Addictive Behaviors, Vol. 15, pp. 235-245, 1990
0306-4603/90 $3.00 + .00 Copyright © 1990 Pergamon Press plc
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SLIP-UPS AND RELAPSE IN ATTEMPTS TO QUIT SMOKING RON B O R L A N D Centre for Behavioural Research in C~ncer, Victoria, Australia Abstract -- This paper is concemed with documenting the contexts in which slip-ups in attempts to stop smoking occur, and of the consequences of the slip-up on the continuationof smoking cessation. A sample of people who had called a Quit Smoking telephone service for information was recontacted three months later. A total of initial 216 slip-up episodes was reported, 44 of which resulted in a resumption of abstinence and 172 which led to relapse. Slip-ups were found to occur in a broad range of contexts, and context was also related to outcome. Slip-ups when in a positive mood, when socializing and drinking alcohol were associated with higher levels of reCOVeryof abstinence, as were those that occurred after more than two weeks of abstinence. Sex differences were also found, with men more likely to slip-up at work, and women to slip-up in a broader variety of contexts.
A large amount of time and effort has been put into developing methods to help smokers give up their habit. In general, the results of these endeavours have not been impressive (Schwartz, 1987). In Australia, 85% of current smokers have made attempts to quit (Borland & Hill, 1988L It is clear that most quit attempts end in relapse. Such findings have led to a change in research emphasis, with some investigators beginning to focus on relapse episodes (e.g., Marlatt & Gordon, 1980, 1985; Shiffman, 1982; Shiffman & Jarvik, 1987). The aim is to develop methods to reduce the occurrence of relapse. In the process of addressing this goal it is important to obtain good descriptive information on the situations in which cigarettes are smoked after a period of abstinence (called slip-ups in this paper) or in which temptations occur which are overcome. Research into slip-up episodes is of two kinds, those that have provided a multivariate description of slip-up contexts (e.g., Cummings, Jaen, & Giovino, 1985; Shiffman, 1982) and those that have used the set of mutually exclusive categories developed by Marlatt and Gordon (1980) (e.g., O ' C o n n e l l & Martin, 1987). It is difficult to directly compare the two methods; they will be dealt with separately. Descriptions of slip-up episodes have been collected from both those who recovered from the slip-up but promptly resumed abstinence, and those for whom the slip-up represented the beginning of a relapse. In addition, several authors (e.g., O ' C o n n e l l & Martin, 1987; Shiffman, 1982) have also studied crisis episodes which did not result in a slip-up (variously called close-calls or near lapses). Shiffman (1982) found that crises involving alcohol tended to result in slip-ups, and that crises that did not end in slip-ups were associated with a broader range of cognitions. However, there is a major methodological problem in comparing close-calls with actual slip-ups when they are both recalled retrospectively. Crises that do not result in a slip-up can only be defined by the individual through the thoughts they have, whereas slip-ups can be identified after the event independent of any thoughts had at the time. This means that it is impossible to report on a resisted temptation without having cognitions about it, while it is possible to have a slip-up with no associated
This research was funded by the Anti-Cancer Council of Victoria and the Victorian Smoking and Health Program. Thanks are due to David Hill and Virginia Lewis for comments on an earlier version of this manuscript. Requests for reprints should be sent to Ron Borland, Ph.D., Behavioural Scientist, Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, 1 Rathdowne Street, Carlton South, Victoria 3053, Australia. 235
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cognitions. This problem is likely to be maximal in Shiffman's (1982) study, as his subjects had telephoned a relapse crisis line. Even in studies where the researcher selects the subject, the problem is still likely to exist. There is likely to be an overrepresentation of situations with salient cues, either cognitions or subjective experiences, among the close-calls as compared with slip-ups, because the slip-up itself is sufficiently salient to be reported independent of other cognitions. As a result, close-calls cannot be directly compared with actual slip-ups when using subject-defined criteria of crises. Slip-ups are likely to occur equally throughout the working day (Shiffman, 1982), although Marlatt and Gordon (1980) found more slip-ups in the evening. Slip-ups have been found to occur most commonly at home, and in the presence of other smokers. Alcohol consumption has been found to be a factor in around one-quarter of cases, and consuming food and/or coffee is also common around relapse. Most relapses seem to occur when the person is in a negative mood, and to be precipitated by some kind of stressful crisis (Cummings et al., 1985; Shiffman, 1982). The generality of these results is open to question. Shiffman's (1982) data is from callers to a relapse hot line, and Cummings et al. (1985) used people attending a smoking cessation clinic. It is possible that the results typify smokers who find quitting especially difficult. Similar research is needed on samples who are more characteristic of smokers in general. O'Connell and Martin (1987) have attempted to identify differences in slip-ups as a function of the outcome. They also included crises that did not result in slip-ups; but these cases have been excluded from the results summarized here. They found few differences between temporary slip-ups ("lapses") and relapses. Relapsers were more likely than lapsers to report withdrawal symptoms, and interpersonal conflict as the cause of the slip-up. Curry, Marlatt, and Gordon (1987) studied 36 slip-ups, 20 of which resulted in a resumption of smoking (relapse). They found that relapsers reported higher levels of what they call the Abstinence Violation Effect (AVE) than those who simply lapsed and resumed abstinence. The AVE is a central component of Marlatt and Gordon's (1980, 1985) theory of relapse. The AVE is the cognitive-emotional response to the initial slip-up and has two components: (a) a causal attribution of responsibility for the slip (personal vs. external to the individual), and (b) an affective reaction to the attribution (e.g., guilt, feelings of failure). Marlatt and Gordon propose that the intensity of the AVE is increased by causal attributions that focus on internal, stable and global factors that are perceived to be uncontrollable. Emotional reactions (e.g., guilt and self-blame) to such attributions inhibit recovery following a slip-up. This research suggests that if a method could be found to make AVEs more external, unstable, specific and controllable (i.e., due to circumstances that the person believes they can control), it might be possible to reduce the probability of relapse following a slip-up. Prior to a more detailed investigation of the role of AVEs it is important to further characterise the contexts in which slip-ups occur because the context of the slip-up may affect the kinds of cognitions that the person has, just as Marlatt's theory would predict. The major aim of this paper is to provide descriptive information about the context in which a person smokes his/her first cigarette (or puff of a cigarette) after a decision not to smoke again. The sample chosen is presumed to be closer in character to the general population of smokers who are planning to quit than those reviewed above. Slip-ups following a quit attempt can either result in a full relapse, that is, a return to smoking, or they may be transitory with the person renewing his or her commitment to abstinence. A secondary aim is to consider whether the outcome of the slip-up (resuming abstinence vs. relapse) is associated with the context in which it occurs.
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METHOD
Subjects The subjects were drawn from a pool of callers to the Quit Information Line, a counselling and information service available during the major annual anti-smoking campaign in the state of Victoria, Australia (Victorian Smoking and Health Program, 1986, 1988). A sample of 536 smokers who intended to quit and who had agreed to a follow-up phone call was identified from 711 callers in the last three weeks of a 12-week campaign, prematurely leaving a total of 378 respondents. A total of 378 of the 536 (70.5%) were interviewed about three months after the initial contact. The 158 unsuccessful calls included four refusals, four who were unable to complete the interview, 78 cases where the person no longer appeared to be at the address given, and 72 cases where the person could not be contacted after at least four attempts. There were 149 males and 229 females of median age 35. These were predominantly white collar workers (54.5%), with 19.8% blue collar workers and 25.7% not in the full-time paid workforce. In comparison with community estimates, the sample overrepresents women and people in the white collar sector of the workforce. The sample reported smoking an average 25.7 cigarettes a day at the time of initial contact. The structured interview Respondents were taken through a structured interview over the telephone. They were initially queried about whether they had stopped smoking for at least a day since calling the Quit Information Line. Those who had were queried about whether they had had a slip-up episode. All respondents who reported a slip-up were questioned about the context of the initial slip-up. In particular, they were asked: how long they had been abstinent at the time of the slip-up; what caused the slip-up; what they were doing; where and when it occurred; whether other smokers were present; where they got the cigarette; and what their mood was. They were also asked about how many cigarettes they smoked in the slip-up and whether it led to their resuming regular smoking. RESULTS The 378 respondents consisted of 64 persons who were no longer smoking, 25 of whom had had a slip-up episode, 191 respondents who stopped for at least a day, but had resumed smoking by the time of the interview, and 123 who had not even stopped smoking for 24 h. Sixty-eight percent of respondents therefore made a quit attempt, including 16.9% who were abstinent at call back. Of the 255 respondents who had stopped for at least a day, 216 reported slip-up episodes. Of these, 172 resulted in relapse (Relapsers) and 44 cases resumed abstinence (Lapsers) of which 25 were still abstinent at interview. It is apparent from these data that most slip-ups (80%) end in relapse. It is important to determine whether the context in which the slip-up occurs affects the rate of relapse. There was no relationship between the reported number of cigarettes smoked a day at initial contact and the outcome of the quit attempt.
Slip-up contexts and their relationship to relapse The estimates of the period of abstinence prior to the slip-up were divided into three categories: periods of 1-3 days, periods of four days to two weeks, and those of more than two weeks. Forty percent of slip-ups occurred within the first three days of abstinence, another 34% within two weeks, leaving only 26% of cases where the period of abstinence was longer than two weeks. There was a marked relationship between the length of the period
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Table 1. Slip-up context by outcome Lapsers
Re!apsers
Sig
Period of abstinence 1-3 days 4 d a y s - 2 weeks more than 2 weeks
14% 36% 50%
48% 34% 19%
×2 = 23,1, df = 2 p < .0001
Reason t'rot~lems/crisis Mental attitude Addiction/habit Smoking cues
26% 5% 19% 51%
44% 15% 23% 18%
×2 = 21.3, df = 3 p < .001
Where Work Home Social situations Other
21% 18% 46% 16%
33% 42% 15% 9%
X2 = 23.4, df = 3 p < .0001
When Morning Afternoon Evening
11% 46% 43%
35% 37% 27%
X2 =
Mood Positive Stressed Negative Other
54% 12% 33% 2%
26% 24% 36% 14%
~(2 = 14.5, df = 3 p < .01
Who with smokers Non-smokers Alone
67% 14% 19%
49% 17% 34%
Activity tzavtarink Alcohol Relaxing Working Talking Other
9% 41% 5% 23% I 1% 11%
12% 12% 15% 33% 9% 19%
Cigarette from omers Had it Bought it
71% 10% 19%
42% 36% 22%
10.0 p < .01
X2 = 4.9, df = 2 NS
X2 = 21.6, df = 5 p < .001
Xz = 13.8 p < .001
of abstinence and the outcome (X 2 = 23.1, df = 2, p < .0001). The earlier the slip-up occurred, the more likely it was to end in a full blown relapse (see Table l). Reasons given for the initial slip-up were divided into four broad categories. The reason were crises, personal problems and external life pressures (collectively called " p r o b l e m s , " accounting for 40% of all cases); smoking cues and situations (cues, 25%); addiction, habit or transient negative feelings (craving, 22%), and lack of willpower and other aspects of mental attitude (13%). There was a significant overall relationship between reasons given and the outcome of the slip-up (X2 = 21.3, df = 3, p < .0001). As can be seen from Table 1, the difference was largely due to lapsers (as compared to relapsers) slipping-up more in
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the presence of smoking cues, and somewhat less in response to problems and mental attitude. Slip-ups were reported as occurring at home (37%), work (30%) and among social contacts, largely in restaurants/hotels/friends' homes (21%), with only 11% in other situations (e.g., in cars, shopping centres, outdoors, etc.). Again there was a difference as a function of outcome, (X2 = 23.4, df = 3, p < .0001), with Lapsers being more likely to slip-up in social situations and Relapsers to slip-up at home (see Table 1). Slip-ups were reported as being fairly evenly spread across the day with 30.0% occurring in the morning, 39% in the afternoon and 31% in the evening. Again there was a relationship with outcome (×2 = 12.2, df = 4, p < .05). Lapsers were more likely to slip-up later in the day than were Relapsers. The person's mood was also related to slip-up; 32% were while in positive moods, 35% in negative moods (sad, angry, upset, anxious), 21% when under stress or pressures, and 12% in an "other" category that largely consisted of less common negative mood states. There was a significant relationship between mood and outcome (×2 = 14.5, df = 3, p < .01). Lapsers were more likely to slip-up when in Positive Mood states. The majority of slip-ups occurred in the presence of other smokers (53%), compared to 16% in the company of nonsmokers and 31% while alone. Outcome was unrelated to the company kept during the slip-up episode. The most common activities reported to be associated with slip-ups were work (31%), drinking alcohol (18%), relaxing (13%), eating and/or nonalcoholic drinking (12%) and talking (9%), leaving a large 18% in a variety of other situations such as driving a car and waiting. Activities were significantly related to outcome (×2 = 21.6, df = 5, p < .001). Lapsers were more likely to slip-up while drinking alcohol. Slip-ups which result in relapse appear to occur with a broader range of activities (see Table 1). The most common source of cigarettes for a slip-up was other smokers (either offered or requested, 48%), while 31% reported having cigarettes or around about, leaving only 21% who had to buy them. Outcome differed as a function of source of cigarettes, (×2 = 13.8, df = 2, p < .001). Lapsers were more likely to get their cigarettes from others. Taken together, there is an impressive amount of difference between Relapsers and Lapsers given the limited power of the study.
Covariation of aspects of the slip-up context There were strong interactions between the various context variables. To give a picture of this interaction, associations with each of the categories of action engaged in and length of period of abstinence have been explored. There were highly significant associations between the activity at slip-up and each of the other seven context variables. The initial period of abstinence was associated with the activity at slip-up (X2 --- 23.9, df = 10, p < .01). Alcohol-related slip-ups tended to occur after a longer period of abstinence while the others either showed no pattern, or tended to decline with the length of period of abstinence (see Table 2). The main reason given for the slip-up and the activity engaged in were highly associated (×2 = 93.8, df = 15, p < .0001). Forty-four percent (n = 37) of slip-ups attributed to problems were at work, as were 36% (n = 10) of those attributed to mental attitude. By contrast, 55% (n = 29) of slip-ups attributed to smoking cues occurred when drinking alcohol (see Table 2). The place of the slip-up varied with the activity, (X2 = 285.3, df = 15, p < .0001). The effect was mainly due to 60% (n = 15) of eating and drinking related slip-ups being at home, as were 91% (n = 32) of those when relaxing. Seventy-eight percent (n = 31) of slip-ups involving alcohol were in social situations, and not surprisingly, 82% (n = 62) of
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Table 2. Numbers of slip-ups a function of "'Relapse Context" Eat/ drink
Alcohol
Relaxing
Working
Period of abstinence l - j days 4 d a y s - 2 weeks more than 2 weeks
14 6 5
6 14 18
13 10 2
30 22 13
9 4 7
12 14 7
Reason l-'roblems Mental attitude Addiction/habit Smoking cues
8 1 11 5
4 3 2 29
8 5 10 4
37 10 13 6
11 0 2 7
16 9 10 2
Where Work Home Social Other
4 15 5 1
I 6 31 2
1 32 1 1
62 12 0 2
4 9 9 1
3 19 2 18
When Morning Afternoon Evening
11 8 7
2 9 29
11 11 12
30 38 5
6 6 8
14 16 5
Mood t'ositive Stress/Positive Negative Other
10 2 9 4
32 2 5 1
11 5 14 4
10 27 29 9
5 3 12 2
5 10 17 7
Who with smokers Non-smokers Alone
12 5 9
37 1 2
8 8 18
35 16 21
17 5 0
6 5 23
Cigarette from utiaers Found it Bought it
9 10 6
30 6 2
6 24 5
37 23 15
17 3 1
4 21 14
Situation
Talking
Other
work-related slip-ups were at work. No place predominated for talking or other activity (see Table 2). The time of slip-up was related to the activity (×2 = 62.6, df = 10, p < .0001). The main associations were alcohol consumption in the evenings, (73%, n --- 29) and both work and other, which rarely happened in the evening (7%, n = 5, and 14%, n = 5 respectively). Mood at slip-up was also related to activity (×2 = 74.3, df = 15, p < ,0001). Mood at slip-up was likely to be positive when drinking alcohol (80%, n -- 32), and slightly more likely to be negative when talking (55%, n = 12), while in other contexts there was no clear pattern. The social context of the slip-up was also associated with activity (×2 = 71.3, df = 10, p < .0001). Slip-ups tended to occur with other smokers when drinking (93%, n = 37) and talking (77%, n = 17), while relaxing (53%, n -- 18) and other (68%, n = 23) tended to occur when alone. As might be expected from this pattern, there was also a relationship between activity and the source of the cigarette (×2 = 67.2, df = 10, p < .0001), Drinkers (79%, n = 30) and talkers (81%, n = 17) got their cigarettes from others, while those
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Table 3. Length of initial abstinenceby context of slip-up Length Morethan 2 weeks
Less than 3 days
3 days2 weeks
Reason rroolems Mental attitude Craving Cues
37% 16% 33% 14%
35% 13% 23% 30%
50% 6% 6% 39%
×2 = 23.2 df = 6 p < .001
Where work Home Social Other
41% 44% 8% 7%
24% 42% 23% 11%
25% 17% 42% 15%
X2 = 30.5 df = 6 p < .0001
When Morning Afternoon Evening
38% 46% 17%
27% 35% 38%
22% 37% 41%
X2 = 12.5 df = 4 p < .05
Who with ~mokers Non-smokers Others
39% 22% 40%
55% 13% 31%
75% 10% 16%
×2= 16.5 df = 4 p < .01
Cigarette from t)mers Bought it Had it
32% 43% 25%
59% 25% 16%
65% 10% 25%
x2 = 22.8 df = 4 p < .0001
Context
Significance
relaxing tended to have them lying about (69%, n = 24). The length of the period of abstinence was significantly associated with all other context variables except mood (see Table 3). The major effects were that craving became a less common reason and cues a more common reason over time. Slip-ups were more likely to occur at work in the first three days and at home in the first two weeks, while they were increasingly likely to occur in social situations as the period of abstinence increased. Slip-ups were also less likely to occur in the evening during the first three days of abstinence. They tended to occur more when alone in the first two weeks and increasingly in the presence of other smokers over time. In parallel with this, the slip-up cigarettes were increasingly obtained from others, and less likely to be had on or about the person. One other untabulated association warrants mention. Mood was associated with time of day (X2 = 45.0, df = 6, p < .0001). Most positive mood slip-ups occurred in the evening (51%), most stress-related slip-ups in the aftemoon (63%), with very few in the evening (4%), and most " o t h e r " mood slip-ups in the morning (63%). Negative mood slip-ups were reasonably evenly distributed across the day. One constellation of factors appears to stand out. It is that alcohol-related slip-ups occur mostly when the person is in a good mood in social situations, in the evening, with other smokers present from whom the person gets his or her cigarettes. However, the prognosis from these slip-ups is the most optimistic as this combination of context variables is also associated with high levels of recovery from the slip-ups.
Sex differences among slip-ups There was no significant sex difference in the outcome of slip-ups, nor in the proportions of males and females having slip-ups. Further, there were no sex differences in length of
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RON BORLAND
Table 4. Relapse context by sex (significanteffects) Male
Female
Significance
Where ~ k Home Social Other
48% 24% 22% 6%
19% 46% 21% 14%
Activity lzat/arink Drink alcohol Relaxing Work Talking Other
8% 25% 11% 44% 5% 8%
14% 14% 14% 23% 12% 24%
Mood Positive Pressure/Stress Negative (specified) Other
38% 27% 24% 11%
28% 17% 43% 12%
×2 = 9.5 df = 3 p < .05
Cigarette from omers Had/found it Bought it
61% 20% 20%
40% 38% 22%
X2 = 9.6 df = 2 p < .01
×2 = 23.4 df = 3 p < .0001
×2 = 23.0 df = 5 p < .001
initial period of abstinence or in reasons for slip-up, but sex differences were associated with several other variables (see Table 4). Although the time of day the slip-up occurred was unrelated to sex, there was a sex difference in where the slip-ups occurred (×2 = 23.4, df = 3, p < .0001). Men were more likely to report slipping-up at work (48%), while the women slipped up more at home (46%) and in " o t h e r " situations (14%). The activity at slip-up also differed (×2 = 23.0, df = 5, p < .001), with men more likely to slip-up when working and when drinking alcohol, and women more likely to slip-up in " o t h e r " situations. In general, it appears that women slipped-up in a broader variety of situations and places than men. It should be noted that the difference in slip-up as a function of alcohol drinking disappeared when those not in the paid workforce were excluded from the analysis. Mood at slip-up was also related to the sex of the smoker (×2 = 9.5, df = 3, p < .05). W o m e n were more likely to report negative moods at slip-up, particularly sadness and depression. The other significant effect was in the source of the slip-up cigarette (×2 = 9.6, df = 2, p < .01). W o m e n were more likely to have had the cigarette on them or found it nearby, and the men more likely to get it from somebody else. There was no clear evidence that any of those differences had any impact on the outcome of the slip-up. DISCUSSION The results reported in this study are generally similar to those in other comparable studies (Cummings et al., 1985; Shiffman, 1982) but extend them in three major respects. Firstly, the results generally confirmed the reported patterns of slip-up occurrences in a sample which is closer to the general population of smokers intending to quit and extended them by identifying work as an important locus of slip-ups. Secondly, the study identified clear sex differences in the contexts in which slip-ups occur. Thirdly, the results provide evidence that the context of the slip-up was associated with the likelihood of resuming the quit attempt.
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The pattern of slip-up contexts was similar to that reported in studies by Shiffman (1982) and Cummings et al. (1985). The only notable difference was that in the present study, work appeared to be a more important perceived cause and place of slip-ups. It may be because people in the workforce were underrepresented in the previous studies. This could be because working people have less time to become involved in intensive smoking cessation programs and/or they have less need for the social support such programs provide. Whatever the reason for its absence as a major factor in past studies, this study clearly shows work to be a major locus of slip-ups, especially among men. The sex differences found in this study are of potential relevance to campaigns to facilitate quitting. Women appear to slip-up in a broader variety of situations, and seem more likely to be experiencing negative emotions when they do slip-up. Men, by contrast, more often report slipping-up when under external pressure, and consistent with this, they slip-up more often at work. It may be that smoking is playing slightly different roles in the lives of male and female smokers, with men more likely to smoke while dealing with external pressures, and women to smoke in response to the emotional consequences of such pressures. It may be that this difference is associated with differences in the optimal coping strategies. Slip-up crises that occur when engaged in activities (e.g., work) may be more difficult to deal with at the time because of the competing demands of the ongoing activity. Unless the maintenance of abstinence is given a higher priority than the immediate activity, the possible options for successful coping will be limited. In such cases a slip-up may be unavoidable. If this were so, it could be important for these episodes to have prepared strategies during the early part of the quit attempt, e.g., like making provision for work demands to be moderated. In cases where there is no competing activity, the person may have more opportunity to direct his or her energies towards overcoming the temptation to smoke. Further, they may have a greater range of alternatives open to them. For example, take the risk associated with drinking with friends. There are many options which include avoiding the situation, asking the friends to provide support, and reducing alcohol intake. This means that there is a good chance that slip-ups can be avoided. By contrast, when there is a work deadline to meet it is difficult to maintain staying stopped as the number one priority, thus limiting the options for coping, and making a slip-up more likely. Of particular note is the finding that people attempting to quit were more likely to recover from slip-ups associated with socializing and drinking. This contrasts with Shiffman's (1982) finding that such situations are more likely to result in slip-ups than abstinence, but it is not necessarily contradictory. It may be that the actual slip-up is more likely when socializing, but, perhaps because of the perceived external pressures, it is easier to recover from such slip-ups. It is apparent from the results that the longer the period of abstinence, the more likely it is that the individual will recover from the slip-up. Because a resumption of abstinence becomes more likely as the period of initial abstinence increases, it is possible that some of the differences in contexts may be a function of the period of abstinence as ex-smokers test themselves in progressively more difficult contexts. For example, alcohol consumption is a slip-up context that appears most important the first two weeks after cessation. One explanation of this would be that people adopt the sensible strategy of avoiding drinking situations early in the quit attempt. Alternatively it might be that vigilance about risky situations decreases with the length of the period of abstinence. Shiffman (1982) found some evidence for this latter explanation. Regardless of the mechanism by which some situations are managed early in the quit attempt, there is a need to focus on the skills required to cope with the situation in which early slip-ups commonly occur. This is because no attempt can succeed unless those immediate high-risk situations are survived. Furthermore, slip-ups early in the attempt are
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likely to have a more marked negative effect on self-efficacy beliefs. This may inhibit persisting with the attempt, and when this occurs, further reduce the likelihood of trying again in the future. The relationships between the context of the slip-up and its outcome are generally consistent with Marlatt and Gordon's (1980, 1985) theory of AVE as a determinant of relapse. Where aspects of the situation are more likely to result in attribution of external causation (e.g., drinking, getting the cigarette from others), and thus should result in less intense AVEs, recovery from slip-ups was more common. Similarly, where affect was positive, and thus the AVE was less likely to be severe, recovery was more frequent. The major discrepency between predictions based on the AVE theory and these results was the lack of effect on outcome as a function of the presence of other smokers. The subjective abstinence violation effect might be expected to be less intense in cases where other persons were available to blame for the slip-up, that is, external attributions of causality would be more probable. The finding that longer periods of abstinence was associated with higher recovery is compatible with the role of self-efficacy (Bandura, 1977, 1986) in moderating the AVE. The evidence the person gains from the period of abstinence that he/she can remain abstinent for extended periods seems to increase her/his tendency to have another go (resume abstinence) after a slip-up. Taken together, the results clearly indicate that the context of a slip-up is related to its outcome. It is important to consider whether some situations are intrinsically more difficult to recover from than others, or whether the differences are due to other factors. It was argued above that in situations where there is a high priority for ongoing activity, psychological resources will be less likely to be available to address the crisis so relapse may be more likely. However, if smokers are to succeed in quitting their habit, they must adopt strategies to cope with such situations. Forward planning and learning from mistakes would seem to be important strategies to use to ensure that the cognitions and behaviours needed to maintain abstinence can be implemented when necessary. This means that any situations which lead to potentially competing behaviours and cognitions must be regulated. This may involve negotiating with others to assume responsibilities or to assist in pressing tasks, so that these pressures do not take priority over the cognitions and behaviours required to maintain abstinence. It was suggested above that avoidance of some high-risk situations is a strategy that some quitters adopt early in smoking cessation attempts. This is a sensible strategy as it can free up resources to cope in the high-risk situations that cannot be avoided as readily. Further, it appears that, at least in the case of drinking alcohol, avoidable contexts which lead to slip-ups are more likely to be recovered from. Interpreted in terms of Marlatt and Gordon's (1985) AVE, this may be because avoidable contexts are more likely to be perceived as external, unstable and controllable by the individual. Thus there is likely to be less need of professional assistance to help the person understand that these situations are ones that he or she can influence. By contrast, unavoidable situations often result in relapse. Unless people can get through the situations that they cannot avoid, they are never going to need to face the ones they can. The focus of research attention needs to be directed towards a better understanding of the common unavoidable slip-up contexts, so that better strategies can be suggested as means of overcoming the temptation to smoke in these situations, or to facilitate recovery of abstinence when they occur. One of the major, relatively unavoidable situations in which relapse is common is in coping with stressful events. As was noted above, some stressors (e.g., work) can be regulated by gaining assistance and support from others. Further, anxiety and tension can be managed through the use of relaxation techniques or by structuring time-outs into the
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working day. It is beyond the scope of this paper to develop techniques for coping with the most difficult situations, but it is clear that smokers are in need of more practical suggestions if there is to be an improvement in the relatively modest quit rates that are currently being achieved.
REFERENCES Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioural change. Psychological Review, 84, 191-215. Bandura, A. (1986). Social foundations of thought and action. A social cognitive theory. Englewood Cliffs, N J: Prentice-Hall. Borland, R.o & Hill, D. (1988). Two-month follow-up on callers to a telephone quit smoking service. Manuscript submitted for publication. Cummings, K.M., Jaen, C.R., & Giovino, G. (1985). Circumstances surrounding relapse in a group of recent ex-smokers. Preventive Medicine, 14, 195-202. Curry, S., Marlatt, G.A., & Gordon, J.R. (1987). Abstinence violation effect: Validation of an attributional construct with smoking cessation. Journal of Consulting and Clinical Psychology, 55(2), 145-149. Marlatt, G.A., & Gordon, J.R. (1980). Determinants of relapse: Implications for the maintenance of behaviour change. In P.O. Davidson, & S.M. Davidson (Eds.), Behavioral medicine: Changing health lifestyles (pp. 410-452). Brunner-Mazel. Marlatt, G.A., & Gordon, J.R. (1985). (Eds.). Relapse prevention. New York: The Guilford Press. O'Connell, K.A., & Martin, E.J. (1987). Highly tempting situations associated with abstinence, temporary lapse, and relapse among participants in smoking cessation programs. Journal of Consulting and Clinical Psychology, 55(3), 367-371. Shiffman, S. (1982). Relapse following smoking cessation: A situational analysis. Journal of Consulting and Clinical Psychology, 50(1), 71-86. Shiffman, S,, & Jarvik, M.E. (1987). Situational determinants of coping in smoking relapse crisis. Journal of Applied Social Psychology, 17, 3-15. Schwartz, J.L. (1987). Review and evaluation of smoking cessatio methods: The United States and Canada, 1978-1985. Division of Cancer Prevention and Control, N.C.I., U.S. Department of Health and Human Services. Victorian Smoking and Health Project. (1986). Evaluation No. 1. Victorian Smoking and Health Program. (1988). Quit; Evaluation No. 2.
0306-4603/90 $3.00 + .00 Copyright © 1990 Pergamon Press plc
Printed in the USA. All rights reserved.
SLIP-UPS AND RELAPSE IN ATTEMPTS TO QUIT SMOKING RON B O R L A N D Centre for Behavioural Research in C~ncer, Victoria, Australia Abstract -- This paper is concemed with documenting the contexts in which slip-ups in attempts to stop smoking occur, and of the consequences of the slip-up on the continuationof smoking cessation. A sample of people who had called a Quit Smoking telephone service for information was recontacted three months later. A total of initial 216 slip-up episodes was reported, 44 of which resulted in a resumption of abstinence and 172 which led to relapse. Slip-ups were found to occur in a broad range of contexts, and context was also related to outcome. Slip-ups when in a positive mood, when socializing and drinking alcohol were associated with higher levels of reCOVeryof abstinence, as were those that occurred after more than two weeks of abstinence. Sex differences were also found, with men more likely to slip-up at work, and women to slip-up in a broader variety of contexts.
A large amount of time and effort has been put into developing methods to help smokers give up their habit. In general, the results of these endeavours have not been impressive (Schwartz, 1987). In Australia, 85% of current smokers have made attempts to quit (Borland & Hill, 1988L It is clear that most quit attempts end in relapse. Such findings have led to a change in research emphasis, with some investigators beginning to focus on relapse episodes (e.g., Marlatt & Gordon, 1980, 1985; Shiffman, 1982; Shiffman & Jarvik, 1987). The aim is to develop methods to reduce the occurrence of relapse. In the process of addressing this goal it is important to obtain good descriptive information on the situations in which cigarettes are smoked after a period of abstinence (called slip-ups in this paper) or in which temptations occur which are overcome. Research into slip-up episodes is of two kinds, those that have provided a multivariate description of slip-up contexts (e.g., Cummings, Jaen, & Giovino, 1985; Shiffman, 1982) and those that have used the set of mutually exclusive categories developed by Marlatt and Gordon (1980) (e.g., O ' C o n n e l l & Martin, 1987). It is difficult to directly compare the two methods; they will be dealt with separately. Descriptions of slip-up episodes have been collected from both those who recovered from the slip-up but promptly resumed abstinence, and those for whom the slip-up represented the beginning of a relapse. In addition, several authors (e.g., O ' C o n n e l l & Martin, 1987; Shiffman, 1982) have also studied crisis episodes which did not result in a slip-up (variously called close-calls or near lapses). Shiffman (1982) found that crises involving alcohol tended to result in slip-ups, and that crises that did not end in slip-ups were associated with a broader range of cognitions. However, there is a major methodological problem in comparing close-calls with actual slip-ups when they are both recalled retrospectively. Crises that do not result in a slip-up can only be defined by the individual through the thoughts they have, whereas slip-ups can be identified after the event independent of any thoughts had at the time. This means that it is impossible to report on a resisted temptation without having cognitions about it, while it is possible to have a slip-up with no associated
This research was funded by the Anti-Cancer Council of Victoria and the Victorian Smoking and Health Program. Thanks are due to David Hill and Virginia Lewis for comments on an earlier version of this manuscript. Requests for reprints should be sent to Ron Borland, Ph.D., Behavioural Scientist, Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, 1 Rathdowne Street, Carlton South, Victoria 3053, Australia. 235
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cognitions. This problem is likely to be maximal in Shiffman's (1982) study, as his subjects had telephoned a relapse crisis line. Even in studies where the researcher selects the subject, the problem is still likely to exist. There is likely to be an overrepresentation of situations with salient cues, either cognitions or subjective experiences, among the close-calls as compared with slip-ups, because the slip-up itself is sufficiently salient to be reported independent of other cognitions. As a result, close-calls cannot be directly compared with actual slip-ups when using subject-defined criteria of crises. Slip-ups are likely to occur equally throughout the working day (Shiffman, 1982), although Marlatt and Gordon (1980) found more slip-ups in the evening. Slip-ups have been found to occur most commonly at home, and in the presence of other smokers. Alcohol consumption has been found to be a factor in around one-quarter of cases, and consuming food and/or coffee is also common around relapse. Most relapses seem to occur when the person is in a negative mood, and to be precipitated by some kind of stressful crisis (Cummings et al., 1985; Shiffman, 1982). The generality of these results is open to question. Shiffman's (1982) data is from callers to a relapse hot line, and Cummings et al. (1985) used people attending a smoking cessation clinic. It is possible that the results typify smokers who find quitting especially difficult. Similar research is needed on samples who are more characteristic of smokers in general. O'Connell and Martin (1987) have attempted to identify differences in slip-ups as a function of the outcome. They also included crises that did not result in slip-ups; but these cases have been excluded from the results summarized here. They found few differences between temporary slip-ups ("lapses") and relapses. Relapsers were more likely than lapsers to report withdrawal symptoms, and interpersonal conflict as the cause of the slip-up. Curry, Marlatt, and Gordon (1987) studied 36 slip-ups, 20 of which resulted in a resumption of smoking (relapse). They found that relapsers reported higher levels of what they call the Abstinence Violation Effect (AVE) than those who simply lapsed and resumed abstinence. The AVE is a central component of Marlatt and Gordon's (1980, 1985) theory of relapse. The AVE is the cognitive-emotional response to the initial slip-up and has two components: (a) a causal attribution of responsibility for the slip (personal vs. external to the individual), and (b) an affective reaction to the attribution (e.g., guilt, feelings of failure). Marlatt and Gordon propose that the intensity of the AVE is increased by causal attributions that focus on internal, stable and global factors that are perceived to be uncontrollable. Emotional reactions (e.g., guilt and self-blame) to such attributions inhibit recovery following a slip-up. This research suggests that if a method could be found to make AVEs more external, unstable, specific and controllable (i.e., due to circumstances that the person believes they can control), it might be possible to reduce the probability of relapse following a slip-up. Prior to a more detailed investigation of the role of AVEs it is important to further characterise the contexts in which slip-ups occur because the context of the slip-up may affect the kinds of cognitions that the person has, just as Marlatt's theory would predict. The major aim of this paper is to provide descriptive information about the context in which a person smokes his/her first cigarette (or puff of a cigarette) after a decision not to smoke again. The sample chosen is presumed to be closer in character to the general population of smokers who are planning to quit than those reviewed above. Slip-ups following a quit attempt can either result in a full relapse, that is, a return to smoking, or they may be transitory with the person renewing his or her commitment to abstinence. A secondary aim is to consider whether the outcome of the slip-up (resuming abstinence vs. relapse) is associated with the context in which it occurs.
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METHOD
Subjects The subjects were drawn from a pool of callers to the Quit Information Line, a counselling and information service available during the major annual anti-smoking campaign in the state of Victoria, Australia (Victorian Smoking and Health Program, 1986, 1988). A sample of 536 smokers who intended to quit and who had agreed to a follow-up phone call was identified from 711 callers in the last three weeks of a 12-week campaign, prematurely leaving a total of 378 respondents. A total of 378 of the 536 (70.5%) were interviewed about three months after the initial contact. The 158 unsuccessful calls included four refusals, four who were unable to complete the interview, 78 cases where the person no longer appeared to be at the address given, and 72 cases where the person could not be contacted after at least four attempts. There were 149 males and 229 females of median age 35. These were predominantly white collar workers (54.5%), with 19.8% blue collar workers and 25.7% not in the full-time paid workforce. In comparison with community estimates, the sample overrepresents women and people in the white collar sector of the workforce. The sample reported smoking an average 25.7 cigarettes a day at the time of initial contact. The structured interview Respondents were taken through a structured interview over the telephone. They were initially queried about whether they had stopped smoking for at least a day since calling the Quit Information Line. Those who had were queried about whether they had had a slip-up episode. All respondents who reported a slip-up were questioned about the context of the initial slip-up. In particular, they were asked: how long they had been abstinent at the time of the slip-up; what caused the slip-up; what they were doing; where and when it occurred; whether other smokers were present; where they got the cigarette; and what their mood was. They were also asked about how many cigarettes they smoked in the slip-up and whether it led to their resuming regular smoking. RESULTS The 378 respondents consisted of 64 persons who were no longer smoking, 25 of whom had had a slip-up episode, 191 respondents who stopped for at least a day, but had resumed smoking by the time of the interview, and 123 who had not even stopped smoking for 24 h. Sixty-eight percent of respondents therefore made a quit attempt, including 16.9% who were abstinent at call back. Of the 255 respondents who had stopped for at least a day, 216 reported slip-up episodes. Of these, 172 resulted in relapse (Relapsers) and 44 cases resumed abstinence (Lapsers) of which 25 were still abstinent at interview. It is apparent from these data that most slip-ups (80%) end in relapse. It is important to determine whether the context in which the slip-up occurs affects the rate of relapse. There was no relationship between the reported number of cigarettes smoked a day at initial contact and the outcome of the quit attempt.
Slip-up contexts and their relationship to relapse The estimates of the period of abstinence prior to the slip-up were divided into three categories: periods of 1-3 days, periods of four days to two weeks, and those of more than two weeks. Forty percent of slip-ups occurred within the first three days of abstinence, another 34% within two weeks, leaving only 26% of cases where the period of abstinence was longer than two weeks. There was a marked relationship between the length of the period
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Table 1. Slip-up context by outcome Lapsers
Re!apsers
Sig
Period of abstinence 1-3 days 4 d a y s - 2 weeks more than 2 weeks
14% 36% 50%
48% 34% 19%
×2 = 23,1, df = 2 p < .0001
Reason t'rot~lems/crisis Mental attitude Addiction/habit Smoking cues
26% 5% 19% 51%
44% 15% 23% 18%
×2 = 21.3, df = 3 p < .001
Where Work Home Social situations Other
21% 18% 46% 16%
33% 42% 15% 9%
X2 = 23.4, df = 3 p < .0001
When Morning Afternoon Evening
11% 46% 43%
35% 37% 27%
X2 =
Mood Positive Stressed Negative Other
54% 12% 33% 2%
26% 24% 36% 14%
~(2 = 14.5, df = 3 p < .01
Who with smokers Non-smokers Alone
67% 14% 19%
49% 17% 34%
Activity tzavtarink Alcohol Relaxing Working Talking Other
9% 41% 5% 23% I 1% 11%
12% 12% 15% 33% 9% 19%
Cigarette from omers Had it Bought it
71% 10% 19%
42% 36% 22%
10.0 p < .01
X2 = 4.9, df = 2 NS
X2 = 21.6, df = 5 p < .001
Xz = 13.8 p < .001
of abstinence and the outcome (X 2 = 23.1, df = 2, p < .0001). The earlier the slip-up occurred, the more likely it was to end in a full blown relapse (see Table l). Reasons given for the initial slip-up were divided into four broad categories. The reason were crises, personal problems and external life pressures (collectively called " p r o b l e m s , " accounting for 40% of all cases); smoking cues and situations (cues, 25%); addiction, habit or transient negative feelings (craving, 22%), and lack of willpower and other aspects of mental attitude (13%). There was a significant overall relationship between reasons given and the outcome of the slip-up (X2 = 21.3, df = 3, p < .0001). As can be seen from Table 1, the difference was largely due to lapsers (as compared to relapsers) slipping-up more in
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239
the presence of smoking cues, and somewhat less in response to problems and mental attitude. Slip-ups were reported as occurring at home (37%), work (30%) and among social contacts, largely in restaurants/hotels/friends' homes (21%), with only 11% in other situations (e.g., in cars, shopping centres, outdoors, etc.). Again there was a difference as a function of outcome, (X2 = 23.4, df = 3, p < .0001), with Lapsers being more likely to slip-up in social situations and Relapsers to slip-up at home (see Table 1). Slip-ups were reported as being fairly evenly spread across the day with 30.0% occurring in the morning, 39% in the afternoon and 31% in the evening. Again there was a relationship with outcome (×2 = 12.2, df = 4, p < .05). Lapsers were more likely to slip-up later in the day than were Relapsers. The person's mood was also related to slip-up; 32% were while in positive moods, 35% in negative moods (sad, angry, upset, anxious), 21% when under stress or pressures, and 12% in an "other" category that largely consisted of less common negative mood states. There was a significant relationship between mood and outcome (×2 = 14.5, df = 3, p < .01). Lapsers were more likely to slip-up when in Positive Mood states. The majority of slip-ups occurred in the presence of other smokers (53%), compared to 16% in the company of nonsmokers and 31% while alone. Outcome was unrelated to the company kept during the slip-up episode. The most common activities reported to be associated with slip-ups were work (31%), drinking alcohol (18%), relaxing (13%), eating and/or nonalcoholic drinking (12%) and talking (9%), leaving a large 18% in a variety of other situations such as driving a car and waiting. Activities were significantly related to outcome (×2 = 21.6, df = 5, p < .001). Lapsers were more likely to slip-up while drinking alcohol. Slip-ups which result in relapse appear to occur with a broader range of activities (see Table 1). The most common source of cigarettes for a slip-up was other smokers (either offered or requested, 48%), while 31% reported having cigarettes or around about, leaving only 21% who had to buy them. Outcome differed as a function of source of cigarettes, (×2 = 13.8, df = 2, p < .001). Lapsers were more likely to get their cigarettes from others. Taken together, there is an impressive amount of difference between Relapsers and Lapsers given the limited power of the study.
Covariation of aspects of the slip-up context There were strong interactions between the various context variables. To give a picture of this interaction, associations with each of the categories of action engaged in and length of period of abstinence have been explored. There were highly significant associations between the activity at slip-up and each of the other seven context variables. The initial period of abstinence was associated with the activity at slip-up (X2 --- 23.9, df = 10, p < .01). Alcohol-related slip-ups tended to occur after a longer period of abstinence while the others either showed no pattern, or tended to decline with the length of period of abstinence (see Table 2). The main reason given for the slip-up and the activity engaged in were highly associated (×2 = 93.8, df = 15, p < .0001). Forty-four percent (n = 37) of slip-ups attributed to problems were at work, as were 36% (n = 10) of those attributed to mental attitude. By contrast, 55% (n = 29) of slip-ups attributed to smoking cues occurred when drinking alcohol (see Table 2). The place of the slip-up varied with the activity, (X2 = 285.3, df = 15, p < .0001). The effect was mainly due to 60% (n = 15) of eating and drinking related slip-ups being at home, as were 91% (n = 32) of those when relaxing. Seventy-eight percent (n = 31) of slip-ups involving alcohol were in social situations, and not surprisingly, 82% (n = 62) of
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Table 2. Numbers of slip-ups a function of "'Relapse Context" Eat/ drink
Alcohol
Relaxing
Working
Period of abstinence l - j days 4 d a y s - 2 weeks more than 2 weeks
14 6 5
6 14 18
13 10 2
30 22 13
9 4 7
12 14 7
Reason l-'roblems Mental attitude Addiction/habit Smoking cues
8 1 11 5
4 3 2 29
8 5 10 4
37 10 13 6
11 0 2 7
16 9 10 2
Where Work Home Social Other
4 15 5 1
I 6 31 2
1 32 1 1
62 12 0 2
4 9 9 1
3 19 2 18
When Morning Afternoon Evening
11 8 7
2 9 29
11 11 12
30 38 5
6 6 8
14 16 5
Mood t'ositive Stress/Positive Negative Other
10 2 9 4
32 2 5 1
11 5 14 4
10 27 29 9
5 3 12 2
5 10 17 7
Who with smokers Non-smokers Alone
12 5 9
37 1 2
8 8 18
35 16 21
17 5 0
6 5 23
Cigarette from utiaers Found it Bought it
9 10 6
30 6 2
6 24 5
37 23 15
17 3 1
4 21 14
Situation
Talking
Other
work-related slip-ups were at work. No place predominated for talking or other activity (see Table 2). The time of slip-up was related to the activity (×2 = 62.6, df = 10, p < .0001). The main associations were alcohol consumption in the evenings, (73%, n --- 29) and both work and other, which rarely happened in the evening (7%, n = 5, and 14%, n = 5 respectively). Mood at slip-up was also related to activity (×2 = 74.3, df = 15, p < ,0001). Mood at slip-up was likely to be positive when drinking alcohol (80%, n -- 32), and slightly more likely to be negative when talking (55%, n = 12), while in other contexts there was no clear pattern. The social context of the slip-up was also associated with activity (×2 = 71.3, df = 10, p < .0001). Slip-ups tended to occur with other smokers when drinking (93%, n = 37) and talking (77%, n = 17), while relaxing (53%, n -- 18) and other (68%, n = 23) tended to occur when alone. As might be expected from this pattern, there was also a relationship between activity and the source of the cigarette (×2 = 67.2, df = 10, p < .0001), Drinkers (79%, n = 30) and talkers (81%, n = 17) got their cigarettes from others, while those
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241
Table 3. Length of initial abstinenceby context of slip-up Length Morethan 2 weeks
Less than 3 days
3 days2 weeks
Reason rroolems Mental attitude Craving Cues
37% 16% 33% 14%
35% 13% 23% 30%
50% 6% 6% 39%
×2 = 23.2 df = 6 p < .001
Where work Home Social Other
41% 44% 8% 7%
24% 42% 23% 11%
25% 17% 42% 15%
X2 = 30.5 df = 6 p < .0001
When Morning Afternoon Evening
38% 46% 17%
27% 35% 38%
22% 37% 41%
X2 = 12.5 df = 4 p < .05
Who with ~mokers Non-smokers Others
39% 22% 40%
55% 13% 31%
75% 10% 16%
×2= 16.5 df = 4 p < .01
Cigarette from t)mers Bought it Had it
32% 43% 25%
59% 25% 16%
65% 10% 25%
x2 = 22.8 df = 4 p < .0001
Context
Significance
relaxing tended to have them lying about (69%, n = 24). The length of the period of abstinence was significantly associated with all other context variables except mood (see Table 3). The major effects were that craving became a less common reason and cues a more common reason over time. Slip-ups were more likely to occur at work in the first three days and at home in the first two weeks, while they were increasingly likely to occur in social situations as the period of abstinence increased. Slip-ups were also less likely to occur in the evening during the first three days of abstinence. They tended to occur more when alone in the first two weeks and increasingly in the presence of other smokers over time. In parallel with this, the slip-up cigarettes were increasingly obtained from others, and less likely to be had on or about the person. One other untabulated association warrants mention. Mood was associated with time of day (X2 = 45.0, df = 6, p < .0001). Most positive mood slip-ups occurred in the evening (51%), most stress-related slip-ups in the aftemoon (63%), with very few in the evening (4%), and most " o t h e r " mood slip-ups in the morning (63%). Negative mood slip-ups were reasonably evenly distributed across the day. One constellation of factors appears to stand out. It is that alcohol-related slip-ups occur mostly when the person is in a good mood in social situations, in the evening, with other smokers present from whom the person gets his or her cigarettes. However, the prognosis from these slip-ups is the most optimistic as this combination of context variables is also associated with high levels of recovery from the slip-ups.
Sex differences among slip-ups There was no significant sex difference in the outcome of slip-ups, nor in the proportions of males and females having slip-ups. Further, there were no sex differences in length of
242
RON BORLAND
Table 4. Relapse context by sex (significanteffects) Male
Female
Significance
Where ~ k Home Social Other
48% 24% 22% 6%
19% 46% 21% 14%
Activity lzat/arink Drink alcohol Relaxing Work Talking Other
8% 25% 11% 44% 5% 8%
14% 14% 14% 23% 12% 24%
Mood Positive Pressure/Stress Negative (specified) Other
38% 27% 24% 11%
28% 17% 43% 12%
×2 = 9.5 df = 3 p < .05
Cigarette from omers Had/found it Bought it
61% 20% 20%
40% 38% 22%
X2 = 9.6 df = 2 p < .01
×2 = 23.4 df = 3 p < .0001
×2 = 23.0 df = 5 p < .001
initial period of abstinence or in reasons for slip-up, but sex differences were associated with several other variables (see Table 4). Although the time of day the slip-up occurred was unrelated to sex, there was a sex difference in where the slip-ups occurred (×2 = 23.4, df = 3, p < .0001). Men were more likely to report slipping-up at work (48%), while the women slipped up more at home (46%) and in " o t h e r " situations (14%). The activity at slip-up also differed (×2 = 23.0, df = 5, p < .001), with men more likely to slip-up when working and when drinking alcohol, and women more likely to slip-up in " o t h e r " situations. In general, it appears that women slipped-up in a broader variety of situations and places than men. It should be noted that the difference in slip-up as a function of alcohol drinking disappeared when those not in the paid workforce were excluded from the analysis. Mood at slip-up was also related to the sex of the smoker (×2 = 9.5, df = 3, p < .05). W o m e n were more likely to report negative moods at slip-up, particularly sadness and depression. The other significant effect was in the source of the slip-up cigarette (×2 = 9.6, df = 2, p < .01). W o m e n were more likely to have had the cigarette on them or found it nearby, and the men more likely to get it from somebody else. There was no clear evidence that any of those differences had any impact on the outcome of the slip-up. DISCUSSION The results reported in this study are generally similar to those in other comparable studies (Cummings et al., 1985; Shiffman, 1982) but extend them in three major respects. Firstly, the results generally confirmed the reported patterns of slip-up occurrences in a sample which is closer to the general population of smokers intending to quit and extended them by identifying work as an important locus of slip-ups. Secondly, the study identified clear sex differences in the contexts in which slip-ups occur. Thirdly, the results provide evidence that the context of the slip-up was associated with the likelihood of resuming the quit attempt.
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243
The pattern of slip-up contexts was similar to that reported in studies by Shiffman (1982) and Cummings et al. (1985). The only notable difference was that in the present study, work appeared to be a more important perceived cause and place of slip-ups. It may be because people in the workforce were underrepresented in the previous studies. This could be because working people have less time to become involved in intensive smoking cessation programs and/or they have less need for the social support such programs provide. Whatever the reason for its absence as a major factor in past studies, this study clearly shows work to be a major locus of slip-ups, especially among men. The sex differences found in this study are of potential relevance to campaigns to facilitate quitting. Women appear to slip-up in a broader variety of situations, and seem more likely to be experiencing negative emotions when they do slip-up. Men, by contrast, more often report slipping-up when under external pressure, and consistent with this, they slip-up more often at work. It may be that smoking is playing slightly different roles in the lives of male and female smokers, with men more likely to smoke while dealing with external pressures, and women to smoke in response to the emotional consequences of such pressures. It may be that this difference is associated with differences in the optimal coping strategies. Slip-up crises that occur when engaged in activities (e.g., work) may be more difficult to deal with at the time because of the competing demands of the ongoing activity. Unless the maintenance of abstinence is given a higher priority than the immediate activity, the possible options for successful coping will be limited. In such cases a slip-up may be unavoidable. If this were so, it could be important for these episodes to have prepared strategies during the early part of the quit attempt, e.g., like making provision for work demands to be moderated. In cases where there is no competing activity, the person may have more opportunity to direct his or her energies towards overcoming the temptation to smoke. Further, they may have a greater range of alternatives open to them. For example, take the risk associated with drinking with friends. There are many options which include avoiding the situation, asking the friends to provide support, and reducing alcohol intake. This means that there is a good chance that slip-ups can be avoided. By contrast, when there is a work deadline to meet it is difficult to maintain staying stopped as the number one priority, thus limiting the options for coping, and making a slip-up more likely. Of particular note is the finding that people attempting to quit were more likely to recover from slip-ups associated with socializing and drinking. This contrasts with Shiffman's (1982) finding that such situations are more likely to result in slip-ups than abstinence, but it is not necessarily contradictory. It may be that the actual slip-up is more likely when socializing, but, perhaps because of the perceived external pressures, it is easier to recover from such slip-ups. It is apparent from the results that the longer the period of abstinence, the more likely it is that the individual will recover from the slip-up. Because a resumption of abstinence becomes more likely as the period of initial abstinence increases, it is possible that some of the differences in contexts may be a function of the period of abstinence as ex-smokers test themselves in progressively more difficult contexts. For example, alcohol consumption is a slip-up context that appears most important the first two weeks after cessation. One explanation of this would be that people adopt the sensible strategy of avoiding drinking situations early in the quit attempt. Alternatively it might be that vigilance about risky situations decreases with the length of the period of abstinence. Shiffman (1982) found some evidence for this latter explanation. Regardless of the mechanism by which some situations are managed early in the quit attempt, there is a need to focus on the skills required to cope with the situation in which early slip-ups commonly occur. This is because no attempt can succeed unless those immediate high-risk situations are survived. Furthermore, slip-ups early in the attempt are
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likely to have a more marked negative effect on self-efficacy beliefs. This may inhibit persisting with the attempt, and when this occurs, further reduce the likelihood of trying again in the future. The relationships between the context of the slip-up and its outcome are generally consistent with Marlatt and Gordon's (1980, 1985) theory of AVE as a determinant of relapse. Where aspects of the situation are more likely to result in attribution of external causation (e.g., drinking, getting the cigarette from others), and thus should result in less intense AVEs, recovery from slip-ups was more common. Similarly, where affect was positive, and thus the AVE was less likely to be severe, recovery was more frequent. The major discrepency between predictions based on the AVE theory and these results was the lack of effect on outcome as a function of the presence of other smokers. The subjective abstinence violation effect might be expected to be less intense in cases where other persons were available to blame for the slip-up, that is, external attributions of causality would be more probable. The finding that longer periods of abstinence was associated with higher recovery is compatible with the role of self-efficacy (Bandura, 1977, 1986) in moderating the AVE. The evidence the person gains from the period of abstinence that he/she can remain abstinent for extended periods seems to increase her/his tendency to have another go (resume abstinence) after a slip-up. Taken together, the results clearly indicate that the context of a slip-up is related to its outcome. It is important to consider whether some situations are intrinsically more difficult to recover from than others, or whether the differences are due to other factors. It was argued above that in situations where there is a high priority for ongoing activity, psychological resources will be less likely to be available to address the crisis so relapse may be more likely. However, if smokers are to succeed in quitting their habit, they must adopt strategies to cope with such situations. Forward planning and learning from mistakes would seem to be important strategies to use to ensure that the cognitions and behaviours needed to maintain abstinence can be implemented when necessary. This means that any situations which lead to potentially competing behaviours and cognitions must be regulated. This may involve negotiating with others to assume responsibilities or to assist in pressing tasks, so that these pressures do not take priority over the cognitions and behaviours required to maintain abstinence. It was suggested above that avoidance of some high-risk situations is a strategy that some quitters adopt early in smoking cessation attempts. This is a sensible strategy as it can free up resources to cope in the high-risk situations that cannot be avoided as readily. Further, it appears that, at least in the case of drinking alcohol, avoidable contexts which lead to slip-ups are more likely to be recovered from. Interpreted in terms of Marlatt and Gordon's (1985) AVE, this may be because avoidable contexts are more likely to be perceived as external, unstable and controllable by the individual. Thus there is likely to be less need of professional assistance to help the person understand that these situations are ones that he or she can influence. By contrast, unavoidable situations often result in relapse. Unless people can get through the situations that they cannot avoid, they are never going to need to face the ones they can. The focus of research attention needs to be directed towards a better understanding of the common unavoidable slip-up contexts, so that better strategies can be suggested as means of overcoming the temptation to smoke in these situations, or to facilitate recovery of abstinence when they occur. One of the major, relatively unavoidable situations in which relapse is common is in coping with stressful events. As was noted above, some stressors (e.g., work) can be regulated by gaining assistance and support from others. Further, anxiety and tension can be managed through the use of relaxation techniques or by structuring time-outs into the
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working day. It is beyond the scope of this paper to develop techniques for coping with the most difficult situations, but it is clear that smokers are in need of more practical suggestions if there is to be an improvement in the relatively modest quit rates that are currently being achieved.
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