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Outcome expectancy considering the use of alcohol

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Outcome expectancy considering the use of alcohol
Original article
Outcome expectancy considering the use of alcohol, cannabis and tobacco
Rosemeri Siqueira Pedroso*
Margareth da Silva Oliveira**
Renata Brasil Araujo***
Maria da Graça Castro****
Wilson Vieira Melo†
This article is based on the master’s thesis “Outcome expectancy considering the use of cannabis:
validation of the Marijuana Expectancy Questionnaire,” defended on March 1, 2005 as part of the
Graduation Program in Psychology – Master’s Degree in Clinical Psychology, Pontifícia
Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil.
* Psychologist, MSc. in Clinical Psychology, PUCRS, Porto Alegre, RS, Brazil.
** Psychologist, PhD in Health Sciences, Universidade Federal de São Paulo (UNIFESP), São
Paulo, SP, Brazil.
*** Psychologist, PhD in Psychology, PUCRS, Porto Alegre, RS, Brazil.
**** Psychiatrist, MSc. in Clinical Psychology, PUCRS, Porto Alegre, RS, Brazil.
† Psychologist, MSc. in Clinical Psychology, PUCRS, Porto Alegre, RS, Brazil.
Received May 14, 2005. Accepted July 3, 2006.
INTRODUCTION
Drug effect expectancies are essential for the development of drug abuse and dependence,
hence the importance of in-depth studies that comprehend different psychoactive substances.
Brown1 has analyzed the involvement of each expectancy in the process of changing a dependent
behavior, in an approach based on the following questions: 1. What is the drug effect expectancy?
2. How do expectancies relate to the development of addictive behavior? 3. How to incorporate
expectancies about drug effects, considering both intervention and prevention?
Cognitive or informational behavior is associated with what one “knows” or “expects” to
happen, as a result of a given behavior. On the other hand, motivational or encouraging behavior
comprehends the desire and reinforcement value of the expected result or effect. Positive outcome
expectancies may originate from the exposure to conditioning stimuli, associated with previous
expectancies about the drug, physical dependence, personal and cultural beliefs about the drug
effects and situational/environmental factors.2
Such expectancies about the use of psychoactive substances are important for the treatment
and prognosis of chemically dependent patients, being useful to study and relate them to different
drugs, samples and populations. Therefore, this paper aims at presenting a theoretical review about
the “outcome expectancy” construct considering the use of alcohol, cannabis and tobacco.
METHOD
We performed searches in the following electronic databases: MEDLINE, PsycINFO,
ProQuest, Ovid, LILACS and Cork, using the following descriptors: belief, expectancy, expectation,
drug, and effect.
2
Inclusion criteria
- Indexed articles, published from 1991 to 2005;
- Non-indexed articles, books, master’s theses and doctoral dissertations, as well as classical
articles about the theme, regardless of publication date.
Exclusion criteria
Articles that are not specifically about outcome expectancy considering the use of
psychoactive substances.
RESULTS
Outcome expectancy and dependent behavior
Marlatt & Gordon2 define outcome expectancy as cognitive, cultural and personal beliefs
about the effects of a given drug that lead the individual to engage in dependent behavior. Bandura3
has distinguished between two types of expectancy related to any form of behavior: efficacy
expectancies, which involve the ability to perform the behavior, and outcome expectancies, which
are related to what is expected as an outcome of such behavior. Both types of expectancies are
important to understand the recurrence process, since they may influence the performance of a
confrontation response: resisting a risk situation is more likely when outcomes resulting from such
resistance are related to long-term benefits.
With regard to drug use, outcome expectancies are expressed in different response systems:
physical effects (changes in sensations and feelings associated with the physiological effects of the
drug); psychological effects (cognition and altered emotional states); and behavioral effects
(changes in acts and manifest behavior).4
Marlatt & Rohsenow5 argue that few studies assess the individual’s preconceived
expectancies about alcohol and other drugs. Further studies about cessation of substance
3
consumption may assess attitudes before the beginning of this process, separating 1) expectancies
about effects and abstinence, and 2) symptoms themselves.6
Outcome expectancy and use of alcohol
Darkes et al.7 assessed the concept of expectancy based on the studies by Bolles8 and
Tolman,9 and reported that the empirical studies show a strong relationship between positive
expectancies to alcohol effects, which were measured using psychometric instruments, and
expectancies analyzed in self-reports by individuals who use this substance. These authors also state
that positive expectancies to the use of alcohol are predictive factors for the use of this substance
among adolescents and young adults, as well as for the reduction of consumption levels in such
individuals. Participants in the study by Darkes et al.10 had mean age of 18.38 years, and 42%
reported family history of alcoholism related to their biological father or mother. They also
confirmed using alcohol with frequency ranging from “rarely” to “18 times or more a week,” which
was measured through ingested and reported doses. The findings suggest that positive expectancies
may serve as a path to carry the effect of major predicting variables in order to determine alcohol
consumption. In this process, some possible antecedents, such as family history of alcoholism and
family environment, were eliminated because they did not present a significant correlation with the
variable alcohol consumption. Thus, positive outcome expectancies can be understood, in order to
assess a wide range of risks and factors that avoid or anticipate onset of alcohol consumption, which
may lead to a dependent behavior.
Aarons et al.11 compared outcome expectancies about alcohol and the amount and form of
its consumption. They developed alcohol expectancy models using a cognitive paradigm in which
expectancies are projected. The research was carried out at a major public university in the
American Southeast. A total of 927 college students, male and female, aged between 17-35 years,
participated in the study. Positive expectancies to alcohol use were associated with heavy
consumption of this substance in a high number of individuals, children of "problem-drinking"
4
parents, which might reveal the importance of family exposure to establish this type of belief in
severe alcoholics.
Alcohol-related positive expectancies may be assessed using the Alcohol Expectancy
Questionnaire, as well as other scales that assess this factor.12 In addition, alcohol-related
expectancies vary according to the complexity of risk factors, and should be interpreted using the
multifactorial model.13
According to Leigh & Stacy,14 it is likely that the relationship of outcome expectancy to
drinking will differ with age. These authors examined the prediction of drinking behavior from
positive and negative outcome expectancy at different ages. Data were collected from 2,875
subjects, male and female, aged 12 and older. They surveyed drinking habits, including questions
about frequency, minimum and maximum quantity, beliefs about the effects of alcohol and alcohol
expectancies. The relationship between positive and negative expectancy and the drinking behavior
was tested for different age groups. Outcome expectancy accounted for a larger portion of the
variance in drinking among younger respondents than among older respondents. When suppression
effects were considered, positive expectancy predicted drinking among respondents under 35 years,
whereas negative expectancy was a better predictor of drinking status in most respondents over 35
years. Among drinkers, positive expectancy related to suppression effects predominated over
negative expectancy, without a separation by age groups. These results suggest that negative
expectancy predicts abstinence, while positive expectancy predicts level of drinking among
drinkers.
In recent years, outcome expectancy has emerged as a key concept in psychosocial models
of alcohol use. The opinion about the effects of alcohol on behavior, modes and emotions correlated
with drinking in adolescents and adults has grown stronger.15 Consistency of such relationship in all
surveys carried out shows that these expectancies play a role in starting and maintaining an alcohol
addictive behavior.12,16-18 Decision about drinking is partly influenced by the expectancy that
alcohol will result in certain desirable consequences, such as reduction of tension, social and sexual
5
facilitation. The drinking behavior is then maintained by these positive expectancies about alcohol
effect, which, as the drinking experience, are accumulated through time. Therefore, it is likely that
positive expectancies to alcohol use will differ with age.14
Oliveira & Werlang19 developed the Brazilian version of the Inventory of Alcohol
Expectancies and Personal Beliefs (IECPA). They studied a sample of 502 subjects, male and
female, from the community, outpatient clinics and hospitals, aged between 16-74 years. The
authors applied the IECPA and observed that the heavier the drinking pattern, the higher the
expectancies about the use of alcohol, according to the scores in the following four groups: “does
not, or rarely, drink,” “does not drink more than 80 g of alcohol,” “systematically drinks more than
80 g of absolute alcohol,” “systematically drinks more than 80 g of alcohol and has been submitted
to or is undergoing treatment.”
The most used instrument to measure adolescent and adult expectancies is the Alcohol
Expectancy Questionnaire (AEQ), which has separate versions for adolescents and adults. The adult
version of the AEQ only measures positive expectancies; on the other hand, the adolescent version
includes items that measure negative effects.14
There is more than one theory trying to explain the drinking behavior. According to Oei &
Morawska,20 the theory of alcohol positive expectancy spawns from the theory of social learning,
which presumes that cognitive activities, such as anticipation, expectancy and memory about the
history of alcohol use, shape and may determine the dependent behavior.21 Another theory
presupposes that behaviors and expectancies by young alcohol dependents are mainly determined
by social influences of culture, family, and partners. It should be stressed that even the
predisposition of individual factors will suffer the influence of such social agents. The concept of
alcohol expectancies originates from studies that indicate that alcohol effects are not associated only
with physiological factors, but to cognitive factors, as a consequence of beliefs and opinions about
the effects of this substance. For example, individuals who are given a placebo believe that they
drank alcohol and behave according to their expectancies about its effect.5
6
The AEQ assesses the opinion about the effects of alcohol on several aspects of behavior
and cognition.15 Although Bandura3 proposed the distinction between outcome expectancy and selfefficacy expectancy more than two decades ago, most researches have focused only on outcome
expectancies, which indicates these are the most important predictors of alcohol consumption.20,22,23
The effect of expectancies on drinking behavior is based on the information about alcohol
and its effects, acquired during childhood and adolescence and stored in the long-term memory, in
the shape of a semantic network.10 Once these expectancies are established, they guide the behavior
when exposed to alcohol, so that an individual may produce the predicted effects when alcohol is
used. Thus, the individual’s opinion about the power of alcohol may change more the behavior
associated with the use of this substance than physiological actions themselves.12 The automatic
processing of consequences of alcohol use determines the choice for using the drug, as well as the
behaviors subsequent to this consumption. As a consequence, when alcohol is used, expectancies
are confirmed. The environmental contingencies and the real physiological effects of drinking
reinforce outcome expectancies about alcohol effects, which makes the maintenance of drinking
dependent on these expectancies, which are being confirmed or not.20,23
Positive expectancies are generally better predictors of alcohol consumption for adolescents
than for adults. This might reflect the meaning of expectancies to behavior, which vary according to
age.12
Expectancies about social and physical pleasures have been associated with individuals who
used to drink socially. They have reported the expectancy that alcohol would reduce tension.1
Women generally present positive outcome expectancy, in a more global manner, whereas men
focus on sexual facilitation. However, both genders seem to strongly endorse social expectancies.20
Outcome expectancy and use of cannabis
Schafer & Brown24 have applied the Marijuana Expectancy Effect Questionnaire (MEEQ) to
704 students from two universities in the south of California. Around 62% of the sample was
7
composed of women, and mean age was 19.23 years (SD = 3.42), range 17-54 years. As to the use
of substances, 295 students (42%) reported using cannabis, seven times a month in average (SD =
8.16). The MEEQ was applied for the whole group, along with a record containing
sociodemographic data and the usual consumption of the drug. In this MEEQ validation, the
psychometric properties found were satisfactory, indicating that the instrument was appropriate for
assessing beliefs about the use of cannabis.
Aarons et al.25 have assessed the psychometric properties of the MEEQ, in a longitudinal
study, by using a clinical and non-clinical sample of adolescents. They confirmed the MEEQ as a
reliable scale for adolescents (15-19 years). Internal consistency was good and similar to the
findings by Schafer & Brown,26 when they validated the MEEQ with a sample of adults. The
test/retest reliability coefficient, after 2 years, was moderate, revealing the notion that expectancies
are usually stable, and may fluctuate according to changes in social context and learning about the
social and pharmacological effects of the drug.
Adolescents with higher expectancies for cognitive/behavioral impairment and negative
global effects presented lower probability of using cannabis, after 2 years of study. This suggests
that such expectancies may prevent adolescents from using cannabis.26
In general, higher scores in negative expectancy scales and higher expectancies for
cognitive/behavioral impairment and negative global effects were associated with cessation of
cannabis use, whereas lower negative expectancies and lower expectancies for cognitive/behavioral
impairment and negative effects were associated with continuous use of this substance.
Findings by Aarons et al.21 correlate low expectancies for cognitive/behavioral impairment
and other negative effects with a higher probability of getting involved with the substance.
However, these data may suggest the search for a strategic potential for the prevention of the
development and sequential progress of cannabis use, as negative expectancies about the use of
substances start being developed and reinforced, to the detriment of positive expectancies.
8
Galen & Henderson27 validated the MEEQ24 in a study with a clinical population, whose
sample consisted of 149 males, aged between 23-59 years, hospitalized for treatment at an inpatient
substance abuse unit (21-28 days). Nonusers of cannabis presented higher negative expectancies
than users. With regard to expectancies for greater relaxation and craving effects, users presented
higher scores than nonusers or those who quit using cannabis. Findings also suggest a change in the
theory that presents negative expectancies as factors able to avoid the onset of drug use in nonusers,
since this study showed that users present lower negative global expectancies when compared to
nonusers.
Researches have shown that domains of expectancies related to the use of cannabis are
similar to those related to alcohol.28 These authors modeled a semantic network of cannabis
expectancies stored in memory, by using a methodology based on the study of alcohol expectancies.
They mapped expectancies into memory network format and preference, aiming to model likely
paths of expectancy activation. The instrument used to assess expectancies considering the use of
cannabis, the Memory Model-Based Marijuana Expectancy Questionnaire (MMBMEQ), was
created by the authors and applied to two groups. Group 1 consisted of 172 subjects, 105 women
and 67 men, aged between 17-47 years (mean of 20.97 years), volunteers, psychology students,
whose consumption of cannabis varied from “no use” to “daily use.” There were 54 impersonal
items, which participants could answer even if they had never tried the drug before. Group 2
consisted of 754 volunteers, 539 women and 215 men, aged between 17-50 years (mean of 20.99
years), whose consumption of cannabis should have occurred at least once in their lives, since the
participants answered according to their experience after smoking cannabis. Guarantee of secrecy,
anonymity and the ethical principles of the research facilitated the responses given by this group.
Organization and activation of cannabis expectancies were found to vary with consumption level.
Heavy cannabis consumers presented expectancies for relaxing and being less agitated, and were
most likely to activate positive expectancies of relaxation, cognitive enhancement, and social
facilitation. Nonconsumers, however, emphasized a detached-aware dimension and were more
9
likely to activate negative expectancies of cognitive performance and social facilitation. According
to these authors, further efforts, using such standard tests of likely activation patterns of outcome
expectancy, may be successful in assessing change in behavior regarding the use or onset of
cannabis use.
A brief version of the 70 items in the MEEQ was developed to be used among hospitalized
adolescents. A single item was created to represent each of the six subscales of the original
instrument. About 124 adolescents answered the brief version of the instrument (MEEQ-B).
Psychometric analyses suggested that the MEEQ-B had two factors: one with 29% of response
variation, about positive expectancies, and another one with 23% of response variation, for negative
expectancies. In addition, internal consistencies of each factor were 61 and 38%, respectively. This
study concluded that the researchers must continue to use the longer version of the instrument, but
that the brief version may be useful as a clinical instrument, to raise discussions about cannabis
expectancies.29
Stein et al.30 assessed the implications of cannabis use among adolescents undergoing
treatment. Eight-two adolescents participated in the randomized study. They had high rates of
alcohol, cannabis, and tobacco use. Cannabis and tobacco use was associated with high rates of
depressive symptoms. With regard to expectancies about the use of such drugs, adolescents
generally did not expect alcohol to have a great impact on their lives, except concerning increase in
courage, and the adolescents felt confident about their ability to resist alcohol. Nevertheless, the
adolescents expected cannabis to have a greater positive impact and a very small negative impact on
their lives. They were not confident about their abilities to resist cannabis, although many showed
interest in making changes with this respect.
Pedroso et al.31 validated the Marijuana Expectancy Questionnaire (MEQ) – Brazilian
Adaptation. The convenience sample consisted of 400 subjects, men (n = 217) and women (n =
183), aged between 12-60 years (mean = 25.41; SD = 9.42), cannabis users (n = 147) and nonusers
(n = 253). Among the users, 90 were dependent on cannabis; of these, 56 were hospitalized. For the
10
semantic validation, the researchers used a committee of experts and brainstorming. The study
presented α = 0.89 for the 78-item scale, and α = 0.89 for the reduced 55-item scale. In this
Brazilian sample, all 78 items were applied, but the statistical analysis was based on the reduced
scale, since the psychometric properties were similar. Discriminant validity for the reduced scale
was statistically significant (p = 0.001). Temporal stability was examined in a sample of 123
subjects, with a 1-week interval between test and retest, indicating a consistent response standard
through time (r = 0.990). The MEQ – Brazilian Adaptation presented good psychometric results and
was able to assess outcome expectancy related to cannabis use.
Outcome expectancy and use of tobacco
Gilbert & Warburton,6 in a survey with smokers, found results that suggest that negative
beliefs about tobacco use have an association with abstinence, whereas beliefs in pleasant effects
are related to the consumption of this substance. The classical theory of substance removal implies
that the negative effects of abstinence are universal and inevitable due to the pharmacological effect
of nicotine withdrawal. These effects will interfere in expectancies related to tobacco use and,
consequently, in the consumption of this drug. The researchers concluded that cognitive therapy
techniques may encourage patients to change their expectancies by focusing on positive outcome of
cessation, in order to make permanent changes in their lifestyle.
DISCUSSION
Despite the limitations in terms of studies that associate outcome expectancies and addictive
behavior, results found in the reviewed literature show that the domains of outcome expectancy
about the use of several psychoactive substances are similar.28 Nevertheless, this study showed that
it is important to develop and validate instruments to specifically measure outcome expectancies
related to the use of different psychoactive substances, since there is evidence that subjective and
behavioral effects of drugs are influenced by expectancies.31
11
Beliefs have been studied as indicators of people’s feelings about their expectancies and
how much this is connected to effects caused by drug use. It is necessary to know how beliefs are
acquired and maintained, in order to understand how they can be changed.32
Outcome expectancy may be understood as cognitive representations of direct and vicarious
learning that create a memory network, which can be activated by drug-related factors. Outcome
expectancies are activated and trigger the voluntary addictive behavior, in which subjects decide to
use the substance when their psychological reactions anticipate the compensation for using the
drug.4
After reviewing the literature, expectancies were seen to serve as a path to carry the effect of
major predicting variables in order to determine alcohol consumption.7 Positive expectancies about
alcohol use are associated with heavy consumption of this substance among individuals with
"problem-drinking" parents, which reveals the importance of family exposure in severe alcoholics.
Empirical researches show that expectancies play a role in the onset and maintenance of an alcoholdependent behavior.11,15,18
This study shows that expectancies about alcohol can maintain drinking behavior, as an
attempt to achieve desired outcomes. Since expectancies about alcohol effects, as well as the
drinking experience, are accumulated through time, it is likely that outcome expectancies to alcohol
use will differ with age.12,16-18
With regard to individuals who drink socially, outcome expectancies to alcohol use are
associated with social and physical pleasure, and the desired effect is related to tension reduction.1
As to gender and its relationship with expectancies to alcohol use, men and women endorse social
expectancies, but women present more positive outcome expectancies in a global functioning sense,
whereas men focus on social and sexual facilitation.20
With regard to tobacco use, expectancies are associated with the pleasure of smoking. There
are variations between individuals, but with similarities in this process. Individuals with more
negative experiences are likely to attribute them to nicotine abstinence. Emphasis on positive
12
outcomes of abstinence may be treated using cognitive therapy, with the aim of changing
expectancies, focusing on positive outcomes of cessation.6
Researches about the construction and role of outcome expectancies for the development of
substance abuse are thought to increment cognitive and behavioral strategies that aid changing such
beliefs and their meanings, thus facilitating change in dependent behavior. However, the articles
found in surveyed databases did not focus on applicability of expectancies in the prevention and
change of addictive behavior. Further studies are needed to complement current findings. Validation
of instruments to measure outcome expectancies related to the use of psychoactive substances is
only the beginning of a process that may help preventing the development and sequential progress
of the use of psychoactive substances. These strategies should include education about negative
effects associated with drug use, as well as reinforce negative expectancies associated with them.
CONCLUSIONS
Studying about the outcome expectancy construct related to the use of psychoactive
substances revealed the need of further researches approaching this theme, using different samples
and types of drugs. Alcohol related to outcome expectancies is the most studied theme. Since it is a
theme that still needs more attention in researches, our search for specific articles in the databases
only showed three articles about outcome expectancies related to cannabis use and two articles
related to tobacco use; no articles about the use of other psychoactive substances were found.
Data from the literature showed that outcome expectancies are determined by what people
believe about the effects of a given drug. The effects of psychoactive substances as shown in the
media make these people interact with such information, watching and learning behaviors based on
beliefs in positive or negative outcomes.
Real effects of drug use do not always correspond to desired effects. Therefore, individual
expectancies are the product between the real effect and the desired effect with regard to the
13
consumption of each substance. Thus, in a recurrence process, positive outcome expectancies may
be more relevant than impairments resulting from drug use.
The concept of outcome expectancies related to cannabis use is similar to the concepts found
in relation to other drugs, such as alcohol and tobacco, although researches show the importance of
studying the specific peculiarities of each drug.
There is still the need of characterizing the outcome expectancy construct considering use of
psychoactive substances, diversifying samples and using specific subjects: adolescents, adults, men,
and women.
In this study, we included articles indexed in the databases available on the Internet, which
contained the descriptors mentioned in the methodology. However, no contact was made with the
respective authors, in order to know whether there were other non-indexed articles about the
outcome expectancy construct. It is believed that, at another occasion, a systematic review can be
carried out. This methodological process could bring an in-depth understanding of the theme under
investigation.
Nevertheless, clinical practice and the articles reviewed for this research show that outcome
expectancies influence onset and maintenance of dependent behavior. However, the practical and
ethical value of knowing about the outcome expectancy construct related to the use of psychoactive
substances still has a long path ahead considering prophylactic measures needed to the growing
drug use, as well as to the treatment of chemical dependency.
Acknowledgments
To the National Counsel of Technological and Scientific Development (CNPq).
14
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ABSTRACT
This article aims to perform a theoretical review about the outcome expectancy construct
considering the use of alcohol, cannabis and tobacco. Outcome expectancy is determined by
people’s belief about the effects of a drug. It is an important variable for the treatment of
17
chemically dependent patients. Searches in the electronic databases MEDLINE, PsycINFO,
ProQuest, Ovid, LILACS and Cork were carried out, using the following descriptors: belief,
expectancy, expectation, drugs, psychoactive, and effect. Results showed that outcome expectancy
considering the use of those substances can be generated from: exposure to conditioning stimuli,
physical dependence, personal and cultural beliefs, and situational and environmental factors. In
conclusion, there is the need of new researches on expectancies related to psychoactive substances
and age groups in order to have a better understanding of this construct.
Key words: Outcome expectancy, alcohol, cannabis, tobacco.
Title: Outcome expectancy considering the use of alcohol, cannabis and tobacco
Correspondence:
Rosemeri Siqueira Pedroso
Av. Azenha, 165/305 – Bairro Azenha
CEP 90160-000 – Porto Alegre, RS – Brazil
E-mail: [email protected]
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