quitting smoking now or later: gradual, abrupt, immediate, and delayed quitting

BEHAVIOR Tr;ERAPY 9, 260--270 (1978)

Quitting Smoking Now or Later: Gradual, Abrupt, Immediate,

and Delayed Quitting

JUDITH FLAXMAN

University of North Carolina

This study evaluated gradual versus abrupt smoking cessation techniques, the value of delaying the smoking quit date, and the use of aversive conditioning by means of warm, smoky air and rapid smoking until satiation. Target date quitting was significantly more effective than gradual quitting. Delaying the quit date was more effective than quitting smoking immediately for women, but less effective for men.

Previous research is equivocal about whether it is best to quit smoking at the beginning of treatment or after some time has elapsed and whether gradual or abrupt quitting is preferable. Best and Steffy (1971) found that quitting smoking after 3 weeks of treatment was, at least temporarily, more effective than quitting smoking immediately. However, they con- founded the amount of aversive conditioning subjects received with the amount of time subjects spent in treatment prior to quitting smoking. Gradual quitting has been unsuccessful in several studies (e,g., Bernard & Efran, 1972; Gutmann & Marston, 1967; Sachs, Bean, & Morrow, 1970; Upper & Meredith, Note 1), but has not been directly compared to abrupt quitting. The present study compared gradual quitting to abrupt, immediate quitting and to abrupt quitting on a target date occurring 2 weeks after the beginning of treatment. The gradual quitting technique used was Gutmann and Marston's (1967) stimulus hierarchy approach. This tech-

This paper is based on a dissertation submitted to the Department of Psychology, North- western University, in partial fulfillment of the requirements for the Ph.D. and was sup- ported in part by Mental Health Grant No. MH20751. The author would like to thank her dissertation committee chairman, Richard R. Bootzin, and the members of her dissertation committee, C. Peter Herman, Camille B. Wortman, and Winfred Hill. Special appreciation is extended to Jay Lebow, Bobbi Harada, Lawrence Panciera, John Hibscher, and Edward Michaels, who served as experimenters in this study. Requests for reprints should be sent to Judith Flaxman, Department of Psychology, University of North Carolina, 244 Davie Hall, Chapel Hill, NC 27514.

260 0005-7894/78/0092-0260501.00/0 Copyright (g~ 1978 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

QUITTING SMOKING NOW OR LATER 261

nique attempts to narrow stimulus control over smoking by eliminating it gradually, situation by situation, until no situations remain in which smoking is allowed. A modification of the stimulus hierarchy technique, which was a compromise between gradual and abrupt quitting, was also tested.

The present study also compared aversive conditioning, initiated on the day subjects were to quit smoking, with an attention control treatment. Aversive conditioning was carried out using Lublin and Joslyn's (Note 2) warm, smoky air and rapid smoking technique, a procedure which has yielded 6-month follow-up success rates of 60% or better (Lichtenstein, Harris, Birchler, Wahl, & Schmahl, 1973; Schmahl, Lichtenstein, & Har- ris, 1972). The comparison between aversive conditioning and the attention control group was of particular interest because it tested alternatives to smoking (in the form of self-control techniques) combined with a technique to suppress smoking (aversive conditioning) against the use of the alternatives to smoking alone (in the attention control groups).

METHOD

Design Sixty-four subjects were blocked by sex and number of cigarettes smoked per day and

randomly assigned to one of the eight treatment cells ~ and to two of the six experimenters. 2 Treatment was divided into two phases: Phase I was the time in treatment prior to the subject 's quit date when the self-control techniques were taught. Phase 2 ran from the quit date to the end of treatment. An immediate quit treatment and three delayed quit treatments, gradual, partially gradual, and target date, were studied in Phase 1. Aversive conditioning and an attention control treatment were compared in Phase 2. The four Phase 1 treatments were completely crossed with the two Phase 2 treatments. Thus, half the subjects from each Phase 1 group received aversive conditioning and half received the attention control treatment,

Subjects and Experimenters Subjects were recruited by means of public service announcements in the community.

Their mean reported baseline smoking rate was 26 cigarettes per day, and their mean years smoked was 20.3. Past history of abstinence from smoking averaged 5 months, with a median of I month. Number of previous quit attempts ranged from none to " d o z e n s " with a

Departure from random assignment was made to give four married couples and two friends the same treatment. These subjects were evenly distributed across cells.

2 The four Phase 1 experimenters worked with one male and one female in each treatment condition, totaling 16 subjects each, although an error in assignment disrupted this plan by one subject. The three Phase 2 experimenters worked with 35, 16, and 13 subjects each. Each Phase 2 experimenter worked with an approximately equal number of males and females and of aversive conditioning and attention control group subjects. Although the investigator worked with subjects in both phases of treatment, she never worked with the same subject in both phases of treatment. Fifty subjects were seen by one male and one female experimenter. The remaining 14 subjects were distributed across all cells with between two and four subjects in each cell seeing two experimenters who were the same sex.

262 JUDITH FLAXMAN

mean of three. Twenty-two subjects who failed to return after the orientation session Iprior to being assigned to treatmentl were immediately replaced in the design.

Four male and two female psychology graduate students (five of whom had never smoked) served as experimenters. The one experimenter who was a smoker worked with subjects in Phase 1 of treatment only and concealed his smoking status from subjects.

Orientation Session

Subjects were supplied with general information about the program and given the following tests: Why Do You Smoke? (Horn, 1969), a motivation measure (Keutzer, 1967), the California Personality Inventory Self-Acceptance and Self-Control Scales (Gough, 1956), The Minnesota Multiphasic Personality Inventory Ego Strength Scale, and The Repression-Sensitization Scale IByrne. 1961), Subjects were instructed to smoke normally, record each cigarette smoked, and return the following week with a $20 refundable data deposit.

Phase 1 Treatment Conditions

During Phase I, subjects monitored their smoking and met individually with their Phase I experimenter twice a week for 0.5-hr sessions (except in the immediate quit condition).

Self-control techniques presented to all subjects included: the use of stimulus change and the introduction of novel stimuli into daily activities (Goldiamond, 1%5); a 0.5-hr taped session of muscle relaxation (Jacobson, 1929); thought-stopping (Cautela, 1970): worry beads (Chapman, Smith, & Layden, 1971); a new hobby (Ober, 1968); a public commitment procedure which involved talking to friends about quitting smoking and having five friends or relatives receive letters requesting social support (cf. Elliot & Tighe, 1968); self- reinforcement (Mahoney, Moura, & Wade, 1973); and emphatic rehearsal of reasons for quitting smoking (Skinner, 1953). American Cancer Society literature was made available.

The following Phase 1 treatments were used: Gradual. Following Gutmann and Marston's (1967) stimulus hierarchy technique, situa-

tions leading to smoking were categorized and rank ordered according to anticipated dil~fi- culty of not smoking in each. Subjects were instructed to give up cigarettes in the stimulus situation ranked as easiest, progressing cumulatively up to the hardest, by adding one situation every 3 days.

Partially gradual. Subjects initially followed the same procedure as gradual subjects but quit smoking abruptly when their smoking rates dropped to one half of their base rates.

Target date. A date, approximately 2 weeks from the first session, was selected for abrupt quitting. '~ Phase I was described as a time to "mentally prepare" to quit smoking and practice the self-control procedures.

Immediate. All self-control information was presented to subjects in this group in a single 1.5-hr session. They were scheduled to quit smoking and begin aversive conditioning or attention control sessions the next day.

Phase 2 Treatment Conditions

Subjects first met with their Phase 2 experimenter on their quit day and continued to meet for at least the next 2 days. The number of additional sessions was determined by subjects" ability to control their smoking. Sessions were intended to provide reinforcement for not smoking and for using self-control techniques. If a subject had smoked, discussion focused

Some flexibility was allowed in the choice of a target date in order to permit subjects to quit smoking on the day of the week when external pressure to smoke was likely to be lowest and support for nonsmoking highest.


on the development of self-control activities for use in problem situations. Phone contact and impromptu treatment sessions were offered.

Aversive conditioning. Subjects in this group received warm, smoky air and rapid smoking trials at each Phase 2 session, in addition to the procedures described above. Subjects sat in front of the warm, smoky air machine (a hair dryer with its hose connected to a chamber containing several lit cigarettes, set up so that smoke was blown into an open box facing the subject) and smoked their own brand of cigarettes, inhaling every 6 sec. Subjects were encouraged to continue smoking in front of the machine for as long as possible, with additional lit cigarettes handed to them if necessary. They were instructed to stop when they could smoke no longer, thus ending a trial.

Follow-up Subjects mailed in postcards containing daily cigarette counts (or zeros) each week for 2

months. The eight subjects who failed to return all postcards were contacted by telephone. At the end of 6 months, an assistant, unknown to subjects, telephoned them for reports on their current smoking status. Follow-up data were obtained from all subjects. The impor- tance of honesty in reporting smoking data was emphasized. No validity checks were obtained.

RESULTS

Preliminary Analysis

A n a n a l y s i s o f v a r i a n c e s h o w e d no s ign i f i can t d i f f e r e n c e s b e t w e e n

t r e a t m e n t g r o u p s on p r e t r e a t m e n t s m o k i n g r a t e s o r b e t w e e n e x p e r i m e n -

t e r s on s u b j e c t s ' 6 - m o n t h f o l l o w - u p s m o k i n g ra t e s . S u b s e q u e n t a n a l y s e s

c o l l a p s e d d a t a a c r o s s e x p e r i m e n t e r s .

Process Measures

T a b l e I p r e s e n t s t he m e a n n u m b e r o f s e s s i o n s and the t i m e s p e n t in

P h a s e 1, t he c h a n g e in s m o k i n g r a t e p r i o r to t h e qu i t da t e , and the

r e p o r t e d use o f s e l f - c o n t r o l t e c h n i q u e s fo r e a c h g r o u p . A t w o - f a c t o r

a n a l y s i s o f v a r i a n c e ( t r e a t m e n t c o n d i t i o n a n d t i m e as a r e p e a t e d m e a s u r e )

r e v e a l e d tha t s m o k i n g r a t e s d r o p p e d s ign i f i can t ly f r o m t h e first h a l f o f

TABLE 1 PROCESS MEASURES

Self-control techniques t'

Number of Days spent Change in Aversive Attention Treatment group sessions in Phase I smoking rate" conditioning control

Gradual 4.6 20.4 -6.0 2.0 1.9 Partially gradual 4.6 15.9 -3.5 2.4 1.8 Target date 4.0 13.8 -3.4 2.3 3.2 Immediate 1.0 1.3 1.6 1.7

" Mean change in cigarettes per day, per subject, from first to second half of Phase 1. ~' Mean number of techniques reported used per subject, per Phase 2 session.

264 JUDITH FLAXMAN

Phase 1 to the second (prior to the quit da t e ) ,F (I , 31) = 17.98, p < .001. The analysis revealed no main effect of treatment condition or interaction between time and treatment. An analysis of variance using planned comparisons on treatment groups revealed that subjects in the six delayed quit groups reported significantly more use of self-control techniques than subjects in the two immediate quit groups, F (l , 56) = 4.89, p < .03.

Phase 2 of treatment involved a mean of 3.8 sessions over a period of 6.2 days for aversive conditioning and 4.2 sessions over 10.6 days for attention control subjects. One aversive conditioning subject and one attention control subject failed to complete the 3-day minimum. Thirty- two subjects smoked during Phase 2:16 in the aversive conditioning group and 16 in the attention control group. Table 2 shows how various parame- ters of aversive conditioning in the present study compare to two other studies.

Outcome Measures

Figure I presents mean daily post- t reatment smoking rates by treatment group and sex at each follow-up time (Weeks 1 through 8, and 6 months).

Smoking rates were analyzed using a repeated measures three-factor analysis of variance (subject sex, treatment condition, and time), Seven orthogonal contrasts were made between treatment conditions to evaluate the s tudy 's specific hypotheses (Table 3). No main effect of sex was found. A main effect of time indicated that smoking rates rose significantly during the follow-up period, F (8, 384) = 22.26, p < .001.

Contrast l tested the two immediate quit t reatments against the six delayed quit treatments. Contrast I was significant as an interaction with time, F (8,384) = 2.19, p < .05. Thus, over time, delayed quit subjects smoked significantly less than immediate quit subjects. Contrast 1 also interacted with sex. While delayed quitting was preferable for women, immediate quitting was preferable for men, F (I , 48) = 14.27, p < .01. A

TABLE 2 MEAN VALUES OF AVERSIVE CONDITIONING PROCESS

MEASURES FOR THREE STUDIES

Lichtenstein Schmahl et Measure Present study et al. (1973)" al. (1972)"

Number of sessions 3.8 7.5 8.0 Trials per session 1.8 2.2 2.2 Trial length (sec) 34 186 234 Aversion rating ~' 8.1 7.7 8.9

" Adapted to compare to the present study. /, On a IO-point scale with 10 indicating the most aversiveness.

QUITTING SMOKING N O W OR LATER 265

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C O ~ cb H co~

o

>-- c:~ (1Zoo CY3

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FIG. 1.

RVERSIVE MRLES

1 1 1 1 1 1 1 1 [ ] ~ADUAL

PARTIALLY GRADUAL X TARGET DATE

IMMEDIATE

CONDITIONING FEMALES

I I I I I I I I

ATTENTION CONTROL MRLES

I I I I I I I I

1 2 3 ~ 5 6 7 8 6 WEEK MO

FEMALES I I I I t I I I

1 2 3 ~ 5 6 7 8 6 WEEK MO

Mean follow-up smoking rates by treatment condition and sex.

TABLE 3 P L A N N E D C O M P A R I S O N S U S E D IN A N A L Y S I S O F V A R I A N C E

Treatment groups

Partially Target Gradual gradual date Immediate

Aversive conditioning 1 3 5 7 Attention control 2 4 6 8

Planned comparisons Groups tested

(1) Delayed vs immediate (2) Gradual, partially gradual vs target date (3) Gradual vs partially gradual (4) Gradual: aversive conditioning vs

attention control (5) Partially gradual: aversive conditioning

vs attention control (6) Target date: aversive conditioning vs

attention control (7) Immediate: aversive conditioning vs

attention contro~

1-6 vs 7,8 1-4 vs 5,6 1,2 vs 3,4

l v s 2

3 v s 4

5 v s 6

7 v s 8

2 6 6 JUDIT H F L A X M A N

Newman-Keuls test showed that the smoking rates of women in the delayed quit groups and men in the immediate quit groups were significantly lower than the smoking rates of women who quit smoking immediately and men whose quit dates were delayed (/9 < .05 for all three comparisons), with no differences within each of these pairs of means.

Contrast 2 compared the gradual and partially gradual groups to the target date groups. Subjects in the target date groups smoked significantly less than subjects in the gradual and partially gradual groups after treatment, F (I, 48) = 5.28, p < .05. Contrast 3 compared the gradual to the partially gradual group and found no difference between them.

The remaining four orthogonal contrasts were comparisons between the aversive conditioning and the attention control groups within each of the four Phase 1 conditions. The aversive conditioning treatment was significantly more effective than its control only in the partially gradual group (Contrast 5), where a significant main effect, F (1, 48) = 11.85, p < .01, and a significant interaction with time, F (8, 384) = 1.95, p < .05, were found.

Phase 2 treatment interacted with sex in some comparisons. In gradual quit (Contrast 4), sex interacted with Phase 2 treatment, F (8,384) = 2.69, p < .01, such that aversive conditioning helped men and hindered women in their attempts to quit smoking. In immediate quit (Contrast 7), a similar but not significant pattern of results appeared, F (1,48) = 3.28, p < . 10.

The number of abstinent subjects in each treatment condition at the first week and sixth month of the follow-up period is shown in Table 4. The X 2 analyses revealed that while Phase 1 treatment groups did not differ significantly at the I-week follow-up, they contained significantly different

T AB L E 4 NUMBER OF ABSTINENT SUBJECTS DURING FOLLOW-UP

First week Sixth month

Group Males Females Males Females

Aversive conditioning Gradual 3 2 Partially gradual 2 4 Target date 3 3 Immediate 3 I

Attention control Gradual 0 4 Partially gradual 0 0 Target date 3 3 Immediate 2 0

1 2 1 2 3 2 2 0

0 3 0 0 2 2 0 0

Note. n = 4 males and 4 females in each group.


numbers of abstinent subjects at the 6-month follow-up (p < .05). Phase 2 groups differed significantly at the l-week follow-up (p < .05) but not at the 6-month follow-up. A significant return to smoking occurred during the follow-up period (p < .01). No sex differences were found.

Supplementary Analyses

Two additional analyses were performed to examine overall effects not included in the planned comparisons analysis. Women's mean smoking rate in the aversive conditioning groups was 8.2 and their smoking rate in the attention control groups was 7.3. Men had mean smoking rates of 6.0 in aversive conditioning and 16.6 in the attention control groups. A three-factor analysis of variance (Phase 2 treatment, sex, and time as a repeated measure) failed to find a significant main effect of Phase 2 treatment. A nonsignificant tendency toward an interaction between Phase 2 treatment and sex once again appeared, F ( i , 60) = 3.74,p < . 10. A two-factor analysis of variance (subject sex and treatment condition) using planned comparisons on 6-month smoking rates, instead of repeated measures, revealed that delayed quit subjects smoked less than immediate quit subjects, F ( i , 52), = 5.12, p < .03. No other effects reached significance in this analysis.

Individual Difference Measures

Available smoking history and personality test data were used to com- pute 19 F tests (df = I) comparing men and women. No significant sex differences were found in pretreatment smoking rates, years of Smoking, number of previous attempts to quit smoking, or past success at quitting smoking. On Horn ' s (1969) inventory identifying six types of smoker, men were more likely to smoke for stimulation than women, F (1,62) = 5.82, p < .05 (mean = 8.1 for men, 6.5 for women on a 3-15 scale). A tendency was found for women to rely more heavily on smoking for tension reduction than did men, F (1, 62) = 3.08,p < . 10 (mean = 1 !.4 for men, 12.5 for women on a 0-16 scale). No sex difference was obtained in motivation to quit smoking, as measured by Keutzer 's (1967) Effective Cognitive Dis- sonance Scale. On personality measures, men obtained higher scores on the California Personality Inventory Self-Acceptance Scale (Gough, 1956), F (1,62) = 9.67,p < .005 (mean = 22.1 for men, 19.3 for women), and the Minnesota Multiphasic Personality Inventory Ego Strength Scale, F (1, 62) = 5.44,p < .05 (mean = 22.6 for men, 20.5 for women). Women obtained higher scores than men, however, on the California Personality Inventory Self-Control Scale, F (1,62) = 9.85, p < .005 (mean = 26.0 for men, 30.5 for women).

268 JUDITH FLAXMAN

DISCUSSION

Subjects who spent 2 weeks in treatment prior to quitting smoking maintained their lowered smoking rates during the follow-up period better than subjects who quit immediately. Delayed quitting subjects also reported using more self-control techniques than subjects who were instructed to quit smoking immediately. The finding that delayed quitting is superior to immediate must be qualified by the interaction between time in treatment and sex. While spending time in treatment prior to quitting smoking was beneficial for women, it was detrimental to men. Individuals obtaining high Self-Acceptance and Ego Strength scores (scales on which men scored significantly higher than women) may profit most from an approach like immediate quitting which requires self-reliance. Best's (1975) study which found that the impact an attitude change manipulation had on smokers depended upon their initial level of motivation supports the present results.

Among the delayed quit subjects, those assigned to quit on a target date were significantly more successful than those using either of the two forms of gradual quitting. This finding fails to provide unequivocal evi- dence for the value of abrupt over gradual quitting, however, because self-reports of smoking rates during treatment indicated that subjects in all of the delayed quitting groups cut down on their smoking prior to quitting entirely. This finding does suggest that cutting down according to one's own schedule is preferable to having the decrease in smoking scheduled externally, at least by means of the stimulus hierarchy method used here. A similar outcome using a timer technique for gradual decrease has been reported by Bernard and Efran (1972), who found that subjects scheduled to use a timer to reduce their smoking were ultimately more successful than subjects using the timer to eliminate smoking. Further research is required to determine whether self-scheduling within the structure of target date quitting is preferable to the external scheduling provided by gradual quitting techniques.

With respect to aversive conditioning, the present study failed to rep- licate the success reported by Lichtenstein and his associates (Lichten- stein et al., 1973; Schmahl et al., 1972). Although aversive conditioning subjects had higher abstinence rates than attention control subjects at the beginning of the follow-up period, the two groups did not differ at the 6-month follow-up. Several procedural differences between the present and previous studies (e.g., the delay in instituting aversive conditioning in all but the immediate quit group, the combination of aversive conditioning with self-control techniques, the shorter duration of the trials, and the use of fewer aversive conditioning sessions) may account for the failure of aversive conditioning here. The hypothesis that a combination of aversive


conditioning techniques to suppress smoking and self-control techniques to teach alternative behaviors would be particularly effective failed to obtain support. Sex differences in the effect of aversive conditioning are noteworthy. In the gradual quitting condition men achieved less success than women without aversive conditioning and more success than women with it. This suggests that attention might profitably focus on interactions between particular treatments and subject variables.

The value of the present study as a demonstration of the absolute success of a smoking modification program is limited, a significant return to smoking occurred during the follow-up period, and conclusions are based on uncorroborated self-report follow-up data. When treatment groups are compared, however, several conclusions can be drawn about aspects of the treatment package. First, the timing of the attempt to quit smoking, a largely neglected variable, may be important, especially as it interacts with subject characteristics, such as sex. Second, further explo- ration of target date quitting, both in combination with self-control techniques and alone, is required. Third, self-scheduling of quitting and the interaction between subject variables and aversive conditioning deserve further investigation.

REFERENCE NOTES 1. Upper, D., & Meredith, L. A timed-interval procedure for modifying cigarette-smoking

behavior. Paper presented at the meeting of the American Psychological Association, Washington, D.C., September 1970.

2. Lublin, I., & Joslyn, L. Aversive conditioning of cigarette addiction. Paper presented at the meeting of the American Psychological Association, Los Angeles, September 1968.

REFERENCES Bernard, H. S., & Efran, J. S. Eliminating versus reducing smoking using pocket timers.

Behaviour Research and Therapy. 1972, 10, 399-401. Best, J. A. Tailoring smoking withdrawal procedures to personality and motivational differ-

ences. Journal of Consulting and Clinical Psychology, 1975, 43, 1-8. Best, J. A., & Steffy, R. A. Smoking modification procedures tailored to subject characteris-

tics. Behaviour Research and Therapy, 1971, 2, 177-191. Cautela, J. R. Treatment of smoking by covert sensitization. Psychological Reports, 1970,

26, 415-420. Chapman, R. F., Smith, J. W., & Layden, T. A. Elimination of cigarette smoking by

punishment and self-management training. Behaviour Research and Therapy, 1971, 9, 255-264.

Elliot, R., & Tighe, T. Breaking the cigarette habit: Effects of a technique involving threatened loss of money. Psychological Record, 1968, 18, 503-513.

Goldiamond, I. Self-control procedures in behavior problems. Psychological Reports, 1965, 17, 851-868.

Gough, H. G. California Psychological Inventory. Palo Alto: Consulting Psychologists Press, 1956.

270 JUDITH FLAXMAN

Gutmann, M., & Marston, A. Problems of subject's motivation in a behavioral program for the reduction of cigarette smoking. Psychological Reports, 1967, 20, 1107-1114.

Jacobson, E. Progressive relaxation. Chicago: University of Chicago Press, 1929. Keutzer, C. S. A measure of cognitive dissonance as a predictor of smoking treatment

outcome. Psycholo~,ical Reports, 1968, 22, 655-658. Lichtenstein, E., Harris, D., Bitchier, G., Wahl, J.. & Schmahl, D. Comparison of rapid

smoking, warm, smoky air, and attention placebo in the modification of smoking behavior. Journal of Consulting and Clinical Psychology, 1973, 40, 92-98.

Mahoney, M. J., Moura, N. G., & Wade, T. C. Relative efficacy of self-reward, self- punishment, and self-measuring techniques for weight loss. Journal of Consulting and Clinical Psychology, 1973, 40, 404-407.

Ober, D. C. Modification of smoking behavior. Journal of Consulting and Clinical Psychol- ogy, 1968, 32, 543-549.

Sachs, L. B., Bean, H., & Morrow, J. E. Comparison of smoking treatments. Behavior Therapy, 1970, 1,465-472.

Schmahl, D. P., Lichtenstein, E., & Harris, D. E. Successful treatment of habitual smokers with warm, smoky air and rapid smoking. Journal of Consulting and Clinical Psychol- ogy, 1972, 38, 105-Il l .

Skinner, B. F. Science and human behavior. New York: The Free Press, 1953.

RECEIVED: August 20, 1976; REVISED: November 4, 1976 FINAL ACCEPTANCE: November I I, 1976

quitting smoking now or later: gradual, abrupt, immediate, and delayed quitting

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