Patient experience of smoking lapse and relapse back to smoking

Dr Caitlin NotleySSA Research Fellow, Norwich Medical

School, University of East Anglia

Faculty of Medicine and Health Science Norwich Medical School

Background• NHS Stop Smoking services are effective and cost-

effective (West et al, 2013), but relapse is common (Ferguson, 2005)

• Insufficient evidence for any specific RP intervention (Hajek et al, Cochrane review, 2009, Agboola et al, 2010)

• Current smoking cessation guidelines do not recommend any specific interventions for smoking relapse prevention (NICE, 2008)

Faculty of Medicine and Health Science Norwich Medical School

Norwich Medical SchoolFaculty of Medicine and Health Science

A Randomised Controlled Trial of Self-help Materials for the Prevention of

Smoking Relapse (09/91/36)

Investigators: F Song (PI)1, R Holland1, G Barton1, M Bachman1, P Aveyard2, S Sutton3, J Leonardi-Bee4, T Brandon5

Project coordinators: V Maskrey1, A Blyth1 Collaborators: M Adeney6, K McGoldrick6, T Dyer7, C Slater8

1. Norwich Medical School, University of East Anglia, UK2. Nuffield Department of Primary Care Health Sciences, University of Oxford, UK3. Institute of Public Health, University of Cambridge, UK4. Epidemiology and Public Health, University of Nottingham, UK5. Tobacco Research and Intervention Program, University of South Florida, USA 6. SmokeFree Norfolk, Norfolk Community Health and Care Trust 7. Norwich CRTU 8. NHS Norfolk Stop Smoking Services

Acknowledgement: ‘This project was funded by the NIHR Health Technology Assessment programme and will be published in full in the Health Technology Assessment journal series. Visit the HTA programme website for more details www.hta.ac.uk/link to project page. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Department of Health’ ref: 09/91/36

Smoking lapse and relapse

• The Sharpish trial: “Following the Russell Standard, the primary outcome was prolonged abstinence from months four to 12, with no more than five cigarettes in total, and confirmed by CO<10ppm at the 12 month follow-up”

• Therefore relapse = more than five cigarettes in months 4-12 of the study

• Following this, lapse = less than 5 cigarettes within the last year.

Faculty of Medicine and Health Science Norwich Medical School

Previous studies of smoking lapse and relapse

• Primarily quantitative – identification of relapse ‘triggers’ and high risk situations, e.g. being around smokers, stress (Brandon, 1986, Piasecki, 2006)

• Psychological factors – cue reactivity, attentional bias (Powell et al, 2010)

• Association between level of dependence and likelihood of relapse (Powell et al, 2010)

• Response: Focus on coping skills (ineffective coping in response to high risk situations → relapse) (Marlatt 1980, Marlatt & George, 1984; Song, 2009)

Faculty of Medicine and Health Science Norwich Medical SchoolFaculty of Medicine and Health Science Norwich Medical School

SHARPISH Q• 43 In depth qualitative interviews• Purposive sampling across trial sample

• Sample was representative of the study population as a whole • Focus groups with participants and SS professionals• Grounded theory approach to analysis. 10% coding independent verification

• Secondary analysis aim to explore participant experiences of lapses and relapse

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  Intervention groupSmoking status Intervention control

abstinent 15 11

relapsed 8 9

Findings• 874/1404 (62%) trial participants relapsed at

12 months (530/1404) CO verified abstinence)

• 17/43 (40%) qualitative sample self reported relapse

• 23 ‘lapse narratives’ (within last 12 months)

Faculty of Medicine and Health Science Norwich Medical School

Findings – the process of a smoking lapse

Faculty of Medicine and Health Science Norwich Medical School

Prior to lapse

Lapse triggers

Outlook following lapse

Cognitive

rationalising

Lapse leading to relapse

Motivation

Identity

feelings

reflection

Brief lapse only – no relapse (4)

Mood

Lapse quickly leads to relapse (7)

Lapse slowly leads to relapse (2)

Social

Situational

Psychological

Environmental cue

From lapse to relapse

1. Unplanned lapse‘before I knew it I was smoking again’‘I don’t know what I was thinking’‘that was it’ ‘I was drunk’

‘so we were going fishing and I went to [supermarket] as it happens on the er Thursday prior to going fishing, to get some bits and pieces of food for, for going, and I went up to the tobacco kiosk to buy a lottery ticket …And er- the woman in front of me, she bought some cigarettes and (coughs), God knows what made me do it, I just- I said if you can- do us some lucky dips on that one please, oh and I said, while I’m at it, I’ll have half an ounce of one of your- (0677, male, age 75, Relapsed)

From lapse to relapse1. Planned lapse, unplanned relapse‘I thought I could just have one’‘I was on holiday’

Faculty of Medicine and Health Science Norwich Medical School

well it was kind of outdoors like a club every night for the kids…and then the adults will stay there you know…and people were smoking around and then I was really, really craving a cigarette and I couldn’t get ??...and then the next day I found a cigarette machine in the hotel …and I bought some but I didn’t buy any to take back with me I didn’t plan to smoke when I came back…but I did (0940, female, aged 56. Relapsed but abstinent again at follow up)

From lapse to relapse2. Planned lapse, and relapse‘I couldn’t cope’‘what the hell’‘things can’t get any worse’

Faculty of Medicine and Health Science Norwich Medical School

I had to walk away from the situation, my parents, and I had to say no, and it was a case of I, that’s what I’m going to do and I drove five miles, even on the way there I thought to myself why am I doing this, and it was a case of something in my brain was saying I want one (0674, female, age 49, relapsed.)

From lapse to abstinence3. Unplanned lapse, avoidance of full relapse‘I thought it would help, but it didn’t’‘I don’t need it anymore’‘I used my e cigarette instead’

Faculty of Medicine and Health Science Norwich Medical School

‘that was it… although everyone thought that I was going to go back to cigarettes, right on top of Christmas, cos we moved, and I didn’t… and they were all shocked that I didn’t because, you know ‘(NAME) has a crisis (NAME) immediately goes for a cigarette’, that’s what they assumed would happen, and it was just those two times (0728, female, age 49, abstinent)

‘and my partner and I had a bit of a to-do argument or whatever…and we were at the pub at the time…so I just asked someone I knew for a couple of ciggy’s so I did have a bit of a but I knew the next day I would go straight to not having any…because as I suspected the cigarettes didn’t really do anything at all’ (0818, female, age 37, abstinent)

The process of a smoking lapse – Sharpish-Q Analysis and the RP model

Expectations / anticipation

Mood

Feelings/reflection

Physical effects

rationalising

Lapse triggers:•Environmental•Social•Psychological•Identity •Socio-cultural

Psychological, social, cultural and identity related factors for describing the move to relapse

2 groups:Planned vs. unplanned relapsers

Mood

Identity

Conclusions• In-depth understanding of patient experience of smoking

lapse/relapse• Lapsing and/or relapsing back to smoking is a complex

process rather than a discrete event• The concept of identity appears to be important for

describing the move to relapse• Possible adaption of our current theoretical understanding

of relapse to incorporate instances of planned relapse, and lapse situations where relapse is avoided.

• Importance of addressing the concept of identity within smoking relapse prevention interventions for future testing.

Faculty of Medicine and Health Science Norwich Medical School

ReferencesHajek P, Stead LF, West R, Jarvis M, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane database of systematic reviews (Online) 2009(1):CD003999

NICE. NICE public health guidance -Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. NICE public health guidance 10. National Institute for Health and Clinical Excellence; 2008.

Piasecki, T.M. (2006) Relapse to Smoking, Clinical Psychology Review, 26:2, March 2006, p196–215

Marlatt GA, Gordon JR: Determinants of relapse: implications for the maintenance of behavior change. In: Behavioral medicine: changing health lifestyles. edn. Edited by Davidson P, Davidson S. New York: Brunner/Mazel; 1980: 410-452.

Song F, Huttunen-Lenz M, Holland R. Effectiveness of complex psycho-educational interventions for smoking relapse prevention: an exploratory meta-analysis. Journal of Public Health 2009, doi:10.1093/pubmed/fdp109.

Agboola S, McNeill A, Coleman T, Leonardi Bee J. A systematic review of the effectiveness of smoking relapse prevention interventions for abstinent smokers. Addiction 2010, 105(8):1362-1380.West R, May S, West M, Croghan E, McEwen A. Performance of English stop smoking services in first 10 years: analysis of service monitoring data. BMJ 2013, 347:f4921. Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: one-year outcomes. Addiction 2005, 100 Suppl 2:59-69.

Brandon, Thomas H., Stephen T. Tiffany, and Timothy B. Baker. "The process of smoking relapse." Relapse and recovery in drug abuse 72 (1986): 104.

Marlatt, G.A. & George, W.H Relapse prevention: Introduction and Overview of the Model. British Journal of Addiction, 79 (1984): 261-273

Marlatt, G.A. & Gordon, J.R 1985 Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. Guilford Press

We’ve come a long way . . .