The Quest to Quit: an Exploration of the Cessation - Relapse Cycle of Cigarette Smoking

The smoker's perspective is seldom sought in cessation research. Consequently, cessation approaches may be less effective because they are not based on assumptions and interpretations shared by those who smoke. Understanding how chronic relapsing smokers interpret their predicament could enhance cessation approaches, improving the chances for complete, permanent cessation. To generate such an understanding, five participants were recruited who had attempted to quit smoking several times. Aiming for depth rather than breadth, multiple interviews were conducted with each participant, who also kept an event diary, recording current smoking, nicotine withdrawal, lapsing and relapsing. Narratology, a biographical method of symbolic interactionism drawing on thematic, structural, and dialogic analysis, was used to elicit the participants' points of view from interview and diary data. The findings show that participants make sense of their chronic relapsing through a master narrative of 'willpower versus weakness'. Meanwhile, the tobacco control domain is largely driven by 'cost', and subsidised treatments are driven by the 'addiction' master narrative. This gap between ways of making sense of smoking and relapse can cause self-stigma, reducing the likelihood that quitting will be attempted and that quit attempts will succeed. Changes are proposed to mitigate the negative effects on self-efficacy brought about through the present approach to tobacco control. Ways to improve the effectiveness of existing treatments are suggested. Finally, the value of the narrative method is highlighted, with suggestions for its use in research where elucidating the insider point of view may improve treatment outcomes

Diagnostic Accuracy of the Index Screening Instruments and their Short Forms by Cut-offs for Current Major Depression (N = 190).

<p>^a PROC01 is defined as a distance between the ROC curve and the point of (0, 1) [defined as (NPV-1)² + (PPV-1)²] (Gallop et al, 2003; Vermont et al, 1991).</p><p>^b Youden index (YI) is defined as Se+Sp-1 (Youden, 1950).</p><p>^c Diagnostic odds ratios (DOR) is defined as LR+/LR- (Böhning et al., 2011; Glas et al., 2003).</p><p>Diagnostic Accuracy of the Index Screening Instruments and their Short Forms by Cut-offs for Current Major Depression (N = 190).</p

Inter-rater Agreement of Pairs of Index Screening Instruments and Internal Consistency for each Instrument.

<p>^a S.E. = standard error</p><p>Inter-rater Agreement of Pairs of Index Screening Instruments and Internal Consistency for each Instrument.</p

Baseline Characteristics, the Mean Scores of the Screening Instruments the Sample, and the Prevalence of DSM-defined Psychiatric Disorders of the Sample (N = 179^a).

<p>^a Of 190 patients, 179 provided demographic, psychosocial and behavioural information.</p><p>^b SD = Standard Derivation</p><p>^c Immigrants are study participants who are not Canadian-born.</p><p>^d Receipt of Ontario Disability Support Program subsidies served as a proxy for physical or mental disability.</p><p>^e Recreational drug use was defined as use of drugs either not prescribed or not used according to instructions.</p><p>^f Harmful alcohol consumption in past 12 months was assessed using the 3-item Alcohol Use Disorders identification Test. (AUDIT-C) instrument (male: cut-point: ≥ 4; female: cut-point: ≥3) by Bush et al. (1998) and Bradley et al. (2003). AUDIT-C is an ultra-brief assessment developed by World Health Organization (WHO) to examine excess consumption of alcohol.</p><p>^g Frequency and proportion for dysthymia (recurrent depression) was not reported because cell size was <6.</p><p>Baseline Characteristics, the Mean Scores of the Screening Instruments the Sample, and the Prevalence of DSM-defined Psychiatric Disorders of the Sample (N = 179<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0142706#t004fn001" target="_blank">^a</a>).</p

Comparison of AUCs between Pairs of Index Screening Instruments and the AUCs between Original and the Short-form of Each Instrument (N = 190).

<p>* p<0.05 ** p<0.01 ***p<0.001</p><p>^a AUC₁ was defined as the area under the curve of the first index screening instrument of the specific pair.</p><p>^b AUC₂ was defined as the area under the curve of the second index screening instrument of the specific pair.</p><p>^c CI = confidence interview. All the reported 95% confidence intervals were constructed by bias-corrected bootstrap method with 2000 replicates (Efron & Tibshirani, 1994).</p><p>^d |AUC₁ –AUC₂| was defined as an absolute value of difference between AUCs of the specific comparison pair.</p><p>^e Mann-Whitney U- test was used to assess for equality of AUCs of the specific pair (E.R. DeLong, D.M. DeLong, & Clarke-Pearson, 1988).</p><p>Comparison of AUCs between Pairs of Index Screening Instruments and the AUCs between Original and the Short-form of Each Instrument (N = 190).</p

Comparison Between Adjusted ROC Curves of the Original Instruments for Current Major Depression and that of their Corresponding Reduced Scales After Removing Items Related to Somatic Symptoms of HIV (N = 179^a); Footnotes: All reported 95% confidence intervals were constructed by bias-corrected bootstrap method with 2000 replicates (Efron & Tibshirani, 1994); AUC = Area under the curve; ^aOf 190 patients, 179 provided demographic, psychosocial and behavioural information; ^bItems (i.e., fatigue, sleep, appetite, not being able to shake the blues, feeling bothered, feeling depressed, and lack of concentration) correspond to previously reported somatic symptoms of HIV infection (Kalichman, Rompa, &Cage, 2000).

<p>Comparison Between Adjusted ROC Curves of the Original Instruments for Current Major Depression and that of their Corresponding Reduced Scales After Removing Items Related to Somatic Symptoms of HIV (N = 179^a); Footnotes: All reported 95% confidence intervals were constructed by bias-corrected bootstrap method with 2000 replicates (Efron & Tibshirani, 1994); AUC = Area under the curve; ^aOf 190 patients, 179 provided demographic, psychosocial and behavioural information; ^bItems (i.e., fatigue, sleep, appetite, not being able to shake the blues, feeling bothered, feeling depressed, and lack of concentration) correspond to previously reported somatic symptoms of HIV infection (Kalichman, Rompa, &Cage, 2000).</p

Description of Individual Covariates of the Sample.

<p>^a Source: Bush K. (1998)</p><p>^b Source: Bradley KA et al. (2003)</p><p>Description of Individual Covariates of the Sample.</p

Multivariable ROC Analysis^a for the Index Screening Instruments and their Short Forms for Current Major Depression Disorder (N = 179^b).

<p>* p<0.05 ** p<0.01 ***p<0.001</p><p>^a Adjusted multivariable non-parametric ROC analyses were also performed (Jane H., et al., 2009) because some covariates may affect the accuracy of the instruments. Bivariate analysis was first performed to examine the crude association between the ROC curve of each instrument and each covariate. Covariates generally entered into the final multivariable model if p-value <0.25 in bivariate analysis (Vittinghoff E., et al., 2005). The multivariable models also controlled for other covariates (age, current smoking status, immigration status, educational attainment, recent CD4 cell count, and recent viral loads), but not all of them were statistically significant.</p><p>^b Of 190 patients, 179 provided demographic, psychosocial and behavioural information.</p><p>^c Coefficients of adjusted multivariable model generally reflect impacts of a specific covariate on the adjusted ROC curve by assuming a linear relationship (Jane H., et al., 2009).</p><p>^d Receipt of Ontario Disability Support Program (ODSP) subsidies was used as a proxy measure for physical or mental disability</p><p>Multivariable ROC Analysis<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0142706#t006fn002" target="_blank">^a</a> for the Index Screening Instruments and their Short Forms for Current Major Depression Disorder (N = 179<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0142706#t006fn003" target="_blank">^b</a>).</p

Crude ROC Curves of the Index Screening Instruments and their Short Forms for Current Major Depression (N = 190); Footnotes: All reported 95% confidence intervals were constructed by bias-corrected bootstrap method with 2000 replicates (Efron & Tibshirani, 1994)

<p>Crude ROC Curves of the Index Screening Instruments and their Short Forms for Current Major Depression (N = 190); Footnotes: All reported 95% confidence intervals were constructed by bias-corrected bootstrap method with 2000 replicates (Efron & Tibshirani, 1994)</p

Adjusted ROC Curves of the Index Screening Instruments and their Short Forms for Major Depressive Disorder (N = 179^a); Footnotes: All reported 95% confidence intervals were constructed by bias-corrected bootstrap method with 2000 replicates (Efron & Tibshirani, 1994); AUC = Area under the curve; ^aOf 190 patients, 179 provided demographic, psychosocial and behavioural information;

<p>Adjusted ROC Curves of the Index Screening Instruments and their Short Forms for Major Depressive Disorder (N = 179^a); Footnotes: All reported 95% confidence intervals were constructed by bias-corrected bootstrap method with 2000 replicates (Efron & Tibshirani, 1994); AUC = Area under the curve; ^aOf 190 patients, 179 provided demographic, psychosocial and behavioural information;</p