Research article
Smoker Characteristics and Smoking-Cessation Milestones

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Background

Contextual variables often predict long-term abstinence, but little is known about how these variables exert their effects. These variables could influence abstinence by affecting the ability to quit at all, or by altering risk of lapsing, or progressing from a lapse to relapse.

Purpose

To examine the effect of common predictors of smoking-cessation failure on smoking-cessation processes.

Methods

The current study (N=1504, 58% female, 84% Caucasian; recruited from January 2005 to June 2007; data analyzed in 2009) uses the approach advocated by Shiffman et al. (2006), which measures cessation outcomes on three different cessation milestones (achieving initial abstinence, lapse risk, and the lapse–relapse transition) to examine relationships of smoker characteristics (dependence, contextual and demographic factors) with smoking-cessation process.

Results

High nicotine dependence strongly predicted all milestones: not achieving initial abstinence, and a higher risk of both lapse and transitioning from lapse to complete relapse. Numerous contextual and demographic variables were associated with higher initial cessation rates and/or decreased lapse risk at 6 months post-quit (e.g., ethnicity, gender, marital status, education, smoking in the workplace, number of smokers in the social network, and number of supportive others). However, aside from nicotine dependence, only gender significantly predicted the risk of transition from lapse to relapse.

Conclusions

These findings demonstrate that (1) higher nicotine dependence predicted worse outcomes across every cessation milestone; (2) demographic and contextual variables are generally associated with initial abstinence rates and lapse risk and not the lapse–relapse transition. These results identify groups who are at risk for failure at specific stages of the smoking-cessation process, and this may have implications for treatment.

Introduction

Smoking-cessation research generally uses long-term abstinence to index the characteristics of a person associated with quitting success. However, Shiffman and colleagues1 suggested that long-term abstinence reflects multiple cessation processes,2, 3 and successful cessation may depend on several components (“milestones”): achievement of short-term abstinence, avoidance of lapse, and if lapse occurs, avoidance of relapse.1 Parsing this multicomponent process into meaningful subunits may provide insight into the cessation process. The current study aims to advance understanding of the critical determinants of abstinence by relating smoker characteristics to cessation milestones.

Shiffman and colleagues1 argued that smoking-cessation milestones may reflect different causal instigators and mechanisms. For instance, initial cessation may reflect the severity of the nicotine withdrawal syndrome.4 Lapsing often occurs in the presence of smoking cues and stressors, and it may reflect the strength of associative processes or coping skills.4, 5, 6, 7, 8, 9 The lapse–relapse transition may reflect nicotine dependence processes being primed or reinstated following a lapse.10, 11, 12

Research has not systematically explored how smoker characteristics relate to cessation processes. The relationships between risk factors and milestones could provide insight into causes of cessation failure and suggest treatment strategies (e.g., by addressing risk factors for lapse–relapse progression for smokers who have lapsed).

Research13, 14, 15, 16 shows that cessation outcomes are affected by smoker characteristics and life context variables. Theory and multivariate studies13, 14, 15, 16 of relapse risk identified nicotine dependence, demographic, and life context variables as likely influences on cessation milestones.

Based on research relating smoker characteristics with long-term abstinence, five contextual and five demographic variables were selected for analysis (contextual variables: home and work smoking bans,17, 18, 19, 20, 21 smokers in the social network,22, 23, 24, 25 social support,24, 26, 27, 28, 29 and stress27, 30, 31, 32, 33, 34; demographic variables: marital status,35 gender,36 SES,37, 38, 39 ethnicity,40, 41, 42 and age14, 15, 43). Many of the contextual and demographic variables used in the present study predict encounters with key contexts, cues, and episodic events (stressors, strength of phasic affective reactions). For instance, the probability of exposure to smoking cues may be related to home and work smoking bans and smokers in the social network.4, 44, 45, 46, 47, 48 Other variables may predict exacerbation or buffering of episodic events such as stressor occurrence or affective reactions (e.g., social support24, 26). Finally, several demographic variables may affect relapse because they are catch-all indicators of both contextual risk and stress (e.g., SES, ethnicity19, 27, 33, 39, 49, 50). Because previous research4, 5, 6, 7, 8, 9 has linked lapses with particular contexts (e.g., social situations) and with episodic environmental challenges such as smoking cues, negative affect, and stressors,7 it was predicted that the contextual and demographic variables would be consistently associated with lapse likelihood. A further prediction was that nicotine dependence would be especially associated with initial cessation and the risk of lapse–relapse transition. This could be due, respectively, to dependence-related withdrawal2, 4, 51 and lapse-induced priming of dependence processes.11, 52

The current study uses clinical trial data53 to determine the relationship between smoker characteristics (nicotine dependence, demographics, and life context) and the achievement of smoking-cessation milestones.

Section snippets

Participants

Participants were 1504 smokers (58% female, 83% Caucasian; Table 1) from southeastern Wisconsin, participating in a clinical trial.53 Participants were recruited January 2005–June 2007; data were analyzed in 2009. Inclusion criteria were daily smoking (>9 cigarettes/day) and being motivated to quit. Exclusion criteria included medical contraindications to study medications; heavy alcohol consumption (≥6 drinks 6 days per week); or self-reported history of seizure, schizophrenia, psychosis,

Achievement of Milestones

Of the 1504 smokers in the study, 1429 (95.0%) had complete calendar data for the first 14 days. Of those 1429, a total of 1259 achieved initial abstinence (88.1%; median=0 days). Of the 1259 who achieved initial abstinence, 930 lapsed (73.9%; median=7 days). Of those 930 who lapsed, 585 relapsed (62.9%; median days to relapse=38; median days from lapse to relapse=15; Table 2).

Reporting of Results

Main effects and alpha-corrected significance levels are presented in Table 3.

Nicotine Dependence

Those with higher FTND scores were less

Discussion

Consistent with hypotheses, nicotine dependence was associated with decreased rates of initial cessation and higher risk of transitioning from lapse to relapse, independent of demographic and life context factors. This is consistent with Edwards' (1975) theory60 that rapid reinstatement of drug use is a hallmark of dependence. Nicotine dependence was related to lapse risk when tested alone, but not in multivariate models. This suggests that nicotine dependence has some relationship to the

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