A longitudinal study into the reciprocal effects of identities and smoking behaviour: Findings from the ITC Netherlands Survey

The stigma of smoking among women: A systematic review

BACKGROUND

Smoking stigma has been well documented, but little is known regarding its specific features and effects on women. Notably, women face unique social, cultural, and economic challenges that may interact with smoking stigma and impact health outcomes. This review investigates the extent to which smoking women encounter and internalise stigma, while examining the various coping mechanisms they employ to manage these negative experiences.

METHODS

In November 2022, major databases were systematically searched with no time restrictions. After applying inclusion and exclusion criteria, 23 studies (three quantitative and 20 qualitative) met our criteria. We conducted a quality assessment and summarised the findings pertaining to public stigma, self-stigma, and coping strategies.

RESULTS

The stigma about smoking emerges from a variety of sources, such as family, healthcare providers, or internet forums. Women smokers are universally aware of the negative image they have in society. Yet, their experiences and management of the stigma of smoking are shaped by other variables such as cultural background, social class, or motherhood status. Smoking stigma produces ambivalent effects, such as concealment, reduced usage of support services, and to a lesser extent, smoking cessation motivation.

CONCLUSIONS

These results indicate that smoking stigma is an important social justice and public health issue and that further research is needed to better prevent its effects on women's well-being and health behaviours.

"Boy, what are we all doing? We are crazy, really crazy": a qualitative study of psychosocial processes around an atypical one-time smoking cessation course

BACKGROUND

Smoking prevalence is still high, which requires effective interventions that help many people who smoke at once in addition to time-consuming individual interventions. 'I Quit' is a large-scale smoking cessation course in The Netherlands. This qualitative study explored I Quit participants' experiences during and after the course, and perceptions of whether and how the course may have altered their smoking behavior.

METHODS

We performed individual semi-structured interviews with course participants (N = 21) who had either quit successfully, attempted to quit but relapsed, or had continued to smoke after 'I Quit'. Shortly after qualitative data collection was completed, Foundation I Quit was accused in the media of a number of misbehaviors. Although unplanned, this provided a unique opportunity to explore participants' views on alleged fraud in a second round of interviews (N = 16). Data were collected from 2016 to 2018.

RESULTS

Qualitative findings showed two psychosocial processes that may explain smoking cessation after course attendance. First, the confrontation with a large group of people who smoke, of whom some had already developed smoking-related complaints, triggered identity processes both towards and away from quitting smoking. Unorthodox methods used in the course appeared to trigger identity processes. Second, social support after the course from participants' own social network facilitated maintenance of successful quitting. The study also found that interview participants' opinions on I Quit did not change much after allegations of fraud in the media.

CONCLUSIONS

Findings suggest that a one-time course might initiate psychosocial processes that could help certain smokers to gain motivation to quit, requiring a minimum of resources. Identity processes triggered by the course seem tricky as people have different ways of dealing with identity threat, some of which can be counterproductive and even result in more difficulty quitting. More research is needed to examine who can benefit from a one-time course, and who needs more support in order to quit successfully.

Prisoners' experience of health self-management: A qualitative study

PURPOSE

Among the noninstitutionalized population, health care is increasingly shifting from a paternalistic model toward promoting patients' involvement in decision-making and in managing their condition. This paradigm shift toward health self-management is less applicable to individuals in prison whose health management choices are limited. The aim of this study was to explore prisoners' health self-management needs and the strategies used to maintain health self-management in a highly restrictive prison environment.

DESIGN

A qualitative phenomenological study design was selected for this research.

METHODS

An interpretive phenomenological analysis was chosen to present the narratives of prisoners regarding their health self-management. Semi-structured interviews were conducted with 15 male prisoners followed by content analysis.

RESULTS

The analysis of the participants' narratives revealed four major themes: (1) "I thrive on the anger so I can turn it into some more sit-ups:" Initiating sporting activities (2) "Food shouldn't be that white…:" Prisoners' quest for healthier eating (3) "I felt I want more out of life…:" Avoiding an unhealthy lifestyle (4) "I want to be taken care of:" The struggle for better health care.

CONCLUSIONS

The findings suggest that prisoners can overcome the challenges of maintaining health in prison and become committed to better health management. Prisoners who serve as health resources may help reduce the load on correctional facilities' health care systems and the public.

Predictors of changes in running and smoking identity among individuals in the Run to Quit smoking cessation program

OBJECTIVES

Multiple health behaviour change is a viable strategy to promote health outcomes. An example is the use of running behaviour to support smoking cessation in the group-mediated Run to Quit program. On the basis that changes in running and smoking identity were related to changes in running and smoking behaviour among individuals in the Run to Quit program, the purpose of this study was to extend these findings by examining key predictors of change in both running and smoking identity.

METHODS

We analyzed data collected from 450 adult individuals (70.67% female, and 92.44% white) during the program evaluation of Run to Quit from 2016 to 2018. Participants completed assessments at week 1 (baseline), week 3 (mid-program), and week 10 (follow-up) of the program. Relevant predictor variables for change in identity were identified by drawing from theory (identity theory, identity control theory, physical activity self-definition model, social identity theory) and past research regarding exercise and smoking identity. Potential predictors of changes in running and smoking identity included changes in behaviour, self-efficacy, perceptions of the social environment (task and social cohesion, descriptive norms), as well as smoking identity and running identity, respectively. Two regression models, using residualized change scores (for each variable) and relative Pratt indices, were constructed for both running and smoking identity.

RESULTS

Changes in running self-efficacy, running frequency, and individual attractions to the group exercise tasks were significant and meaningful predictors of change in running identity, whereas changes in objectively measured smoking behaviour and running identity were significant and meaningful predictors of change in smoking identity.

CONCLUSION

Consistent with identity theories and past research, ensuring individuals develop a sense of efficacy and enjoy group exercise tasks both represent viable strategies to enhance exercise identity. Including an exercise component within smoking cessation programs may help individuals replace their existing smoking identity with a healthier exercise identity.

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.

Maturing Out: Between- and Within-Persons Changes in Social-Network Drinking, Drinking Identity, and Hazardous Drinking Following College Graduation

Many college students reduce hazardous drinking (HD) following graduation without treatment. Identifying cognitive mechanisms facilitating this "natural" reduction in HD during this transition is crucial. We evaluated drinking identity as a potential mechanism and tested whether within-person changes in one's social network's drinking were linked to within-person changes in drinking identity and subsequent within-person changes in HD. A sample of 422 undergraduates reporting HD was followed from six months before until two years after graduation. Their drinking, drinking identity, and social networks were assessed online. Within-person changes in drinking identity did not mediate the relationship between within-person changes in social network drinking and personal HD, though significant positive between-person associations among all constructs were found. Instead, there was some evidence that within-person changes in drinking identity followed changes in HD, suggesting that drinking identity may function as a marker versus mechanism of "natural" HD reduction during transition out of college.

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.

Illness Perceptions and Self-Management among People with Chronic Lung Disease and Healthcare Professionals: A Mixed-Method Study Identifying the Local Context

Self-management interventions (SMIs) may fail if they misalign with the local context. To optimize the implementation of SMIs in Chinese people with chronic lung disease (CLD), the local context was identified in Chinese primary care (PC) and secondary care (SC). A mixed-method study using semi-structured interviews and quantitative surveys was conducted on people with CLD and healthcare professionals (HCPs). The qualitative data was collected until data saturation was reached, and participants were invited to complete the survey after the interview. The qualitative data—analyzed with the framework approach—was triangulated with the quantitative data. A total of 52 participants completed the interviews, and 48 also finished the survey. Four themes were identified; (a) illness perceptions (e.g., patients had poor CLD knowledge and SM, inadequate resources lead to suboptimal disease control in PC); (b) self-management skills (e.g., most patients delayed exacerbation recognition and action, and some were admitted at the crisis point); (c) factors influencing self-management skills (e.g., (in)adequate disease knowledge and medical expenditure affordability); and (d) needs for self-management (e.g., increased disease knowledge, individualized self-management plan, eHealth, (healthcare insurance) policy support). Identified themes were dependent on each other and should be leveraged when implementing SMIs. Ultimately, such SMIs can optimize patient health outcomes.

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).

Results of a Feasibility Study of Helpers Stay Quit Training for Smoking Relapse Prevention

INTRODUCTION

Most smoking quit attempts end in relapse, and interventions focused on relapse prevention are lacking. Helpers Stay Quit (HSQ) is a novel behavioral relapse prevention intervention that teaches newly abstinent smokers to offer a "helping conversation" (HC) to help others quit tobacco.

METHODS

Pre-post intervention feasibility study with state quitline participants ≥14 days abstinent. Measures at baseline, 3 months, and 6 months included smoking status, offering HCs, and cessation self-efficacy. Primary outcomes: self-reported 7-day point prevalence abstinence; offering HCs. Cox models explored association of HCs with relapse. Preliminary effects analysis using propensity score matching compared 30-day abstinence of quitline clients with study sample at 7 months.

RESULTS

Participants (N = 104) were as follows: mean age of 53 years (SD 13.9 years), 48.1% male, mean of cigarettes smoked/day of 16.2 (SD 9.7). Compared with participants who remained abstinent (n = 82), relapsers (n = 22) had fewer HCs over 6 months (2.6 vs 7.2; 95% confidence interval [CI]: 1.4, 7.8, p = .006). Using adjusted Cox regression, the hazard ratio of relapse for each HC was 0.85 (95% CI: 0.74, 0.99, p = .03). Compared with a matched sample of quitline clients not exposed to HSQ, study participants were 49% more likely to report 30-day abstinence at 7-month quitline follow-up (95% CI: 40%, 59%, p < .0001).

CONCLUSIONS

HSQ, delivered to newly abstinent smokers who received standard quitline treatment, was associated with less self-reported relapse. These promising preliminary study results warrant further research to evaluate HSQ as a novel behavioral intervention to prevent smoking relapse.

IMPLICATIONS

To date, behavioral interventions for smoking relapse prevention that teach abstainers cessation skills to apply to themselves have not shown effectiveness. This feasibility study examines the preliminary efficacy of a conceptually novel, "help others" behavioral intervention approach for relapse prevention in newly abstinent smokers recruited from a state quitline. HSQ teaches the newly abstinent smoker communication and listening skills to encourage other smokers in their personal social network to quit. Exploratory analysis using propensity score matching suggests that participants exposed to HSQ were significantly more likely to self-report 30-day abstinence at quitline 7-month follow-up than other quitline clients.

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.

An investigation of the relationship between identifying as a smoker and urges to smoke among young adult combustible cigarette smokers

Identifying as a smoker and urges to smoke are 2 predictors of persistent combustible cigarette smoking. We investigated the relationship between them. Specifically, grounded in PRIME Theory (West & Brown, 2013), we investigated whether a smoker identity and urges to smoke predict each other over time independent of their relationships with smoking behavior. At 3 yearly time points, young adult combustible cigarette smokers (N = 286) completed assessments of endorsement and importance of identifying as a smoker as well as smoking behavior; during the subsequent week at the first 2 time points, participants repeatedly completed assessments of momentary smoking urge intensity and current social situation in randomly prompted ecological momentary assessments (EMA). Within time points, greater endorsement of identifying as a smoker predicted more intense momentary urges to smoke, particularly when in the presence of other people than when alone. Across time points, both elevated and elevating levels of smoker identity endorsement predicted increases in average smoking urge intensity; vice versa, both elevated and elevating levels of average smoking urge intensity predicted increases in smoker identity endorsement and importance. All relationships were independent of smoking behavior. These findings add to our understanding of persistent combustible cigarette smoking, as they indicate that a smoker identity and urges to smoke contribute to each other independent of their relationships with smoking behavior. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A qualitative study exploring cues and other motivators among a racially diverse sample of light and intermittent smokers

Introduction

Light and intermittent smokers (LITS) represent almost 50% of all current smokers. Research is needed to understand smoking motives among adult light smokers.

Aims

To explore smoking cues and motivators among a racially diverse sample of adult LITS (≤10 CPD). In addition, we explored differences between native (always smoked ≤10), and converted (former heavier) LITS.

Methods

We used purposive sampling to recruit participants who were native and converted LITS and to include equal numbers of African Americans, Whites and Latinos. We coded and analyzed transcripts using a stage approach to identify themes.

Results

Four main themes emerged that may be unique to light smokers and suggests potential strategies for intervention: (1) smoking in response to cues and control, (2) identifying as a smoker, (3) concern about health consequences, and (4) other priorities influencing smoking. There were some differences among smoking cues and motivators by race and ethnicity, and differences between native and converted LITS.

Conclusions

Overall, LITS reported drivers of smoking that were unrelated to symptoms of nicotine withdrawal. Even when experiencing salient cues, our LITS cohort expressed the ability to assert control over smoking by abstaining when situational contexts made smoking inconvenient.

Social identity differentiation predicts commitment to sobriety and wellbeing in residents of therapeutic communities

RATIONALE

Therapeutic communities (TC) for alcohol and other drug treatment rely strongly on social factors as agents of recovery; an approach known as 'community-as-method'. This study adopted a social identity approach in examining the relative strength of participants' recovery group identity and substance using group identity at admission (T1) and after six months (T2) in a TC.

OBJECTIVES

Were to investigate whether identity differentiation - the extent to which respondents see themselves more as belonging to recovery groups than belonging to substance using groups - (a) is related to individuals' primary substance of concern (i.e., amphetamine type stimulants; alcohol; other drugs), and (b) predicts positive indicators of recovery six months after entering a therapeutic community.

METHOD

Adults (N = 307) entering one of five Australian therapeutic communities (TC) completed measures of identification (user, recovery), commitment to sobriety, psychological distress, and personal wellbeing.

RESULTS

Participants' endorsement of the user and recovery identity at T1 and T2 did not differ as a function of primary substance of concern. User identity diminished over the six months while recovery identity remained high, regardless of primary drug category. Identity differentiation measured at T2 accounted for 20-25% variance in commitment to sobriety and wellbeing, after accounting for participant demographics, addiction severity, and T1 identity variables.

CONCLUSIONS

These findings highlight the importance of the relative strength of recovery over substance use related identities in supporting recovery indicators and the central role of the TC in supporting this trajectory.

Changing from the inside out? Examining relationships between overweight identification, dieting behaviours, and body measurements over time

OBJECTIVE

To investigate whether changes in overweight identification were associated with dieting behaviours and body measurements over time.

DESIGN

Longitudinal study with assessments at three time points: before and twice during (i.e., baseline, 6 months, 12 months) a 1-year self-directed weight loss attempt.

METHOD

Eighty individuals with overweight or obesity (classified by BMI ≥ 25) reported their personal (i.e., I see myself as overweight), social (i.e., I identify/feel strong ties with other overweight people), and affective (i.e., I am pleased to be overweight) overweight identification; dieting behaviours (e.g., eat less, exercise, eat more fruit and vegetables); and had their body measurements taken (i.e., weight, height, body fat, waist circumference).

RESULTS

Linear mixed modelling was used to examine between-person differences and within-person changes in overweight identification on dieting behaviours and body measurements over time. Between-person differences mattered for measurements: Higher personal overweight identification was associated with higher BMI, body fat, and waist circumference over time. Higher social overweight identification was associated with higher BMI over time. Within-person changes mattered for behaviours over time: At 12 months, decreases in social overweight identification were associated with increases in a subset of 'Eat Less, Move More' dieting behaviours, but not a subset of 'Healthy' dieting behaviours. At 12 months, decreases in affective overweight identification were also associated with increases in 'Eat Less, Move More' dieting behaviours.

CONCLUSION

Addressing different aspects of overweight identification and how they change over time, may harness an important psychological pathway to support behavioural change and health irrespective of weight loss. Statement of contribution What is already known on this subject? Psychological factors, such as self-concept clarity and weight stigma, are associated with dieting behaviours and body measurements. Qualitative data suggest that identity change may be tied to dieting behaviours and weight loss. What does this study add? New insights into the nature of another psychological factor, overweight identification, among individuals with overweight and obesity attempting to lose weight. The first quantitative evidence that different aspects of overweight identification, and changes in these aspects of overweight identification over time, influence body measurements and dieting behaviours.

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.

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.