Does non-smoker identity following quitting predict long-term abstinence? Evidence from a population survey in England

Change in vaping, smoking and dual-use identities predicts quit success and cigarette usage: A prospective study of people quitting smoking with electronic cigarette support

OBJECTIVE

Electronic cigarettes (ECs) are an efficacious support for some but not all people wishing to stop using tobacco. While advice and practical support have been identified as increasing quit success, little research has explored the role of changes in smoking and EC-related social identities.

METHODS

A prospective study following 573 people attempting to quit smoking with EC support. Self-report measures of identification with being a smoker, non-smoker, vaper and dual user (people using ECs and tobacco products) were taken prior to the quit attempt and at a 12-week follow-up.

RESULTS

Baseline identifications with being a smoker, non-smoker or dual user were not associated with smoking outcomes. Baseline vaper identity baseline was linked to more frequent tobacco abstinence at follow-up and lower levels of cigarette smoking. Levels of social identification at follow-up were consistently linked with outcomes, with vaper identity and non-smoking identities being protective and dual user identity being related to lower abstinence rates but decreased tobacco usage. Changes in identity over time were the most consistent predictor of outcomes.

CONCLUSIONS

Findings have implications for smoking cessation practice, informing how and when identity-based interventions may be effective and our understanding of how identity transitions occur.

National Smoking Cessation Services (NSCS) enrollment and their effect on long-term tobacco cessation in Korea: Results from a 1-year prospective follow-up of NSCS participants

INTRODUCTION

The study aimed to identify predictors associated with long-term tobacco cessation at 12-month follow-up among users of the National Smoking Cessation Services (NSCS) in Korea.

METHODS

To measure the long-term effect of NSCS delivery, the target sample size of 5167 adult smokers registered in the NSCS in 2018 was enrolled with proportional random sampling. A multiple logistic regression analysis (crude, adjusted) was performed to identify the changes in smoking status at the 12-month follow-up after the last NSCS enrollment and the potential factors associated with changes in smoking status.

RESULTS

The response rate to reach the number of subjects targeted was 22.4%. A total of 41.2% of the tobacco users enrolled had successfully quit at baseline, and the 7-day point prevalence of tobacco cessation at the follow-up at 12 months, via a telephone survey, was 34.4%. Factors positively associated with cessation at the 12-month follow-up were longer experience with tobacco abstinence and additional quitting attempts with or without NSCS enrollment, although every additional quit attempt with NSCS use had a better outcome. In addition, having a successful quit outcome with NSCS use at the baseline and having more satisfaction with the service of professional counseling or incentives than others provided by NSCS, increased cessation at follow-up after adjustment of other factors considered.

CONCLUSIONS

In addition to multiple quitting attempts, longer experience with tobacco abstinence, and additional enrollment in NSCS, the service experience, and satisfaction with the content that NSCS offered, might improve the lasting success of abstinence. These results might be considered to improve the contents and protocols of the NSCS for better outcomes.

My future-self has (not) quit smoking: An experimental study into the effect of a future-self intervention on smoking-related self-identity constructs

OBJECTIVES

Envisioning one's (non)smoking future may make (un)desired future identities more accessible, salient, and personally relevant and facilitate smoking cessation. The current study assessed whether a future-self intervention can weaken smoker self-identity and expected identity loss when quitting smoking, and strengthen quitter- and nonsmoker self-identity, while accounting for personal factors-socioeconomic position, nicotine dependence, consideration of future consequences, and clarity of the envisioned future-self. Additionally, it examined the association between smoking-related identity and quitting intention and behavior.

METHODS

This longitudinal online experimental study randomized 233 adult smokers to an intervention condition (where they completed mental imagery, visual, and verbal tasks about a future (non)smoking self), or to a passive control condition. Smoker-, quitter-, nonsmoker self-identity and identity loss were measured post-intervention and after one- and three-months. Quit intention and attempts were measured at baseline and after one month.

RESULTS

There was a consistent increase in non-smoker self-identity, and decrease in smoker self-identity and identity loss over a period of six months for all participants, but no significant difference in smoking-related identity between the intervention and control group. While personal factors did not moderate the effect of the intervention, we found that smoking-related identity constructs do vary with nicotine dependence, consideration of future consequences, and clarity of the envisioned future-self. Quitting behavior is primarily associated with non-smoker self-identity.

CONCLUSIONS

Although the future-self intervention did not significantly influence smoking-related identity or behavior, identity-in particular, non-smoker self-identity-is important to consider in smoking cessation interventions. More research is needed to find effective operationalizations for identity-based interventions in the context of smoking.

Toward an ontology of identity-related constructs in addiction, with examples from nicotine and tobacco research

BACKGROUND AND AIMS

We aimed to create a basic set of definitions and relationships for identity-related constructs, as part of the Addiction Ontology and E-Cigarette Ontology projects, that could be used by researchers with diverse theoretical positions and so facilitate evidence synthesis and interoperability.

METHODS

We reviewed the use of identity-related constructs in psychological and social sciences and how these have been applied to addiction with a focus on nicotine and tobacco research. We, then, used an iterative process of adaptation and review to arrive at a basic set of identity-related classes with labels, definitions and relationships that could provide a common framework for research.

RESULTS

We propose that 'identity' be used to refer to 'a cognitive representation by a person or group of themselves', with 'self-identity' referring to an individual's identity and 'group identity' referring to an identity held by a social group. Identities can then be classified at any level of granularity based on the content of the representations (e.g. 'tobacco smoker identity', 'cigarette smoker identity' and 'vaper identity'). We propose distinguishing identity from 'self-appraisal' to capture the distinction between the representation of oneself (e.g. as an 'ex-smoker') and (i) the importance and (ii) the positive or negative evaluation that we attach to what is represented. We label an identity that is appraised as enduring as a 'core identity', related to 'strong identity' because of the appraisal as important. Identities that are appraised positively or negatively involve 'positive self-appraisal' and 'negative self-appraisal' respectively. This allows us to create 'logically defined classes' of identity by combining them (e.g. 'positive core cigarette smoker identity' to refer to a cigarette smoker self-identity that is both positive and important). We refer to the totality of self-identities of a person as a 'composite self-identity'.

CONCLUSIONS

An ontology of identity constructs may assist in improving clarity when discussing theories and evidence relating to this construct in addiction research.

'It's not what you'd term normal smoking': a qualitative exploration of language used to describe heated tobacco product use and associated user identity

BACKGROUND AND AIMS

Tobacco and nicotine marketplaces have diversified over the past decade, including with the introduction of heated tobacco products (HTPs), such as the brand IQOS. HTPs typically heat tobacco to generate an aerosol that is inhaled. HTP nomenclature is lacking, and how HTP users define and identify themselves remains understudied. Research in this area is important because language can construct identity, and identity can shape behaviour. This study aimed to explore users' language choice when describing IQOS use, and how language relates to user identity.

METHODS

Qualitative interviews in London, United Kingdom, with 30 adult current and former IQOS users. Analyses were guided by Iterative Categorization.

RESULTS

Overall, participants expressed confusion and a lack of suitable terminology for how to describe IQOS use. Verbs such as heating and IQOSing were rarely endorsed. Most often, participants reverted to smoking when describing IQOS use and commonly referred to HEETS (tobacco sticks) as cigarettes. Yet the lack of combustion, electronic device, cleaner experience and perceived reductions in health risks led some to frame IQOS as distinct from smoking. Vaping was generally considered inappropriate for describing IQOS use. Participants also manipulated language to suit their circumstances and manage their identity, whereas some IQOS users embraced the terms smoking and smoker, most were eager to distinguish between using IQOS and being labelled a smoker because of the associated negative connotations and to align with perceptions of IQOS use as a better, less harmful behaviour. Instead, when describing their identity, IQOS users more willingly identified as vapers, or ex-smokers, or created new identities (e.g. HEET user).

CONCLUSIONS

People who use or have used IQOS (a brand of heated tobacco product) are ambiguous about IQOS terminology. Participants in this study commonly referred to IQOS use as smoking for lack of a more suitable term, but also resisted being labelled as smokers, a choice that may influence smoking cessation. Clear terminology must be used in surveys and by healthcare professionals when asking about cigarette smoking and e-cigarette and heated tobacco product use.

Identified or conflicted: a latent class and regression tree analysis explaining how identity constructs cluster within smokers

Identity, or 'who I am', is important for smoking behaviour. Identity constructs (parts of a person's identity) are typically examined as separate entities, but emerging evidence suggests that the multifaceted nature of identity is relevant in the context of smoking. This cross-sectional study examined how smoking-related self- and group-identity constructs cluster within adult daily smokers (N = 231), whether classes of smokers can be distinguished based on clusters of identity constructs, and which factors explain class membership. Data were collected online in The Netherlands and Belgium, 2017-2018. Latent class and regression tree analyses showed that participants in Class 1 of 'Identified smokers' (estimated population share 54%) reported stronger smoker self- and group-identities, stronger expected identity loss when quitting smoking, and weaker quitter self-identities and non-smoker self- and group-identities (vs. Class 2 of 'Conflicted smokers'). Class membership was explained by the interaction between mental smoking dependence (dominant explanatory variable), consideration of future consequences, age of smoking onset, self-efficacy, and future self thought clarity. Models had good fit. The identity of more dependent smokers is more strongly oriented toward smoking. Smoking is also more strongly embedded in the identity of smokers who started smoking young, are less inclined to think about the future, and have lower self-efficacy.

Mapping the evidence on identity processes and identity-related interventions in the smoking and physical activity domains: a scoping review protocol

INTRODUCTION

Smoking and insufficient physical activity (PA), independently but especially in conjunction, often lead to disease and (premature) death. For this reason, there is need for effective smoking cessation and PA-increasing interventions. Identity-related interventions which aim to influence how people view themselves offer promising prospects, but an overview of the existing evidence is needed first. This is the protocol for a scoping review aiming to aggregate the evidence on identity processes and identity-related interventions in the smoking and physical activity domains.

METHODS

The scoping review will be guided by an adaption by Levac et al of the 2005 Arksey and O'Malley methodological framework, the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses: Extension for Scoping Review (PRISMA-ScR) and the 2017 Joanna Briggs Institute guidelines. It will include scientific publications discussing identity (processes) and/or identity-related interventions in the context of smoking (cessation) and/or physical (in)activity, in individuals aged 12 and over. A systematic search will be carried out in multiple databases (eg, PubMed, Web of Science). Records will be independently screened against prepiloted inclusion/exclusion criteria by two reviewers, using the Active Learning for Systematic Reviews machine learning artificial intelligence and Rayyan QCRI, a screening assistant. A prepiloted charting table will be used to extract data from included full-text articles. Findings will be reported according to the PRISMA-ScR guidelines and include study quality assessment.

ETHICS AND DISSEMINATION

Ethical approval is not required for scoping reviews. Findings will aid the development of future identity-related interventions targeting smoking and physical inactivity.

Persons living with HIV who do not smoke cigarettes: A comparison of ex-smokers and never smokers

Background and Aims

Approximately half of persons living with HIV (PLWH) in the US smoke cigarettes. Large surveys show that 16.9%–37.3% of PLWH are never smokers compared to 57.5% of US adults. Similar proportions of PLWH and general population adults describe themselves as ex-smokers (20.3% vs 21.9% respectively). Little research has been done to characterize PLWH non-smokers. In this study, we compared a group of well characterized PLWH ex-smokers (i.e., no cigarettes for at least 5 years) to PLWH never smokers with the aim of developing a clearer understanding of the characteristics of these groups and the differences between them.

Design

Cross-sectional interview study employing audio computer-assisted self-interview (ACASI).

Setting

Comprehensive HIV care center in New York City.

Participants

In 2018–2019, we recruited a sample of PLWH never smokers (N = 54) and long-term ex-smokers (no cigarettes for at least 5 years, N = 36). Non-smoking status of participants was verified by exhaled carbon monoxide.

Measurements

We collected a range of sociodemographic, historical, clinical, and psychobehavioral data pertaining to tobacco use.

Results

Compared to never smokers, ex-smokers were older, more likely to have heterosexually acquired HIV and less likely to have same-sex-acquired infection, more likely to have parents and/or siblings who smoked, more likely to have current smoker/s in their households, and more likely to have ever used marijuana, cocaine, and/or heroin.

Conclusions

We describe important demographic and sociobehavioral differences between PLWH never smokers and ex-smokers that may be useful in crafting an effective response to the cigarette smoking epidemic in US PLWH.

I am what I am: A meta-analysis of the association between substance user identities and substance use-related outcomes

OBJECTIVE

Research indicates that a substance user identity (i.e., drinking, smoking, and marijuana identity) is positively correlated with substance use-related outcomes (e.g., frequency, quantity, consequences, and disorder symptoms). The current study aimed to meta-analytically derive single, weighted effect size estimates of the identity-outcome association as well as to examine moderators (e.g., substance use type, explicit/implicit assessment, demographic characteristics, and research design) of this association.

METHOD

Random effects meta-analysis was conducted on 70 unique samples that assessed substance user identity and at least one substance use-related outcome (frequency, quantity, consequences, and/or disorder symptoms), and provided the necessary information for effect size calculations.

RESULTS

Substance user identity was found to be a statistically significant moderate-to-large correlate of all substance use-related outcomes examined in the current study (r _w = .365, p < .001, r_w² = .133). The strongest associations were observed between identity and disorder symptoms (alcohol) and frequency of substance use (tobacco or marijuana). In terms of moderators of the identity-outcome association, the link between explicit drinking identity and alcohol use-related outcomes appeared to be stronger in magnitude than the relationship between implicit drinking identity and alcohol use-related outcomes; however, this difference appears to be largely due to the finding that implicit measures have lower reliability. The strongest identity-outcome association was observed among younger individuals.

CONCLUSIONS

Substance user identity is clearly an important correlate of substance use-related outcomes and this association is stronger among younger individuals. Additional theoretical, empirical, and intervention research is needed to utilize knowledge gleaned from the current study on the identity-outcome association. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

What kind of smoking identity following quitting would elevate smokers relapse risk?

BACKGROUND

Research has suggested that smokers who quit smoking and continue to identify themselves as a smoker versus a non-smoker are at greater risk of relapse. This study examines the relationship between post-quit smoker identities and relapse risk of former smokers in Australia and the UK comparing those who still identified as a smoker with firm choice to no longer smoke versus those not expressing a firm choice. Cross-country differences were examined.

METHODS

Data analysed came from 544 former smokers (quit 1 month or more) who participated in the Australian and UK Waves 9 (2013) and 10 (2014) of the International Tobacco Control (ITC) surveys. Post-quit smoker identities were assessed at baseline and smoking relapse at follow-up.

RESULTS

Baseline self-reported smoker identity independently predicted smoking relapse at 12-month follow-up (p < .01). Compared with the subgroup who identified themselves as smokers trying to quit, those who identified themselves as smokers who had chosen to no longer smoke (OR = 0.01, 95% CI = 0.01-0.25, p < .001), ex-smokers (OR = 0.05, CI = 0.01-0.25, p < .001) or non-smokers (OR = 0.07, CI = 0.02-0.37, p < .001) were less likely to relapse at follow-up. No cross-country differences were found.

CONCLUSIONS

Following quitting, smokers who maintained a smoker identity with a firm choice to no longer smoke or adopted a non-smoker or ex-smoker identity were less likely to relapse than those who failed to do so, suggesting that a clear rule/commitment to not smoke and/or a shift to a non-smoking identity may be protective of relapse.

Tobacco Denormalization Indicator in the Prevalence of Positive Smoker Identity and Its Associated Factors

Positive smoker identity (PSI) is a construct that evaluates the degree of smokers' positive thoughts, images and feeling about smoking behavior and culture. PSI encompasses the indicators related to tobacco denormalization strategy, which is one of the four WHO tobacco endgame strategies. PSmoQi is a newly validated instrument which could reliably assess PSI. This study's objectives were to determine the prevalence of positive smoker identity and its associated factors using PSmoQi. A sample of 253 smokers from government agencies in Kota Bharu City, Malaysia were recruited using invitation letters sent to their head of agencies. Data collection was done in a briefing session voluntary attended by the smokers. Factors associated with PSI were analyzed using Multiple Logistic Regression. The prevalence of smokers with positive smoker identity was 72.3%. Factors associated with positive smoker identity were older age (Adjusted Odds ratio; AOR: 1.042; 95% confident interval; CI: 1.004, 1.081); p = 0.028), higher smoking self-concept scale Malay version (SSCS-M) score (AOR: 1.216; 95% CI: 1.112, 1.329; p < 0.001), higher heaviness index (AOR: 1.002; 95% CI: 1.001, 1.004; p = 0.011) and lower educational attainment (AOR: 0.458; 95% CI: 0.233, 0.900; p = 0.024). This study shows a high prevalence of PSI among smokers from government agencies in Kota Bharu City. Factors such as age, SSCS-M score, heaviness index and educational attainment influenced the level of positive smoker identity in a smoker. The finding would contribute an evidentiary guideline in screening smokers for smoking cessation clinic enrollment to achieve the best interventional outcome, as well as it would provide an objective indicator for tobacco denormalization status in a population.

Associations between vaping and relapse to smoking: preliminary findings from a longitudinal survey in the UK

BACKGROUND

Most smokers attempting to quit relapse. There is little evidence whether the use of e-cigarettes ('vaping') increases or decreases relapse. This study aimed to assess 1) whether vaping predicted relapse among ex-smokers, and 2) among ex-smokers who vaped, whether vaping characteristics predicted relapse.

METHODS

Longitudinal web-based survey of smokers, recent ex-smokers and vapers in the UK, baseline in May/June 2016 (n = 3334), follow-up in September 2017 (n = 1720). Those abstinent from smoking ≥ 2 months at baseline and followed up were included. Aim 1: Relapse during follow-up was regressed onto baseline vaping status, age, gender, income, nicotine replacement therapy use and time quit smoking (n = 374). Aim 2: Relapse was regressed onto baseline vaping frequency, device type, nicotine strength and time quit smoking (n = 159).

RESULTS

Overall, 39.6% relapsed. Compared with never use (35.9%), past/ever (45.9%; adjOR = 1.13; 95% CI, 0.61-2.07) and daily vaping (34.5%; adjOR = 0.61; 95% CI, 0.61-1.89) had similar odds of relapse, for non-daily vaping evidence of increased relapse was inconclusive (65.0%; adjOR = 2.45; 95% CI, 0.85-7.08). Among vapers, non-daily vaping was associated with higher relapse than daily vaping (adjOR = 3.88; 95% CI, 1.10-13.62). Compared with modular devices (18.9% relapse), tank models (45.6%; adjOR = 3.63; 95% CI, 1.33-9.95) were associated with increased relapse; evidence was unclear for disposable/cartridge refillable devices (41.9%; adjOR = 2.83; 95% CI, 0.90-8.95). Nicotine strength had no clear association with relapse.

CONCLUSION

Relapse to smoking is likely to be more common among ex-smokers vaping infrequently or using less advanced devices. Research into the effects of vaping on relapse needs to consider vaping characteristics.

Correlates of smoker identity among intermittent and light daily young adult smokers: Findings from Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study

Identifying as a 'smoker' has been associated with many cigarette smoking-related behaviors, including less frequent and intense cigarette use. Additional smoking behaviors (e.g., use of cannabis or cigars) also may contribute to self-identification as a 'smoker'. This study compared correlates of identifying as a 'smoker' and measurement strategies for non-daily cigarette consumption among young-adult intermittent and light daily smokers. Using data from Wave 1 of the PATH Study, different measurements of past 30-day non-daily cigarette use were evaluated. Weighted logistic regression models were used to compare associations with self-identification as a smoker among 18-24 year-old intermittent and light daily smokers (n = 1531). Use of other smoked products (combustible tobacco, cannabis) and other documented correlates of smoker identity were evaluated. As frequency of monthly smoking increased, self-identification as a smoker increased (1-5 days = 24%, 6-19 days = 48%, 20-29 days = 78%, light daily smokers = 93%, daily smokers using >5 cigarettes per day = 99%). Self-reported smoking status 12 months ago significantly contributed to current identification as a smoker. Smoking cigars daily or using cannabis in the past 30 days were each positively associated with smoker identity. Different measurement approaches to non-daily cigarette use offer different advantages in terms of interpretability and granularity of information. Compared to daily smokers, non-daily smokers exhibit significant variability in identifying as a smoker, and systematic correlates of smoker identification are apparent. These findings may serve to enhance understanding of non-daily smokers and potential targets for intervention among this growing subpopulation of tobacco users.

Re-Configuring Identity Postpartum and Sustained Abstinence or Relapse to Tobacco Smoking

Relapse to smoking postpartum is a common and important public health problem. Difficulty in adjusting to a non-smoking identity is a key factor prompting relapse. However, postpartum relapse prevention interventions rarely focus upon offering support for identity change. We conducted an exploratory inductive analysis of a dataset from the Prevention of Return to Smoking Postpartum (PReS) study to understand identity constructs and experiences of pre- and postpartum women (smokers and ex-smokers), partners and health professionals. Data were obtained from 77 unique participants via focus groups, interviews, email or online questionnaires, and were analyzed by two researchers independently, using NVivo 12. Four main themes emerged reflecting identity transition from the pre- to the postpartum period: (i) Pregnancy and the categorization of smoking status; (ii) the disruption of motherhood and loss of self; (iii) adapting to a maternal non-smoking identity; and (iv) factors influencing sustained abstinence versus relapse to smoking. Postpartum relapse prevention interventions need to consider support for women, and the whole family unit, in adjusting to a new identity as a non-smoking mother. Smoking status should be revisited throughout pregnancy and into the postpartum period to aid the long-term integration of smoke-free behavior.

An Interpretative Phenomenological Analysis of Discontinued Use of the E-Cigarette

Introduction: Many UK smokers use e-cigarettes as a quitting aid; however, a substantial number discontinue use of the e-cigarette and revert to smoking. Understanding why this may happen is important both for individuals and for stop smoking services.

Aims: To explore young adult smokers’ experiences of use and discontinued use of the e-cigarette.

Methods: Semi-structured interviews were conducted with six participants who tried e-cigarettes for at least seven days and returned to smoking. Data was transcribed and analysed using interpretative phenomenological analysis.

Results: Findings suggested participants held conflicting attitudes about using e-cigarettes, which undermined attempts to quit smoking, and led to the discontinuation of the e-cigarette. These conflicts centred on participants’ discomfort with the e-cigarette or vaping identity, lack of abstinence self-efficacy and navigation of barriers to e-cigarette use. The complex interplay of these factors may have led to an underestimation of the individual effort required to continue vaping and reinforced participants’ perception of the e-cigarette as an inferior product to the cigarette.

Conclusions: Future research should focus on the role of identity, self-efficacy, control and smokers’ expectations of e-cigarettes on smoking cessation as these may be important factors to consider for a more tailored service for e-cigarette users.

Development and Validation of Positive Smoker Identity Questionnaire (PSmoQi): A New Instrument for Smoking Cessation Correlates

Background: The positive smoker identity construct, which was based on West's PRIME Theory, affected the smoking prevalence, quit attempts and cessation success. A validated questionnaire which could measure this rich and complex construct may facilitate prediction models of successful cessation. We aimed to develop and validate a questionnaire that assesses positive smoker identity based on West's PRIME Theory. Method: The initial item pool was developed based on a theoretical framework, empirical literature, existing scales and expert review. The questionnaire was conveniently distributed to 100 smokers. Exploratory factor analysis was utilized to explore domains in the questionnaire. Construct and criterion validity, internal consistency and reliability of the domains were analyzed. Results: The final positive smoker identity questionnaire (PSmoQi) has 26 items under four internally-consistent and reliable domains: Contributory factors, contextual and temporal patterning, identity related to smoking, and behaviour in relation to smoking. The full scale demonstrated good internal consistency (∝ = 0.78), acceptable convergent and divergent validity, and good concurrent validity with the smoker self-concept scale. Conclusion: The current study provides fundamental evidence for the PSmoQi as a valid instrument in research related to smoking cessation and interventional strategy. The PSmoQi contained validated domains which could measure almost a full spectrum of smoking cessation components.

Identity processes in smokers who want to quit smoking: A longitudinal interpretative phenomenological analysis

The importance of identity in smoking cessation is increasingly becoming recognized by researchers. This study is the first in-depth longitudinal qualitative investigation of identity change processes among smokers who intend to quit. Participants' accounts of smoking, attempts to quit and sense of identity were explored over time to examine identity continuity and change. Ten smokers with a quit intention were interviewed three times, approximately 1 month apart, and approached for follow-up 2 years later. Data from 30 in-depth interviews were analyzed using the interpretative phenomenological analysis approach. Two themes of identity change processes are presented: "Identity transition makes it easier to quit" and "Identity conflict resolution is needed when quitting is unsuccessful or not attempted." Identity transition toward the identity of nonsmoker appeared to be facilitated by permeable identity boundaries, a continuous sense of identity, and a sense of mastery of quitting. Conflicted smoker identities were observed among participants who continued to smoke, along with barriers that appeared to prevent them from identifying with nonsmoking. Among these participants psychological (e.g. using downward comparisons with worse-off smokers) and behavioral strategies (e.g. hiding smoking from others) were seen that may serve to resolve identity conflict and protect a positive sense of identity. Our findings suggest that transition toward a nonsmoker identity may be necessary for successful quitting. Future research investigating ways to help smokers to perceive themselves increasingly as nonsmokers appears indicated.

Evaluating Within-Person Change in Implicit Measures of Alcohol Associations: Increases in Alcohol Associations Predict Increases in Drinking Risk and Vice Versa

Aims

Implicit measures of alcohol associations (i.e. measures designed to assess associations that are fast/reflexive/impulsive) have received substantial research attention. Alcohol associations related to the self (drinking identity), the effects of alcohol (alcohol excite) and appetitive inclinations (alcohol approach) have been found to predict drinking cross-sectionally and over time. A critical next step in this line of research and the goal of this study is to evaluate whether increases in the strength of these associations predict increases in drinking and vice versa. These hypotheses were tested in a sample of first- and second-year US university students: a sample selected because this time period is associated with initiation and escalation of drinking, peak levels of alcohol consumption and severe alcohol-related negative consequences.

Short summary

This study's purpose was to evaluate whether increases in the strength of alcohol associations with the self (drinking identity), excitement (alcohol excite) and approach (alcohol approach) as assessed by implicit measures predicted subsequent increases in drinking risk and vice versa using a longitudinal, university student sample. Results were consistent with hypotheses.

Methods

A sample of 506 students' (57% women) alcohol associations and alcohol consumption were assessed every 3 months over a 2-year period. Participants' consumption was converted to risk categories based on NIAAA's criteria: non-drinkers, low-risk drinkers and high-risk drinkers. A series of cross-lagged panel models tested whether changes in alcohol associations predicted subsequent change in drinking risk (and vice versa).

Results

Across all three measures of alcohol associations, increases in the strength of alcohol associations were associated with subsequent increases in drinking risk and vice versa.

Conclusion

Results from this study indicate bi-directional relationships between increases in alcohol associations (drinking identity, alcohol excite and alcohol approach) and subsequent increases in drinking risk. Intervention and prevention efforts may benefit from targeting these associations.

The unique contribution of e-cigarettes for tobacco harm reduction in supporting smoking relapse prevention

BACKGROUND

We have little understanding of how vapers use e-cigarettes beyond cessation. E-cigarettes may have a role to play in reducing the health-related harms of tobacco smoking, through not only assisting smoking cessation attempts but also supporting long-term abstinence from smoking. However, there are fears that vaping may lead to the 'renormalisation' of smoking type behaviours. This study aimed to explore patterns of use and reported experiences of vapers quitting smoking using an e-cigarette in relation to long-term smoking status (abstinence or relapse).

METHODS

A purposive sample of 40 UK vapers was matched to a sampling frame of demographic characteristics from a representative sample of UK quitters. Following full informed consent, semi-structured qualitative interviews were conducted. Data were thematically analysed by two members of the research team. Final thematic analysis was verified and agreed by consensus.

RESULTS

The sample self-reported long histories of tobacco use and multiple previous quit attempts which had eventually resulted in relapse back to smoking, although a small but important group had never before attempted to quit. Initiating e-cigarette use was experienced as a revelation for some, who were quickly able to fully switch to using e-cigarettes as an alternative to tobacco smoking. For others, periods of dual use or smoking relapse combined with attempts at vaping that were not initially satisfactory. Many of these chose a cheaper 'cig-a-like' device which they found to be inadequate. Experimentation with different devices and different setups, over time, resulted in some 'sliding' rather than switching to vaping. This involved periods of 'dual use'. Some settled on patterns of vaping as a direct substitute of previous tobacco smoking, whereas others reported 'grazing' patterns of vaping throughout the day that were perceived to support tobacco smoking abstinence.

CONCLUSIONS

Our data demonstrates that e-cigarettes may be a unique harm reduction innovation for smoking relapse prevention. E-cigarettes meet the needs of some ex-smokers by substituting physical, psychological, social, cultural and identity-related aspects of tobacco addiction. Some vapers reported that they found vaping pleasurable and enjoyable-being more than a substitute but actually preferred, over time, to tobacco smoking. This clearly suggests that vaping is a viable long-term substitute for smoking, with substantial implications for tobacco harm reduction.

Strengthening quitter self-identity: An experimental study

OBJECTIVES

Smoking-related self-identity processes are important for smoking cessation. We examined whether quitter self-identity (i.e. identification with quitting smoking) could be strengthened through a writing exercise, and whether expected social support for quitting, manipulated through vignettes, could facilitate identification with quitting.

DESIGN

Participants (N = 339 daily smokers) were randomly assigned to a 2 (identity: strengthened quitter self-identity vs. control) × 3 (social support: present vs. absent vs. neutral control) between-participants design.

MAIN OUTCOME MEASURES

The main outcome was post-test quitter self-identity.

RESULTS

Post-test quitter self-identity was not strengthened successfully. Only a small and marginally significant intervention effect was found on quitter self-identity, which did not generalise to positively influence quit-intention or behaviour. The social support manipulation did not facilitate quitter self-identity. Secondary content analyses showed that quitter self-identity was strengthened among participants who linked quitting smoking to their lifestyle, wanted to become quitters for health reasons, and whose reasons for becoming quitters included approach of positive aspects of quitting, but not among participants who linked quitter self-identity to their self-perceptions.

CONCLUSIONS

Results provide insight into the content of smokers' self-conceptualizations as quitters. Writing exercises should be improved and tested to eventually successfully strengthen quitter identities.

Smokers' identity and quit advice in general practice: General practitioners need to focus more on female smokers

OBJECTIVE

We examined smoker and non-smoker self-identities among smokers visiting their general practitioner (GP) for other reasons than smoking cessation counselling. We determined whether identity impacted on patients' appreciation of GP-initiated conversations about smoking and quit advice, and subsequent quit attempts, and examined the role of gender.

METHODS

Secondary analyses of a cluster-randomised controlled trial in which baseline and 12-month follow-up data were collected among 527 daily (n=450) and non-daily smokers (n=77).

RESULTS

Participants identified more with smoking than non-smoking. Participants with stronger non-smoker self-identities were more often female, appreciated the conversation about smoking more, were more likely to receive quit-advice and to have attempted to quit at 12-month follow-up. Participants with stronger smoker self-identities were also more often female, and appreciated the conversation more. Men with stronger non-smoker self-identities were more often asked about smoking and advised to quit, and appreciated the conversation more than women.

CONCLUSION

Non-smoker identity was more important for receiving quit-advice, appreciation, and quit attempts than smoker identity. Future research needs to unravel why female smokers appreciated the conversation less than male smokers.

PRACTICE IMPLICATIONS

We suggest to incorporate an identity-component in smoking cessation interventions. GPs should increase their focus on female patients who smoke.

Adapting, Pilot Testing and Evaluating the Kick.it App to Support Smoking Cessation for Smokers with Severe Mental Illness: A Study Protocol

(1) Background: While the prevalence of tobacco smoking in the general population has declined, it remains exceptionally high for smokers with severe mental illness (SMI), despite significant public health measures. This project aims to adapt, pilot test and evaluate a novel e-health smoking cessation intervention to assist relapse prevention and encourage sustained smoking cessation for young adults (aged 18⁻29 years) with SMI. (2) Methods: Using co-design principles, the researchers will adapt the Kick.it smartphone App in collaboration with a small sample of current and ex-smokers with SMI. In-depth interviews with smokers with SMI who have attempted to quit in the past 12 months and ex-smokers (i.e., those having not smoked in the past seven days) will explore their perceptions of smoking cessation support options that have been of value to them. Focus group participants will then give their feedback on the existing Kick.it App and any adaptations needed. The adapted App will then be pilot-tested with a small sample of young adult smokers with SMI interested in attempting to cut down or quit smoking, measuring utility, feasibility, acceptability, and preliminary outcomes in supporting their quit efforts. (3) Conclusions: This pilot work will inform a larger definitive trial. Dependent on recruitment success, the project may extend to also include smokers with SMI who are aged 30 years or more.

Improving implementation of the smoking cessation guidelines with pregnant women: How to support clinicians?

OBJECTIVE

this study aimed to explore the enablers and barriers to implementation of the Australian smoking cessation in pregnancy guidelines. These guidelines direct clinicians to follow the 5As of cessation: Ask, Advise, Assess, Assist and Arrange follow-up.

DESIGN

semi-structured interviews based on the Theoretical Domains Framework (TDF) elicited clinicians' views and experiences of implementing the guidelines.

SETTING

antenatal care in the NSW public health system.

PARTICIPANTS

27 maternity service managers, obstetricians and midwives.

FINDINGS

participants confirmed that implementation of the smoking cessation guidelines was sub-optimal. This was particularly the case with Assist and Arrange follow up at the initial visit, and with following any of the 5As at subsequent visits. Key barriers included systems which did not support implementation or monitoring, lack of knowledge, skills and training, perceived time restrictions, 'difficult conversations' and perceiving smoking as a social activity. Enablers included clinicians' knowledge of the harms of smoking in pregnancy, clinicians' skills in communicating with pregnant women, positive emotions, professional role and identity, the potential of training and of champions to influence practice, and systems that regulated behaviour.

KEY CONCLUSIONS

these findings will contribute to the development of a multifaceted intervention to support clinicians in implementing the guidelines.

IMPLICATIONS FOR PRACTICE

Building on existing strengths, antenatal care providers may be supported in implementing the guidelines by working with systems which remind and support implementation, the clear reframing of smoking as an addiction, knowledge and skills development and by realizing the potential of leadership to maximise the impact of reinforcement and social influence.

Progression towards smoking cessation: Qualitative analysis of successful, unsuccessful, and never quitters

BACKGROUND

Understanding how people transition between phases of not making a quit attempt to stopping smoking successfully is important in order to optimize interventions. This study aimed to explore differences in attitudes towards smoking and quitting among smokers and ex-smokers.

METHODS

Adult (age 18 and over) successful (n = 8), unsuccessful (n = 8) and never quitters (n = 7) were recruited through stop-smoking services in England. Semi-structured interviews were conducted and data were analysed using framework analysis.

RESULTS

Seven themes (starting to smoke, positive appraisal of smoking, responsibility for past/current smoking, negative effects of smoking, reasons to quit, process of quitting, and identity) were identified in all groups. Sub-group differences were explored and used to derive six typologies with descriptive characteristics: committed smokers, aware smokers, forced attempters, struggling attempters, pragmatic ex-smokers, and committed non-smokers. Using these typologies and the smallest number of differentiating factors between them (awareness of negative effects, motivation to stop and acceptance of responsibility), a parsimonious model of progression towards smoking cessation was developed.

CONCLUSIONS

Awareness of negative effects, motivation and, crucially, a sense of commitment for taking responsibility to take actions towards behavior change may be important for whether smokers attempt to quit and progress to a successful quit attempt.

The importance of social identities in the management of and recovery from 'Diabulimia': A qualitative exploration

INTRODUCTION

A significant barrier to recovery for individuals with co-morbid eating disorders and type 1 diabetes is the way in which group members self-categorise. Nonetheless, identity issues are neglected during the recovery process. The aim of this paper is to explore how group memberships (and the associated identities) both contribute to and hinder recovery in this cohort.

METHOD

Transcripts from five online focus groups with 13 members of an online support group for individuals with 'Diabulimia' were thematically analysed.

RESULTS

Findings suggested that those with whom one shares a recovery identity can be well placed to provide psychological resources necessary for successful recovery although such connections can be damaging if group norms are not managed. Members recognised that other important relationships (including family and friends and health professionals) are also key to recovery; these other group memberships (and the associated identities) can be facilitated through the recovery identity group membership, which allows for external validation of the recovery identity, provides encouragement to disclose the illness to supportive others, and provides information to facilitate positive service interactions.

CONCLUSIONS

While clinical interventions typically focus on eliminating disordered behaviours, we suggest that these should also include strengthening important group memberships that promote recovery.

A review of implicit and explicit substance self-concept as a predictor of alcohol and tobacco use and misuse

BACKGROUND

This paper provides an overview of the self-concept as it relates to substance use. Self-concept has a long history in psychological theory and research; however, substance self-concept (e.g., viewing one's self as a drinker or smoker) is an understudied area of research with the potential to expand existing conceptualizations of substance use, addiction, and prevention and treatment efforts, and should receive greater research attention.

OBJECTIVES

First, we review and provide a theoretical framework of substance self-concept that draws from dual process models and distinguishes between implicit and explicit self-concept. Next, we summarize key findings related to substance use in the extant literature, focusing on alcohol and tobacco (smoking).

RESULTS

Across both substances, there is converging evidence that substance self-concept is associated with substance use outcomes, including quantity and frequency of use and problems associated with use, and that change in substance self-concept is associated with recovery from substance misuse. Recommendations for the substance self-concept research agenda include routine assessment of substance self-concept, expanded use of implicit measures, investigation of moderators of substance self-concept, and targeting substance self-concept directly in prevention and intervention efforts.

CONCLUSION

Ultimately, we suggest that substance self-concept is a promising, but understudied, construct. Greater research attention to substance self-concept could clarify its potential as an important risk factor for hazardous use and addiction as well as its utility as a prevention and treatment target.

'Everyone here wants everyone else to get better': The role of social identity in eating disorder recovery

Retention of a positively valued illness identity contributes to poor outcomes for individuals with eating disorders (EDs). Consequently, dis-identification from the illness identity and the adoption of a recovery identity are vital for successful recovery. While social identity processes have been shown to influence ED maintenance, their role in recovery is rarely considered. This study explores how a sense of shared identity helps individuals with EDs manage their condition and promotes recovery. Transcripts from 18 online support sessions involving 75 participants were thematically analysed. Our findings suggest that the illness identity initially operates as a social identity that forms the basis for connections with similar others. For those wishing to recover, identity-based support is then perceived to be more effective than that found outside the group. Online interactions also facilitate construction of a new shared recovery identity which promotes a shift from the illness identity as a primary source of definition and endorses group norms of illness disclosure and treatment engagement. While in the clinical literature, ED identity is seen as problematic and interventions are targeted at challenging an individual's self-concept, we suggest that interventions could instead harness identity resources to support a transition to a recovery identity.