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

Abstract

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