An exploration of the role of identity in smoking, cessation, maintenance and relapse

Objective: A recent theory of motivation (PRIME theory) has proposed that the formation of a ‘non-smoker’ identity is necessary for long-term abstinence. This programme of research aimed to explore how a smoker’s sense of identity changes following smoking cessation and also relapse after a sustained period of abstinence. Design: Two qualitative, semi-structured interview studies with a purposive sample of individuals who had quit smoking were conducted. An interpretative phenomenological approach was taken to elicit in-depth accounts of the participants’ understanding of smoking, stopping and maintaining abstinence. A survey study to examine the findings of the previous studies particularly those of residual attraction and smoker identity in exsmokers, and ‘first lapse’ characteristics in relapsed smokers. Methods: 10 participants who quit smoking with the support of an NHS stop-smoking service in England and were still abstinent a year later were interviewed (Study 1) and 10 participants who had relapsed within the year following at least six months of abstinence (Study 2). An interpretative phenomenological analysis of the interview transcripts was conducted. Prospective contextual detail of motivational and other variables pre-quit were also obtained from the clinic assessment form participants completed at the first group 14 session. A postal questionnaire was then sent to 1390 adults known to have been abstinent 4 weeks after treatment support with the same stop smoking service (Study 3). Time since the end of treatment varied between 6 weeks and 3 years. Results: In Study 1 a process of identity change was observed towards that of a ‘nonsmoker’, assisted initially by a transient identity of ‘team stop-smoker’ accompanied by a sense of achievement. All participants retained a residual attraction to smoking suggesting that the process was not complete. Participants labeled themselves as non-smokers regardless of how much transition had occurred. In Study 2 an identity conflict was seen to precede relapse and an identity reevaluation observed among those abstinent (i.e. Study 1 participants). Following relapse a distancing of the ‘smoker self’ from the ‘spoiled’ smoker identity particularly from perceptions of health irresponsibility was observed with smoking constructed as integral to the maintenance of a socially desirable identity. Forty percent (40.0%, n=556) of those invited to take part in Study 3 responded of whom 357 (64.5%) were not currently smoking. The proportion of ex-smokers reporting a residual attraction to smoking, a ‘smoker identity’, and a vulnerability to relapse declined with duration of abstinence (all p<0.001), although even among those having 2 years or more of abstinence 37.4% reported some residual attraction and 16.3% retained a ‘smoker identity’. By contrast, after 2 or more years of abstinence only 7% thought they would ever return to smoking. Among relapsed responders, at the time of first lapse only 27.1% had made a decision to return to smoking while 48.9% intended to smoke only one or two cigarettes before stopping again. In 45.7% of cases, respondents bought cigarettes to smoke 15 again. Prior to lapse the majority (53.8%) reported 'really needing a cigarette'. Similarly 53.8% reported being miserable at the time, while only 16% were happy. Conclusions and implications: It appears useful to distinguish two levels of ‘non-smoker’ identity: a surface level comprising the simple label and a deep level made up of often conflicting thoughts and feelings about oneself in relation to smoking. A total coherent ‘non-smoker’ identity does not appear to be necessary for long-term abstinence. The findings of Study 2 indicate that smoking affects a sense of identity beyond the micro-identity of smoker/non-smoker. Encouraging identity re-evaluation to accommodate the absence of smoking may reduce the identity conflict that appears to precede relapse. The findings of Study 3 suggest that residual attraction to cigarettes is common among long-term ex-smokers and a significant minority retain a smoker identity. Further studies are needed to determine how far these characteristics are associated with late relapse. The most common pattern of late lapse among relapsed smokers appears to be intending to suspend the quit attempt temporarily in circumstances of needing to smoke and of negative emotional state, and in many cases cigarettes are actually sought out. Promoting strong ‘not a puff’ rules, a non-smoker identity and identifying negative mood as a potential vulnerability are important components of relapse prevention intervention

Mobile Phone Text Messages to Support People to Stop Smoking by Switching to Vaping: Codevelopment, Coproduction, and Initial Testing Study

Background: SMS text messages are affordable, scalable, and effective smoking cessation interventions. However, there is little research on SMS text message interventions specifically designed to support people who smoke to quit by switching to vaping. Objective: Over 3 phases, with vapers and smokers, we codeveloped and coproduced a mobile phone SMS text message program. The coproduction paradigm allowed us to collaborate with researchers and the community to develop a more relevant, acceptable, and equitable SMS text message program. Methods: In phase 1, we engaged people who vape via Twitter and received 167 responses to our request to write SMS text messages for people who wish to quit smoking by switching to vaping. We screened, adjusted, refined, and themed the messages, resulting in a set of 95 that were mapped against the Capability, Opportunity, and Motivation–Behavior constructs. In phase 2, we evaluated the 95 messages from phase 1 via a web survey where participants (66/202, 32.7% woman) rated up to 20 messages on 7-point Likert scales on 9 constructs: being understandable, clear, believable, helpful, interesting, inoffensive, positive, and enthusiastic and how happy they would be to receive the messages. In phase 3, we implemented the final set of SMS text messages as part of a larger randomized optimization trial, in which 603 participants (mean age 38.33, SD 12.88 years; n=369, 61.2% woman) received SMS text message support and then rated their usefulness and frequency and provided free-text comments at the 12-week follow-up. Results: For phase 2, means and SDs were calculated for each message across the 9 constructs. Those with means below the neutral anchor of 4 or with unfavorable comments were discussed with vapers and further refined or removed. This resulted in a final set of 78 that were mapped against early, mid-, or late stages of quitting to create an order for the messages. For phase 3, a total of 38.5% (232/603) of the participants provided ratings at the 12-week follow-up. In total, 69.8% (162/232) reported that the SMS text messages had been useful, and a significant association between quit rates and usefulness ratings was found (χ21=9.6; P=.002). A content analysis of free-text comments revealed that the 2 most common positive themes were helpful (13/47, 28%) and encouraging (6/47, 13%) and the 2 most common negative themes were too frequent (9/47, 19%) and annoying (4/47, 9%). Conclusions: In this paper, we describe the initial coproduction and codevelopment of a set of SMS text messages to help smokers stop smoking by transitioning to vaping. We encourage researchers to use, further develop, and evaluate the set of SMS text messages and adapt it to target populations and relevant contexts

Evaluation of Mental Health First Aid from the Perspective Of Workplace End UseRs—EMPOWER: protocol of cluster randomised trial phase

Background: Mental Health First Aid (MHFA) is a mental health intervention that teaches people how to identify, understand and help someone who may be experiencing a mental health issue. Reviews of the implementation of MHFA found between 68 and 88% of trained Mental Health First Aiders had used their skills when in contact with someone experiencing mental health difficulties. Reviews evaluating the impact of MHFA suggest positive outcomes. However, to date, there has been no systematic, rigorous evaluation of the impact of MHFA on recipients of the intervention, the organisations providing it and the cost-effectiveness of MHFA overall. This trial will evaluate the effectiveness and cost-effectiveness of MHFA. Methods: The study is a multi-centred, two-arm clustered randomised controlled trial. Organisations will be randomly allocated to the control or intervention (estimated sample size 800 recipients). The intervention is the standard MHFA intervention provided by Mental Health First Aid England (MHFAE). The control condition will be organisations having a brief consultation from MHFAE on promoting mental health and well-being in the workplace. The primary outcome is health seeking behaviour, measured using the Actual Help Seeking Questionnaire, at 6 months’ follow-up. Data collection will be undertaken at baseline (T0), post-intervention—up to 3 months (T1), at 6 months (T2), 12 months (T3) and 24 months (T4). The primary analysis will be conducted on those participants who receive MHFA, a per protocol analysis. Discussion: The study is the first to evaluate the effect of MHFA in the workplace on employees with direct and indirect experience of the intervention, when compared with usual practice. Being also the first to assess, systematically, the social impact of MHFA and investigate its cost-effectiveness adds to the originality of the study. The study promises to yield important data, as yet unknown, regarding the effectiveness, cost-effectiveness, implementation issues, and the sustainability of MHFA in the workplace

Residual attraction to smoking and smoker identity following smoking cessation

Anecdotal reports suggest that some long-term ex-smokers retain a residual attraction to smoking and a "smoker identity," although little systematic data on this exist. These are important because they may increase the likelihood of relapse. This study aimed to quantify the extent of these characteristics in relation to length of abstinence.A postal questionnaire on residual attraction to smoking, smoker identity, and vulnerability to relapse was sent to 1,390 adults known to have been abstinent for 4 weeks after treatment support with a large stop smoking service in England. Time since the end of treatment varied between 6 weeks and 3 years. Three hundred and fifty-seven ex-smokers responded and were included in the analysis.The proportion of ex-smokers reporting a residual attraction to smoking, a smoker identity, and a vulnerability to relapse declined with duration of abstinence (all p <.001), although even among those having 2 years or more of abstinence, 37.4% (95% CI = 27.9%-47.7%) reported some residual attraction and 16.3% (95% CI = 9.6%-25.2%) retained a smoker identity. By contrast, after 2 or more years of abstinence, only 7% thought they would ever return to smoking (95% CI = 2.9%-14.2%).The findings suggest that residual attraction to cigarettes is common among long-term ex-smokers, and a significant minority retain a smoker identity. Further studies are needed to determine how far these characteristics are associated with late relapse

Smoking intentions and mood preceding lapse after completion of treatment to aid smoking cessation

Objective: To examine the situation preceding "late" smoking relapse, particularly the availability of tobacco, mood and intentions at first lapse.Methods: A questionnaire was sent to 1439 adults identified as abstinent after treatment with a National Health Service stop-smoking clinic over the previous 3 years. Relapsers were asked where they had obtained their first cigarette, their mood and intentions immediately before first lapse.Results: 40% (n = 556) responded, of whom 35.8% (n = 199) had relapsed. At the time of first lapse, only 27.1% had made a decision to return to smoking while 48.9% intended to smoke only one or two cigarettes before stopping again. In 45.7% of cases, respondents bought cigarettes to smoke again. Prior to lapse the majority (53.8%) reported "really needing a cigarette". Similarly 53.8% reported being miserable at the time, while only 16% were happy.Conclusion: The most common pattern of late lapse appears to be intending to suspend the quit attempt temporarily in circumstances of needing to smoke and of negative emotional state, and in many cases cigarettes are actually sought out.Practice implications: Promoting strong 'not a puff' rules, a non-smoker identity and identifying negative mood as a potential vulnerability are important components of relapse prevention intervention. (C) 2010 Elsevier Ireland Ltd. All rights reserved

Residual attraction to smoking and smoker identity following smoking cessation

Anecdotal reports suggest that some long-term ex-smokers retain a residual attraction to smoking and a "smoker identity," although little systematic data on this exist. These are important because they may increase the likelihood of relapse. This study aimed to quantify the extent of these characteristics in relation to length of abstinence.A postal questionnaire on residual attraction to smoking, smoker identity, and vulnerability to relapse was sent to 1,390 adults known to have been abstinent for 4 weeks after treatment support with a large stop smoking service in England. Time since the end of treatment varied between 6 weeks and 3 years. Three hundred and fifty-seven ex-smokers responded and were included in the analysis.The proportion of ex-smokers reporting a residual attraction to smoking, a smoker identity, and a vulnerability to relapse declined with duration of abstinence (all p <.001), although even among those having 2 years or more of abstinence, 37.4% (95% CI = 27.9%-47.7%) reported some residual attraction and 16.3% (95% CI = 9.6%-25.2%) retained a smoker identity. By contrast, after 2 or more years of abstinence, only 7% thought they would ever return to smoking (95% CI = 2.9%-14.2%).The findings suggest that residual attraction to cigarettes is common among long-term ex-smokers, and a significant minority retain a smoker identity. Further studies are needed to determine how far these characteristics are associated with late relapse

A randomised trial of glucose tablets to aid smoking cessation

Oral glucose has been found to decrease tobacco craving among abstaining smokers. One study has demonstrated an effect of glucose on short-term abstinence. There is a need to examine any long-term benefit of glucose on abstinence.To assess whether glucose tablets improve 6-month continuous abstinence rates compared with low-calorie placebo tablets.Smokers attempting to stop (n = 928) were randomised to receive glucose or sorbitol (placebo) in a double-blind placebo-controlled trial. All participants received group-based psychological support, and approximately half (n = 474) received nicotine replacement therapy (NRT), buproprion, or both. Smokers were seen weekly for 5 weeks and used tablets ad libitum, with a recommended minimum of 12 per day. Participants were recruited through general practitioner referral, word of mouth, and advertising. The participants were 38% male, smoked an average of 23.5 cigarettes per day, and had a mean age of 44 years. There were no significant pretreatment differences between groups. The primary outcome measure was continuous, CO-verified abstinence from the target quit date for 6 months.No significant effect of glucose tablets on abstinence was found (14.6% vs 13.4% abstinence in the glucose and placebo groups, respectively). However, there was a significant interaction with a glucose effect observed in smokers also receiving other medication (18.2% vs 12.6%, p &lt;0.05) but not otherwise (10.7% vs 14.3% ; p &lt;0.05 for the interaction).No significant effect of glucose tablets over and above sweet tasting tablets could be detected overall, but the possibility of an effect as an adjunct to NRT or bupropion merits further investigation

A Systematic Review of Factors Associated with Non-Adherence to Treatment for Immune-Mediated Inflammatory Diseases

BACKGROUND: Non-adherence impacts negatively on patient health outcomes and has associated economic costs. Understanding drivers of treatment adherence in immune-mediated inflammatory diseases is key for the development of effective strategies to tackle non-adherence. OBJECTIVE: To identify factors associated with treatment non-adherence across diseases in three clinical areas: rheumatology, gastroenterology, and dermatology. DESIGN: Systematic review. DATA SOURCES: Articles published in PubMed, Science Direct, PsychINFO and the Cochrane Library from January 1, 1980 to February 14, 2014. STUDY SELECTION: Studies were eligible if they included patients with a diagnosis of rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, or psoriasis and included statistics to examine associations of factors with non-adherence. DATA EXTRACTION: Data were extracted by the first reviewer using a standardized 23-item form and verified by a second/third reviewer. Quality assessment was carried out for each study using a 16-item quality checklist. RESULTS: 73 studies were identified for inclusion in the review. Demographic or clinical factors were not consistently associated with non-adherence. Limited evidence was found for an association between non-adherence and treatment factors such as dosing frequency. Consistent associations with adherence were found for psychosocial factors, with the strongest evidence for the impact of the healthcare professional–patient relationship, perceptions of treatment concerns and depression, lower treatment self-efficacy and necessity beliefs, and practical barriers to treatment. CONCLUSIONS: While examined in only a minority of studies, the strongest evidence found for non-adherence were psychosocial factors. Interventions designed to address these factors may be most effective in tackling treatment non-adherence. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s12325-015-0256-7) contains supplementary material, which is available to authorized users