A Longitudinal Examination of the Interrelationship of Multiple Health Behaviors


      Evaluating the interrelationship of health behaviors could assist in the development of effective public health interventions. Furthermore, the ability to identify cognitive mediators that may influence multiple behavioral changes requires evaluation.


      To evaluate covariation among health behaviors, specifically alcohol consumption, leisure-time physical activity, and smoking, and examine whether mastery acts as a mediating social-cognitive mechanism that facilitates multiple health behavior change in a longitudinal analysis.


      In 2010, secondary data analysis was conducted on the first seven cycles of the Canadian National Population Health Survey. Data collection began in 1994–1995 and has continued biennially. At the time of this analysis, only seven cycles of data (2006–2007) were available. Parallel process growth curve models were used to analyze covariation between health behaviors and the potential mediating effects of perceived mastery.


      Increases in leisure-time physical activity were associated with reductions in tobacco use, whereas declines in alcohol consumption were associated with decreases in tobacco use. Covariation between alcohol consumption and leisure-time physical activity did not reach statistical significance. For the most part, mastery was unsuccessful in mediating the interrelationship of multiple behavioral changes.


      Health behaviors are not independent but rather interrelated. In order to optimize limited prevention resources, these results suggest that population-level intervention efforts targeting multiple modifiable behavioral risk factors may not need to occur simultaneously.
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        • Berrigan D.
        • Dodd K.
        • Troiano R.P.
        • Krebs-Smith S.M.
        • Barbash R.B.
        Patterns of health behavior in U.S. adults.
        Prev Med. 2003; 36: 615-623
        • Fine L.J.
        • Philogene G.S.
        • Gramling R.
        • Coups E.J.
        • Sinha S.
        Prevalence of multiple chronic disease risk factors. 2001 National Health Interview Survey.
        Am J Prev Med. 2004; 27: S18-S24
        • Coups E.J.
        • Gaba A.
        • Orleans C.T.
        Physician screening for multiple behavioral health risk factors.
        Am J Prev Med. 2004; 27: S34-S41
        • Klein-Geltink J.E.
        • Choi B.C.
        • Fry R.N.
        Multiple exposures to smoking, alcohol, physical inactivity and overweight: prevalences according to the Canadian Community Health Survey Cycle 1.1.
        Chronic Dis Can. 2006; 27: 25-33
        • Prochaska J.J.
        • Nigg C.R.
        • Spring B.
        • Velicer W.F.
        • Prochaska J.O.
        The benefits and challenges of multiple health behavior change in research and in practice.
        Prev Med. 2010; 50: 26-29
        • Nigg C.R.
        • Allegrante J.P.
        • Ory M.
        Theory-comparison and multiple-behavior research: common themes advancing health behavior research.
        Health Educ Res. 2002; 17: 670-679
        • de Vries H.
        • Kremers S.
        • Smeets T.
        • Reubsaet A.
        Clustering of diet, physical activity and smoking and a general willingness to change.
        Psychol Health. 2008; 23: 265-278
        • Pronk N.P.
        • Peek C.J.
        • Goldstein M.G.
        Addressing multiple behavioral risk factors in primary care. A synthesis of current knowledge and stakeholder dialogue sessions.
        Am J Prev Med. 2004; 27: S4-S17
        • Haveman-Nies A.
        • de Groot L.P.
        • Burema J.
        • Cruz J.A.
        • Osler M.
        • van Staveren W.A.
        Dietary quality and lifestyle factors in relation to 10-year mortality in older Europeans: the SENECA study.
        Am J Epidemiol. 2002; 156: 962-968
        • Leatherdale S.T.
        • Rynard V.
        A cross-sectional examination of modifiable risk factors for chronic disease among a nationally representative sample of youth: are Canadian students graduating high school with a failing grade for health?.
        BMC Public Health. 2013; 13: 569
        • Gordon L.
        • Graves N.
        • Hawkes A.
        • Eakin E.
        A review of the cost-effectiveness of face-to-face behavioural interventions for smoking, physical activity, diet and alcohol.
        Chronic Illn. 2007; 3: 101-129
        • Prochaska J.O.
        Multiple Health Behavior Research represents the future of preventive medicine.
        Prev Med. 2008; 46: 281-285
        • Schuit A.J.
        • van Loon A.J.
        • Tijhuis M.
        • Ocke M.
        Clustering of lifestyle risk factors in a general adult population.
        Prev Med. 2002; 35: 219-224
        • Poortinga W.
        The prevalence and clustering of four major lifestyle risk factors in an English adult population.
        Prev Med. 2007; 44: 124-128
        • Bock B.C.
        • Marcus B.H.
        • Rossi J.S.
        • Redding C.A.
        Motivational readiness for change: diet, exercise, and smoking.
        Am J Health Behav. 1998; 22: 248-258
        • Ory M.G.
        • Jordan P.J.
        • Bazzarre T.
        The Behavior Change Consortium: setting the stage for a new century of health behavior-change research.
        Health Educ Res. 2002; 17: 500-511
        • O’Hea E.L.
        • Boudreaux E.D.
        • Jeffries S.K.
        • Carmack Taylor C.L.
        • Scarinci I.C.
        • Brantley P.J.
        Stage of change movement across three health behaviors: the role of self-efficacy.
        Am J Health Promot. 2004; 19: 94-102
        • Pearlin L.I.
        • Schooler C.
        The structure of coping.
        J Health Soc Behav. 1978; 19: 2-21
        • Pederson L.L.
        • Koval J.J.
        • McGrady G.A.
        • Tyas S.L.
        The degree and type of relationship between psychosocial variables and smoking status for students in grade 8: is there a dose-response relationship?.
        Prev Med. 1998; 27: 337-347
        • O’Connell K.A.
        • Gerkovich M.M.
        • Cook M.R.
        Reversal theory’s mastery and sympathy states in smoking cessation.
        Image J Nurs Sch. 1995; 27: 311-316
        • Prescott C.A.
        • Neale M.C.
        • Corey L.A.
        • Kendler K.S.
        Predictors of problem drinking and alcohol dependence in a population-based sample of female twins.
        J Stud Alcohol. 1997; 58: 167-181
        • Sorensen M.
        • Anderssen S.
        • Hjerman I.
        • Holme I.
        • Ursin H.
        Exercise and diet interventions improve perceptions of self in middle-aged adults.
        Scand J Med Sci Sports. 1997; 7: 312-320
        • Boyle R.G.
        • O’Connor P.J.
        • Pronk N.P.
        • Tan A.
        Stages of change for physical activity, diet, and smoking among HMO members with chronic conditions.
        Am J Health Promot. 1998; 12: 170-175
        • Garrett N.A.
        • Alesci N.L.
        • Schultz M.M.
        • Foldes S.S.
        • Magnan S.J.
        • Manley M.W.
        The relationship of stage of change for smoking cessation to stage of change for fruit and vegetable consumption and physical activity in a health plan population.
        Am J Health Promot. 2004; 19: 118-127
        • Keller S.
        • Maddock J.E.
        • Hannover W.
        • Thyrian J.R.
        • Basler H.D.
        Multiple health risk behaviors in German first year university students.
        Prev Med. 2008; 46: 189-195
        • King T.K.
        • Marcus B.H.
        • Pinto B.M.
        • Emmons K.M.
        • Abrams D.B.
        Cognitive-behavioral mediators of changing multiple behaviors: smoking and a sedentary lifestyle.
        Prev Med. 1996; 25: 684-691
        • Lippke S.
        • Nigg C.R.
        • Maddock J.E.
        Health-promoting and health-risk behaviors: theory-driven analyses of multiple health behavior change in three international samples.
        Int J Behav Med. 2012; 19: 1-13
        • Audrain-McGovern J.
        • Rodriguez D.
        • Moss H.B.
        Smoking progression and physical activity.
        Cancer Epidemiol Biomarkers Prev. 2003; 12: 1121-1129
        • Breslau N.
        • Peterson E.
        • Schultz L.
        • Andreski P.
        • Chilcoat H.
        Are smokers with alcohol disorders less likely to quit?.
        Am J Public Health. 1996; 86: 985-990
        • Dierker L.
        • Lloyd-Richardson E.
        • Stolar M.
        • et al.
        The proximal association between smoking and alcohol use among first year college students.
        Drug Alcohol Depend. 2006; 81: 1-9
        • Nagaya T.
        • Yoshida H.
        • Takahashi H.
        • Kawai M.
        Cigarette smoking weakens exercise habits in healthy men.
        Nicotine Tob Res. 2007; 9: 1027-1032
        • Terry-McElrath Y.M.
        • O’Malley P.M.
        Substance use and exercise participation among young adults: parallel trajectories in a national cohort-sequential study.
        Addiction. 2011; 106: 1855-1865
        • Laaksonen M.
        • Luoto R.
        • Helakorpi S.
        • Uutela A.
        Associations between health-related behaviors: a 7-year follow-up of adults.
        Prev Med. 2002; 34: 162-170
      1. Statistics Canada. National Population Health Survey, household component, cycles 1 to 7 (1994/1995 to 2006/2007), longitudinal documentation, 2008. Ottawa: Statistics Canada, 2008.

        • Cairney J.
        • Faulkner G.
        • Veldhuizen S.
        • Wade T.J.
        Changes over time in physical activity and psychological distress among older adults.
        Can J Psychiatry. 2009; 54: 160-169
        • MacCallum R.C.
        • Kim C.
        • Malarkey W.B.
        • Kiecolt-Glaser J.K.
        Studying multivariate change using multilevel models and latent curve models.
        Multivariate Behav Res. 1997; 32: 215-253
        • Curran P.J.
        • Harford T.C.
        • Muthen B.O.
        The relation between heavy alcohol use and bar patronage: a latent growth model.
        J Stud Alcohol. 1996; 57: 410-418
        • Curran P.J.
        • Stice E.
        • Chassin L.
        The relation between adolescent alcohol use and peer alcohol use: a longitudinal random coefficients model.
        J Consult Clin Psychol. 1997; 65: 130-140
        • MacKinnon D.P.
        Longitudinal mediation models.
        Introduction to statistical mediation analysis. 1st ed. Routledge, New York2008
        • Cheong J.
        • Mackinnon D.P.
        • Khoo S.T.
        Investigation of mediational processes using parallel process latent growth curve modeling.
        Struct Equ Modeling. 2003; 10: 238
        • Lee I.M.
        • Paffenbarger Jr, R.S.
        • Hsieh C.C.
        Time trends in physical activity among college alumni, 1962–1988.
        Am J Epidemiol. 1992; 135: 915-925
        • Craig C.L.
        • Russell S.J.
        • Cameron C.
        • Bauman A.
        Twenty-year trends in physical activity among Canadian adults.
        Can J Public Health. 2004; 95: 59-63
        • Filion K.B.
        • Steffen L.M.
        • Duval S.
        • Jacobs Jr, D.R.
        • Blackburn H.
        • Luepker R.V.
        Trends in smoking among adults from 1980 to 2009: the Minnesota Heart Survey.
        Am J Public Health. 2012; 102: 705-713
        • CDC
        Consumption of cigarettes and combustible tobacco—U.S., 2000–2011.
        MMWR Morb Mortal Wkly Rep. 2012; 61: 565-569
        • Rose G.
        Sick individuals and sick populations.
        Int J Epidemiol. 1985; 14: 32-38
        • Atkins D.
        • Clancy C.
        Multiple risk factors interventions.
        Are we up to the challenge? Am J Prev Med. 2004; 27: S102-S103
        • deRuiter W.K.
        • Faulkner G.
        • Cairney J.
        • Veldhuizen S.
        Characteristics of physically active smokers and implications for harm reduction.
        Am J Public Health. 2008; 98: 925-931
        • deRuiter W.
        • Faulkner G.
        Tobacco harm reduction strategies: the case for physical activity.
        Nicotine Tob Res. 2006; 8: 157-168
        • Daniel J.Z.
        • Cropley M.
        • Fife-Schaw C.
        Acute exercise effects on smoking withdrawal symptoms and desire to smoke are not related to expectation.
        Psychopharmacology (Berl). 2007; 195: 125-129
        • Wen C.P.
        • Wai P.M.J.
        • Tsai M.K.
        • Yang Y.C.
        Physical activity as a harm reduction strategy for smokers.
        Circulation. 2012; 125: e706-e707
        • Ferrucci L.
        • Izmirlian G.
        • Leveille S.
        • et al.
        Smoking, physical activity, and active life expectancy.
        Am J Epidemiol. 1999; 149: 645-653
        • Milligan R.A.
        • Burke V.
        • Beilin L.J.
        • et al.
        Health-related behaviours and psycho-social characteristics of 18 year-old Australians.
        Soc Sci Med. 1997; 45: 1549-1562
        • Gulliver S.B.
        • Rohsenow D.J.
        • Colby S.M.
        • et al.
        Interrelationship of smoking and alcohol dependence, use and urges to use.
        J Stud Alcohol. 1995; 56: 202-206
        • Miller W.R.
        • Hedrick K.E.
        • Taylor C.A.
        Addictive behaviors and life problems before and after behavioral treatment of problem drinkers.
        Addict Behav. 1983; 8: 403-412
        • Sobell L.C.
        • Sobell M.B.
        • Kozlowski L.T.
        • Toneatto T.
        Alcohol or tobacco research versus alcohol and tobacco research.
        Br J Addict. 1990; 85: 263-269
        • Knoops K.T.
        • de Groot L.C.
        • Kromhout D.
        • et al.
        Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project.
        JAMA. 2004; 292: 1433-1439
        • MacKinnon D.P.
        • Fairchild A.J.
        • Fritz M.S.
        Mediation analysis.
        Annu Rev Psychol. 2007; 58: 593-614
        • Barrett D.H.
        • Anda R.F.
        • Croft J.B.
        • Serdula M.K.
        • Lane M.J.
        The association between alcohol use and health behaviors related to the risk of cardiovascular disease: the South Carolina Cardiovascular Disease Prevention Project.
        J Stud Alcohol. 1995; 56: 9-15
        • Northcote J.
        • Livingston M.
        Accuracy of self-reported drinking: observational verification of “last occasion” drink estimates of young adults.
        Alcohol Alcohol. 2011; 46: 709-713
        • Craig C.L.
        • Russell S.J.
        • Cameron C.
        Reliability and validity of Canada’s Physical Activity Monitor for assessing trends.
        Med Sci Sports Exerc. 2002; 34: 1462-1467
        • Vartiainen E.
        • Seppala T.
        • Lillsunde P.
        • Puska P.
        Validation of self-reported smoking by serum cotinine measurement in a community-based study.
        J Epidemiol Community Health. 2002; 56: 167-170
        • Weller I.
        • Corey P.
        The impact of excluding non-leisure energy expenditure on the relation between physical activity and mortality in women.
        Epidemiology. 1998; 9: 632-635
        • Orleans C.T.
        The behavior change consortium: expanding the boundaries and impact of health behavior change research.
        Ann Behav Med. 2005; 29: S76-S79
        • Prochaska J.J.
        • Prochaska J.O.
        A review of multiple health behavior change interventions for primary prevention.
        Am J Lifestyle Med. 2011; 5: 208-221