process,
number of cigarettes smoked normally and
for example, was carried out over a longer
during the past 24 hours. However, none of the
period of time than initially planned, and as a
participants in the self-help group were able to
result, yoga training was conducted in waves. It
quit, but one of the three who completed the
would have been better to recruit all research
study (33.3%) in the yoga group was able to
participants at the same time, and begin the
completely quit.
study at one point in time rather than spread out

over months. Also, a convenience sample was
Yoga is known to increase self-control
used in this study rather than a randomly
(Maharishi, 1992). In this study, self-control
selected sample of smokers. The convenience
specific to quitting was found to have increased,
sample, however, was the sensible solution at
lending support toward the efficacy of using
the time to study the yoga efficacy question.
yoga as a behavioral intervention. Performance

of yoga behaviors increased significantly at six
Also, efforts were made to make the yoga
weeks which was expected. The study needs to
classes available at more convenient times and
be replicated with better compliance from the
locations. This flexible scheduling made it easier
participants through the use of monetary
for participants to take the yoga classes, thus,
incentives and perhaps longer follow-up.
decreasing the likelihood attrition, but such

flexible scheduling decreased the uniformity of
Limitations
the instruction.
The major limitations in this study are related to

the research methods used to investigate using
Fourth, the person-to-person yoga intervention
yoga as a possible complementary therapy for
protocol was to be conducted over a six-week
smoking cessation. The results of this study are
period, but not all participants completed the
not generalizable to any population other than
person-to-person lessons. Participants were
the few smokers who were motivated to quit
encouraged to continue their yoga practice with
smoking and practice yoga.
the videotape or on their own for the duration of

the study. Better follow up methods should have

been built in to the original study design to

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assure each research participant adhered to the
required in ensuring compliance and decreasing
protocol.
attrition from such interventions. Perhaps the

stages of change model (Prochaska, Redding, &
Fifth, only a paper-and-pencil, self-report survey
Evers, 2002) can be utilized in motivating more
was used to measure the differences between the
smokers to contemplate quitting using yoga.
experimental and control groups. Other data
Modifying the constructs of decisional balance
collection methods could have been used, such
(emphasizing pros and reducing cons),
as measurement of serum cotinine levels, to
consciousness raising (finding and learning new
validate the findings in the survey.
ideas), self re-evaluation (realization that

behavior change is important), and
Finally, long term assessment beyond six
environmental re-evaluation (realization of
months was not done and it would have been
negative impacts of unhealthy behaviors on
nice to follow-up the participants for at least one
one’s proximal social and physical environment)
year.
would be of primary importance (Prochaska,

Redding, & Evers, 2002).
Implications for Practice

The findings of this study provide evidence that
Besides smoking cessation, yoga interventions
scores on measures of social cognitive theory for
can be utilized and tested for enhancing health
quitting and yoga are modifiable among smokers
promotion goals (such as stress reduction,
in a short duration person-to-person yoga
improving problem solving, improving body
intervention. The yoga intervention was short,
flexibility etc.) and influencing specific disease
thus making it quite practical for use by health
treatment outcomes (such as depression, anxiety,
education practitioners who work with smokers
recovery from coronary heart disease, recovery
and have limited time. The techniques taught in
from traumatic brain injury etc) (Sharma, 2001).
this yoga intervention are very simple, easy to
The yoga intervention developed and tested in
master, and can be easily taught by health
this study can serve as a template for replication.
educators in training others. More thought is

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M. Sharma & D. E. Corbin / Californian Journal of Health Promotion 2006, Volume 4, Issue 4, 63-76


Author Information

Manoj Sharma, MBBS, CHES, Ph.D.*
Associate Professor, Health Promotion & Education
University of Cincinnati
526 Teachers College
PO Box 210002
Cincinnati, OH 45221-0002
Ph.: 513-556-3878
Fax.: 513-556-3898
E-Mail: manoj.sharma@uc.edu

David E. Corbin, Ph.D., FASHA
Professor, Health Education, Public Health, Women's
Studies, Gerontology
School of Health, Physical Education, & Recreation
University of Nebraska at Omaha
Omaha, NE 68182-0216
Ph.: 402-554-3237
Fax.: 402-554-3693
E-Mail: dcorbin@mail.unomaha.edu

* corresponding author


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M. Sharma & D. E. Corbin / Californian Journal of Health Promotion 2006, Volume 4, Issue 4, 63-76

Appendix A
Distribution of demographic variables by group at baseline (n=21)

Variable Categories
Yoga
Control
n
?2
p
Group
Group
(%)
(n=11)
(n=10)
(%)
(%)
Gender
Male
2 (18.2)
4 (40.0)
6 (28.6)
1.222 0.269

Female
9 (81.8)
6 (60.0)
15 (71.4)


Race
White/Caucasian American
9 (81.8) 8
(80.0) 17
(80.9) 1.348 0.510

African American
0 (0.0)
1 (10.0)
1 (4.8)



Other
2 (18.2)
1 (10.0)
3 (14.3)


Education
Less than high school
0 (0.0)
0 (0.0)
0 (0.0)
0.531 0.466

Completed high school
6 (54.5)
7 (70.0)
13 (62.0)


Completed
college
5 (45.5)
3 (30.0)
8 (38.0)


education or more
Any smoking cessation
No
5 (45.5)
5 (50.0)
10 (47.6)
0.043 0.835
effort

Yes
6 (54.5)
5 (50.0)
11 (52.4)


NRT
No
5 (45.5)
7 (70.0)
12 (57.1)
1.289 0.256

Yes
6 (54.5)
3 (30.0)
9 (42.9)


Stress management class
No
11 (100.0) 10 (100.0) 21 (100.0)

Bupropion or Zyban
No
8 (72.7)
8 (80.0)
16 (76.2)
0.153 0.696

Yes
3 (27.3)
2 (20.0)
5 (23.8)


Smoking cessation class
No
10 (90.9)
10 (100.0) 20 (95.2)
0.955 0.329

Yes
1 (9.1)
0 (0.0)
1 (4.8)


Fresh Start
No
11 (100.0) 10 (100.0) 21 (100.0)

Yoga
No
10 (90.9)
10 (100.0) 20 (95.2)
0.955 0.329

Yes
1 (9.1)
0 (0.0)
1 (4.8)




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Document Outline

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