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Ildiko Tombor, Lion S hahab, Jamie Brown, Robert West

Positive smoker identity as a barrier to quitting smoking: Findings from a national survey of smokers in England. Ildiko Tombor, Lion S hahab, Jamie Brown, Robert West Department of Epidemiology and Public Health Health Behaviour Research Centre Tobacco Research Group. Outline.

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Ildiko Tombor, Lion S hahab, Jamie Brown, Robert West

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  1. Positive smoker identity as a barrier to quitting smoking: Findings from a national survey of smokers in England Ildiko Tombor, Lion Shahab, Jamie Brown, Robert West Department of Epidemiology and Public Health Health Behaviour Research Centre Tobacco Research Group

  2. Outline

  3. Background A systematic review1 of studies in adult general population samples: • Variables related to motivation to stop smoking: e.g. health concerns and enjoyment of smoking quit attempts • Measures related to cigarette dependence: quit success • Positive smoker identity has not been explored, but might have an impact on both quit attempts and success. It may be an important target for messaging aimed at promoting smoking cessation. 1Vangeli et al., 2011, Addiction, 106, 2110-2121.

  4. Background 2Schwartz et al., 2011, Handbook of Identity, Springer; 3Oyserman et al., 2011, Springer pp 117; 4Vignoles et al., 2011, Springer pp 403; 5West, 2006, The Theory of Addiction, Blackwells.

  5. The PRIME theory of motivation5 Thoughts (self-labels, attributes and personal rules) and images about ourselves and feelings attached to these. Identity www.primetheory.com 5West, 2006, The Theory of Addiction, Blackwells.

  6. Background • Shifting between different smoker identities during smoking cessation6. • Discrepancies between behaviour and smoker identity10. • Making effort to distance themselves from their smoker identity7. • Established smoker identity associated with smoking escalation in adolescents11. • Smokers with a smoker identity were less likely to make a quit attempt12. • Those with strong non-smoker identity were more likely to remain abstinent than those with an established smoker identity7-9. • Smoker and abstainer self-concept at baseline predicted quit success during smoking cessation treatment13. 6Vangeli & West, 2012, Brit J Health Psych, 17, 171-184.; 7Brown et al., 2011, Addictive Behav, 36, 1199-1204.; 8Thompson et al., 2009, Soc Cult Geogr, 10, 565-581.; 9Johnson et al., 2003, Res Nurs Health, 26, 387-397.; 10Levinson et al., 2007, Nicotine Tob Res, 9, 845-852.; 11Hertel et al., 2012, Health Psych, 31, 467-475.; 12van den Putte et al., 2009, Health Psych, 28, 535-544.; 13Shadel & Mermelstein, 1996, Ann Behav Med, 18, 151-156

  7. Aims To examine the role positive smoker identity plays in making quit attempts as well as quit success prospectively. 1. What is the proportion of smokers in a nationally representative sample who report a positive smoker identity? 2. What socio-demographic, smoking variables and smoking- related attitudes are associated with positive smoker identity? 3. What is the predictive relationship between positive smoker identity for quit attempts and quit success at six months follow-up?

  8. Methods Smoking Toolkit Study • Cross sectional monthly survey of a representative sample of smokers (age 16 and over) in England14-15. • A follow-up six months after the baseline. • Measures used in this study were included June 2010 and March 2012. Participants • Representative sample of current cigarette smokers (including hand-rolled cigarettes), who smoke daily or occasionally. • Provided data for all included variables. NBaseline=9,456 N6-month follow-up=2,099 14Fidler et al., 2011, BMC Publ Health, 11(479); 15www.smokinginengland.info

  9. Measures • Demographic characteristics (age, gender, social grade); • Nicotine dendence: Heaviness of Smoking Index; • Motivation to Stop Scale; • Attitudes to smoking: ‘How do you feel about being a smoker?’ (e.g. ‘I like being a smoker’, ‘I enjoy smoking’, ‘I’m confident I could stop if I tried’, ‘I am worried that smoking is harming my health right now’); • Recent quit attempts: ‘Have you made a serious attempt to stop smoking in the past 12 months?’ • At 6-month follow up: ‘How long ago did the most recent quit attempt start?’; • Quit success: A quit attempt has been made during the follow up and still not smoking at follow up.

  10. Results *Significant difference between follow-up and lost to follow-up samples (p<0.05)

  11. Results Prevalence of positive smoker identity* • 18.3% (95% CI=17.5-19.2) of adult smokers had a positive smoker identity. • *Calculated by using weighted data to match the sample with the 2001 census on age, gender and social grade.

  12. Results Demographic and smoking characteristics associated with positive smoker identity* (N=9,456) • Being male [OR=0.87 (0.77-0.97); p=0.013] • Being older [OR=1.11 (1.07-1.15); p<0.001] • Having greater nicotine dependence [OR=1.09 (1.04-1.13); p<0.001] • Less motivated to stop [OR=0.71 (0.68-0.73); p<0.001] • No quit attempt in past year [OR=0.85 (0.74-0.98); p=0.025] • Enjoy smoking [OR=1.65 (1.47-1.86); p<0.001] • Addicted to smoking [OR=1.58 (1.39-1.79); p<0.001] Social Grade [OR=0.97 (0.86-1.09); p=0.610] Confidence in ability to stop [OR=1.15 (1.00-1.32); p=0.054] Worries about current health [OR=1.09 (0.93-1.27); p=0.284] Worries about future health [OR=1.00 (0.87-1.15); p=0.988] Worries about the effects smoking has on family [OR=1.12 (0.97-1.31); p=0.134] Worries about the costs of smoking [OR=1.04 (0.93-1.17); p=0.509] * Logistic regression, adjusted for all study variables

  13. Results Predictors of quit attempts at 6-month follow up* (N=2,099) • Having a positive smoker identity [OR=0.69 (0.53-0.91); p=0.007] • Enjoy smoking [OR=0.71 (0.58-0.87); p=0.001] • Confidence in ability to stop [OR=1.53 (1.22-1.92); p<0.001] • Worries about future health [OR=1.28 (1.02-1.60); p=0.031] • Worries about the effects smoking has on family [OR=1.41 (1.12-1.77); p=0.004] • Being older [OR=1.10 (1.03-1.17); p=0.005] Gender [OR=0.89 (0.74-1.08); p=0.251] Social grade [OR=0.98 (0.80-1.21); p=0.853] Nicotine dependence [OR=0.97 (0.90-1.03); p=0.300] Worries about current health [OR=1.19 (0.94-1.51); p=0.143] Worries about the costs of smoking [OR=1.07 (0.88-1.31); p=0.490] Addicted to smoking [OR=1.14 (0.92-1.41); p=0.245] * Logistic regression, adjusted for all study variables

  14. Results Predictors of quit success at 6-month follow up* (N=638) • Greater nicotine dependence predicted the failure to quit successfully [OR=0.82 (0.72-0.94); p=0.004] Positive smoker identity [OR=0.54 (0.29-1.01); p=0.053] Age [OR=0.96 (0.84-1.09); p=0.496] Gender [OR=0.88 (0.60-1.30); p=0.524] Social grade [OR=0.73 (0.48-1.10); p=0.132] Worries about current health [OR=0.91 (0.56-1.47); p=0.691] Worries about future health [OR=0.79 (0.51-1.24); p=0.305] Worries about the effects smoking has on family [OR=1.16 (0.74-1.80); p=0.518] Worries about the costs of smoking [OR=0.97 (0.64-1.45); p=0.871] Addicted to smoking [OR=1.26 (0.82-1.96); p=0.295] Enjoy smoking [OR=1.03 (0.68-1.55); p=0.904] Confidence in ability to stop [OR=0.90 (0.57-1.41); p=0.637] * Logistic regression, adjusted for all study variables

  15. Discussion • In line with previous work16: the majority of smokers did not like being a smoker. Increasing social stigmatization and unacceptability of smoking: Negative feelings about being a smoker17. Do not want to identify themselves with the this self-label10. 10Levinson et al., 2007, Nicotine Tob Res, 9, 845-852.; 16Jarvis et al., 2002, BMJ, 324(7337): 608; 17Ritchie et al., 2010, Nicotine Tob Res, 12, 622-629.

  16. Discussion • Having a positive smoker identity was independently associated with being older, male, reporting stronger nicotine dependence, lower motivation to stop smoking, addiction to and enjoyment of smoking and not having made a quit attempt in the past year. Similar to some characteristics of ‘hardcore smokers’18. Longer smoking history and established nicotine dependence: smoking becomes a firmly entrenched part of identity. Attempt to reduce their cognitive dissonance. 18Jarvis et al., 2003, BMJ, 326(7398): 1061.

  17. Discussion Congruent with the predictions of PRIME theory5 and previous studies of smoker identity12 and self-perceived motivational factors for continuing smoking1: • Positive smoker identity was an important barrier over and above other predictors of quit attempt prospectively. 1Vangeli et al., 2011, Addiction, 106, 2110-2121.; 5West, 2006, Oxford: Blackwells; 12van den Putte et al., 2009, Health Psych, 28, 535-544.

  18. Discussion • The association between positive smoker identity and quit success was similar in magnitude and was also in the negative direction, but failed to reach statistical significance. Further research is needed to verify whether the lack of significant association holds in different samples13. • As expected1, 19, lower nicotine dependence was associated with quit success. 1Vangeli et al., 2011, Addiction, 106, 2110-2121.; 13Shadel & Mermelstein, 1996, Ann Behav Med, 18, 151-156; 19 Diemert et al., 2013, Am J Public Health, 106, 2110-2121.

  19. Limitations • A single ‘yes or no’ question was used as an indication of whether a smoker had a positive smoker identity. • There was a low follow-up rate at six months and the follow-up sample was not selected on the basis of representativeness for the general adult population in England. • Past quit attempts might be forgotten especially if they were unsuccessful or lasted for a shorter period of time or occurred longer ago.

  20. Conclusions • Only a minority of smokers in England have a positive smoker identity. • However, this identity aspect appears to be an important barrier to quitting smoking.

  21. Acknowledgements Co-authors: Dr Lion Shahab Dr Jamie Brown Professor Robert West Funding sources:

  22. Thank you! Email: ildiko.tombor.11@ucl.ac.uk

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