512878 research-article2013
HPQ0010.1177/1359105313512878Journal of Health PsychologyNaughton et al.
Article Journal of Health Psychology 2015, Vol. 20(11) 1427–1433 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105313512878 hpq.sagepub.com
Use and effectiveness of lapse prevention strategies among pregnant smokers Felix Naughton1, Andy McEwen2 and Stephen Sutton1
Abstract Little is known about the use of lapse prevention strategies to help smokers manage situation-triggered urges to smoke. Pregnant smokers (N = 174) participating in an intervention trial reported use of cognitive– behavioural lapse prevention strategies and smoking abstinence (biochemically verified). Participants typically enacted few strategies. Distraction strategies were most commonly used. Total number of strategies used did not predict abstinence. However, using ‘self-talk’ (odds ratio (OR) = 3.44, 95% confidence interval = 1.14–10.40) or ‘avoiding spending time with other smokers’ (OR = 4.01, 95% confidence interval = 1.34– 11.95) independently increased the odds of abstinence. The promotion of these and other under-utilised evidence-based strategies warrants further attention.
Keywords behaviour change techniques, lapse prevention, pregnancy, relapse prevention, smoking cessation
Introduction Smoking in pregnancy is one of the greatest preventable causes of pregnancy complications and infant health conditions and mortality (Cnattingius, 2004; Flenady et al., 2011; McCowan et al., 2009). While between 14% and 28% of pregnant women who smoke prepregnancy are estimated to stop smoking spontaneously on learning of their pregnancy (Owen and Penn, 1999; Solomon and Quinn, 2004), few successfully stop thereafter despite significant efforts to do so (Pickett et al., 2003). Interventions that promote abstinence during pregnancy can be effective, but the mean abstinence rate post-intervention is only 15% (Lumley et al., 2009). Lapse and relapse are therefore high during pregnancy (Pickett et al., 2005). What is not known, however, is what
action pregnant smokers take to attempt to prevent lapses from occurring to prevent subsequent relapse. A major cause of smoking relapse is the failure to manage situations that cue the individual to smoke, referred to as episodic cravings or cues (Ferguson and Shiffman, 2009). The presence of other smokers, rapid drop in mood or elevated stress and high availability 1University 2University
of Cambridge, UK College London, UK
Corresponding Author: Felix Naughton, Behavioural Science Group, Institute of Public Health, University of Cambridge, Forvie Site, Cambridge CB2 0SR, UK. Email: [email protected]
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of cigarettes all increase the risk of lapse and subsequent relapse among smokers (Ferguson and Shiffman, 2009; O’Connell et al., 2011; Shiffman and Waters, 2004). Smokers can increase their chances of preventing a lapse through enacting cognitive and behavioural lapse prevention strategies to help them cope with or avoid situations or states that might cue them to smoke (Ferguson and Shiffman, 2009). The evidence to date does not support the efficacy of smoking relapse prevention interventions (Hajek et al., 2009), and little is known about the efficacy of lapse prevention strategies. Within a recently developed behaviour change technique (BCT) taxonomy for smoking cessation interventions (Michie et al., 2011a), there are a number of behavioural techniques that relate to lapse prevention, mostly within a self-regulatory skills category. These include ‘facilitate relapse prevention and coping’, ‘advise on changing routine’, ‘advise on/facilitate use of social support’, ‘advise on avoiding social cues for smoking’, ‘facilitate restructuring of social life’ and ‘teach relaxation techniques’. There is evidence, based on an assessment of UK Stop Smoking Service (SSS) treatment manuals, that the first three of these techniques are associated with higher overall CO verified abstinence at a service level (West et al., 2010). Advising on changing routine and advising on/facilitating use of social support are also associated with increased effectiveness in smoking cessation interventions for pregnant smokers (Lorencatto et al., 2012). However, these studies do not focus on what was actually delivered or enacted by smokers, which is a current gap in knowledge. Lapse prevention strategy use has been documented for adolescent smokers (Myers et al., 2007), and the impact of cognitive and behavioural coping responses in managing tempting situations has been explored among adult smokers calling a helpline (Shiffman, 1984). However, there is a dearth of research exploring the use and efficacy of commonly recommended non-pharmacological strategies to manage cravings and to avoid lapse among any population of
smokers, besides deep breathing techniques (Shahab et al., 2012) and brief physical activity (Taylor et al., 2007). The use of lapse prevention strategies are likely to be particularly important for pregnant smokers. This is because the majority have partners who smoke (Lawrence et al., 2003), they experience significant pregnancyspecific barriers to accessing cessation support which can inhibit support access (Ussher et al., 2006), have fewer cessation medications available to them and rarely use those that are appropriate for use in pregnancy (Rigotti et al., 2008). The aim of this study is therefore to identify which commonly recommended lapse prevention strategies pregnant smokers use and to assess whether their use predicts abstinence, using participants of an intervention trial (MiQuit) as an observational cohort.
Methods Participants Pregnant smokers (N = 207) were recruited from seven UK National Health Service (NHS) Trusts between December 2008 and October 2009 to a self-help smoking cessation intervention trial. Community midwives within each Trust were asked to invite all pregnant smokers they saw at their booking visit to participate, providing they met the inclusion criteria: less than 21 weeks pregnant, 16 years of age or over, smoked seven or more cigarettes per week, owned or had regular use of a mobile phone and understood written English. Women enrolled by completing and returning by post a baseline questionnaire and consent form. A more detailed description of procedures can be found elsewhere (Naughton et al., 2012). Participants were sent a follow-up questionnaire 3 months after enrolment and were followed up by text message and telephone if it was not returned within 10 days.
Design and interventions Trial participants were randomly allocated either to a tailored self-help smoking cessation
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Table 1. Lapse prevention strategy use among sample and association with cotinine-validated abstinence. Lapse prevention strategy
Focusing on other tasks Trying not to think about smoking Keeping your mouth busy (e.g. chewing mints or gum) Going for a walk or some fresh air Avoiding spending time with other smokers Changing your routine Self-talk (e.g. I can do it) Avoiding places where you would usually smoke Deep breathing Contacting a friend/family member for support or distraction
Type
Number used (%)
Association with abstinence χ2
P
120 (69) 109 (63)
0.17 0.52
0.684 0.470
Coping-behavioural
79 (45)
0.84
0.359
Coping-behavioural
44 (25)
1.27
0.261
Avoiding-behavioural
40 (23)
9.31
0.002
Avoiding-behavioural Coping-cognitive Avoiding-behavioural
39 (22) 36 (21) 33 (19)
0.09 8.14 0.02
0.768 0.004 0.900
Coping-cognitive Coping-behavioural
20 (12) 11 (6)
0.05 0.07
0.824 0.796
Avoiding-behavioural Avoiding-cognitive
intervention (MiQuit) or to non-tailored selfhelp (control). See elsewhere for a detailed description of the interventions and sample size calculation (Naughton et al., 2012). For the purposes of this article, we are using this sample as an observational cohort.
Measures Demographic and background information and smoking-related baseline measures were collected at enrolment by questionnaire, including partner’s smoking status, previous prenatal smoking history and parity. Nicotine dependence was measured using time to first cigarette after waking and cigarettes per day (Naughton et al., 2012), and motivation to quit was measured by asking when participants planned to quit smoking (within next 2 weeks, 30 days, 3 months or not planning to quit). At 3-month follow-up, participants were asked to indicate which of 10 lapse prevention strategies they used since enrolment to help them avoid smoking. These were strategies commonly recommended in self-help materials
for pregnant smokers assessed for a systematic review (Naughton et al., 2008) and are described in terms of two dimensions of lapse prevention: avoiding or coping with high-risk situations and cognitive or behavioural strategies (Ferguson and Shiffman, 2009). These strategies and corresponding dimensions are listed in Table 1. Smoking abstinence was defined as cotininevalidated 7-day point prevalence abstinence at 3-month follow-up. Saliva samples were collected by post with a cut-off of 13 ng/ml cotinine (Hegaard et al., 2007). A sensitivity analysis removing those reporting use of Nicotine Replacement Therapy (NRT) at follow-up was undertaken in case their cotinine level erroneously classified them as smokers.
Analysis Analyses were undertaken in SPSS v15.0. Participants were withdrawn from the study if they had experienced a miscarriage/stillbirth after enrolment (Naughton et al., 2008). Descriptive statistics were run to describe strategy use at the participant level. Pearson
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correlations and chi-squared tests were run to assess the associations between strategies used and abstinence. Given the exploratory rather than confirmatory nature of the analyses, we did not adjust the α level for multiple comparisons so as to reduce the risk of a type II error. For specific strategies associated with abstinence, logistic regression analyses were run to test for trial group by strategy interactions to check whether associations were similar in the two trial groups. Hierarchical logistic regression was undertaken in which baseline characteristics (listed in the ‘Measures’ section) associated with abstinence- and trial-related variables (trial group and NHS Trust as a stratifier) were entered into the model as control variables at step 1 with individual strategies associated with abstinence entered at step 2 to assess their independent predictive ability.
Results Baseline characteristics and attrition Of those who enrolled into the trial (N = 207), 88% completed follow-up (n = 174) who formed the sample for the analyses. Participants had a median gestation of 13 weeks and a median age of 26 years at baseline, and 67% had a partner who smoked. Regarding cigarettes smoked per day, 30% smoked 5 or less, 39% smoked 6–10 and 31% smoked more than 10. The majority (91%) planned to quit at least within the next 3 months at baseline, with 9% not currently planning to quit. See elsewhere for a full breakdown of participant characteristics (Naughton et al., 2012).
Use of lapse prevention strategies The most commonly used strategies were ‘focusing on other tasks’ (69%), ‘trying not to think about smoking’ (63%) and ‘keeping your mouth busy’ (45%). The remaining strategies were used by one-quarter or less of the participants (see Table 1). The mean number of strategies used per participant was 3.1, and only 19% of participants reported using 5 or more strategies.
At follow-up, 12% of participants were abstinent. The number of strategies used was not associated with abstinence. However, when looking at individual strategies, two were associated with abstinence: the use of ‘self-talk’ (25.0% who used strategy were abstinent vs 8.0% who did not; χ2(1) = 8.1, p = 0.004) and ‘avoiding spending time with other smokers’ (25.0% who used strategy were abstinent vs 7.5% who did not; χ2(1) = 9.3, p = 0.002). No trial group by strategy interactions were found. When these strategies were entered into a logistic regression model, after the inclusion of trial variables and nicotine dependence as the only significant control variable, they independently increased the odds of abstinence: ‘self-talk’ OR = 3.44 (95% confidence interval (CI) = 1.14– 10.40) and ‘avoiding spending time with other smokers’ OR = 4.01 (95% CI = 1.34–11.95). Removing 55 participants reporting any use of NRT at follow-up as part of a sensitivity analysis resulted in an increased effect of ‘self-talk’ (OR = 7.22, 95% CI = 1.77–29.56), and the strategy ‘avoiding spending time with other smokers’ became non-significant (OR = 3.76, 95% CI = 0.94–15.07).
Discussion Lapse prevention strategies that helped participants distract themselves from smoking were most commonly used, cited by around twothirds of participants. This corresponds closely with findings from adolescents (Myers et al., 2007) although less so with findings from adults contacting a helpline, where self-talk and replacement activities were the most common strategies (Shiffman, 1984). Strategies supported by evidence for coping with the physiological effects of cravings, that is, deep breathing and brief physical activity, were among the least used. The strategies ‘changing your routine’ and ‘contacting a friend/family member for support or distraction’ that map onto BCTs associated with abstinence at a SSS level (Lorencatto et al., 2012; Michie et al., 2011b; West et al., 2010) were only used by 22% and 6% of participants, respectively.
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Naughton et al. Our findings indicate that the total number of strategies used may not be important for successful short-term abstinence, as found by Shiffman (1984), although our study may be underpowered. However, two specific strategies, ‘self-talk’ and ‘avoiding spending time with other smokers’, while only used by a minority, were associated with more than a threefold increase in the odds of being abstinent. The presence of other smokers in a smoker’s environment is a strong predictor of relapse (O’Connell et al., 2011) and continued smoking in pregnancy (Lu et al., 2001). It is consistent therefore that actively avoiding other smokers is associated with abstinence. It was not anticipated that the use of self-talk would be so strongly associated with abstinence, given that it had not previously been identified as more effective than other strategies (Shiffman, 1984). Self-talk might work by boosting determination and self-efficacy to quit, potentially as a form of self-affirmation (Steele, 1988). Knowledge of the type of selftalk used would provide valuable insight into this potential mechanism. Alternatively, the use of self-talk may be associated with individual characteristics which also predict abstinence, although we did not find any likely candidates in our analysis of demographic/ background factors. Avoiding spending time with other smokers maps onto two BCTs (‘facilitate restructuring of social life’ and ‘advise on avoiding social cues for smoking’). While ‘self-talk’ is identified as a generic BCT (Michie et al., 2013), it does not yet feature within a technique in the BCT taxonomy for smoking cessation (Michie et al., 2011b). Our results would support the inclusion of this technique into this taxonomy. Furthermore, it may be beneficial to pregnant smokers if these two strategies were more actively promoted within SSS support, although further evaluation is needed.
Limitations The cross-sectional design of this study means that we cannot rule out alternative explanations
of our findings, and retrospective self-reported strategy use may be subject to recall bias. This could have led to an overestimate or underestimate of the number of strategies reported to have been used. Recall bias could be minimised by using repeated data collection methods such as ecological momentary assessment. However, this intensive measurement approach could remind or cue participants into using the strategies, acting as an intervention in itself (Godin et al., 2008), and therefore reduce its validity for assessing typical strategy use after receiving an intervention which might be expected to form part of usual care. We did not measure the frequency of strategy use, which may be an important factor when predicting abstinence in order to distinguish between strategies tried once or twice only and those used more regularly. Furthermore, we did not provide detailed definitions of the strategies, and so some participants may have interpreted them differently. While we made efforts to include strategies commonly present in self-help materials for pregnant smokers, our list is not fully comprehensive, and we did not allow for the addition of any unlisted strategies, and therefore, we may have excluded some effective strategies commonly used.
Conclusion On the one hand, our finding that pregnant smokers do not commonly enact lapse prevention strategies other than those most easily employed, that is, distraction, suggests that they may not be benefiting from their use, especially those with an evidence base. On the other hand, our findings do not implicate the use of multiple strategies as being important in achieving abstinence. Future research assessing the frequency of strategy use in greater depth over time should help provide greater insight. Our findings do suggest, however, that self-talk and avoiding other smokers may be particularly important individual strategies to promote in clinical care. This finding warrants further attention.
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Declaration of conflicting interests F.N. and S.S. have no conflict of interest to disclose. A.M. receives a personal income from Cancer Research UK via University College London. He has received travel funding, honorariums and consultancy payments from manufacturers of smoking cessation products (Pfizer Ltd, Novartis UK and GSK Consumer Healthcare Ltd) and hospitality from North51 who provide online and database services. He also receives payment for providing training to smoking cessation specialists, receives royalties from books on smoking cessation and has a share in a patent of a nicotine delivery device.
Funding This work was supported by Cancer Research UK (CR-UK) grant number C1345/A5809.
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Lorencatto F, West R and Michie S (2012) Specifying evidence-based behavior change techniques to aid smoking cessation in pregnancy. Nicotine & Tobacco Research 14(9): 1019–1026. Lumley J, Chamberlain C, Dowswell T, et al. (2009) Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews 3: CD001055. Lu Y, Tong S and Oldenburg B (2001) Determinants of smoking and cessation during and after pregnancy. Health Promotion International 16(4): 355–365. McCowan LM, Dekker GA, Chan E, et al. (2009) Spontaneous preterm birth and small for gestational age infants in women who stop smoking early in pregnancy: Prospective cohort study. British Medical Journal 338: b1081. Michie S, Churchill S and West R (2011a) Identifying evidence-based competences required to deliver behavioural support for smoking cessation. Annals of Behavioral Medicine 41(1): 59–70. Michie S, Hyder N, Walia A, et al. (2011b) Development of a taxonomy of behaviour change techniques used in individual behavioural support for smoking cessation. Addictive Behaviors 36(4): 315–319. Michie S, Richardson M, Johnston M, et al. (2013) The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: Building an international consensus for the reporting of behavior change interventions. Annals of Behavioral Medicine 46(1): 81–95. Myers MG, MacPherson L, Jones LR, et al. (2007) Measuring adolescent smoking cessation strategies: Instrument development and initial validation. Nicotine & Tobacco Research 9(11): 1131–1138. Naughton F, Prevost AT and Sutton S (2008) Selfhelp smoking cessation interventions in pregnancy: A systematic review and meta-analysis. Addiction 103(4): 566–579. Naughton F, Prevost AT, Gilbert H, et al. (2012) Randomised controlled trial evaluation of a tailored leaflet and SMS text message self-help intervention for pregnant smokers (MiQuit). Nicotine & Tobacco Research 14(5): 569–577. O’Connell KA, Shiffman S and Decarlo LT (2011) Does extinction of responses to cigarette cues occur during smoking cessation? Addiction 106(2): 410–417.
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Naughton et al. Owen L and Penn G (1999) Smoking and pregnancy: A survey of knowledge, attitudes and behaviour 1992 – 1999. Report, Health Education Authority, London. Pickett KE, Rathouz PJ, Kasza K, et al. (2005) Selfreported smoking, cotinine levels, and patterns of smoking in pregnancy. Paediatric and Perinatal Epidemiology 19(5): 368–376. Pickett KE, Wakschlag LS, Dai L, et al. (2003) Fluctuations of maternal smoking during pregnancy. Obstetrics and Gynecology 101(1): 140–147. Rigotti NA, Park ER, Chang Y, et al. (2008) Smoking cessation medication use among pregnant and postpartum smokers. Obstetrics and Gynecology 111(2 Pt 1): 348–355. Shahab L, Sarkar BK and West R (2012) The acute effects of yogic breathing exercises on craving and withdrawal symptoms in abstaining smokers. Psychopharmacology (Berl) 225(4): 875–882. Shiffman S (1984) Coping with temptations to smoke. Journal of Consulting and Clinical Psychology 52(2): 261–267. Shiffman S and Waters AJ (2004) Negative affect and smoking lapses: A prospective analysis.
Journal of Consulting and Clinical Psychology 72(2): 192–201. Solomon L and Quinn V (2004) Spontaneous quitting: Self-initiated smoking cessation in early pregnancy. Nicotine & Tobacco Research 6 (Suppl. 2): S203–S216. Steele CM (1988) The psychology of self-affirmation: Sustaining the integrity of the self. In: Berkowitz L (ed.) Advances in Experimental Social Psychology, vol. 21. New York: Academic Press, pp. 261–302. Taylor AH, Ussher MH and Faulkner G (2007) The acute effects of exercise on cigarette cravings, withdrawal symptoms, affect and smoking behaviour: A systematic review. Addiction 102(4): 534–543. Ussher M, Etter JF and West R (2006) Perceived barriers to and benefits of attending a stop smoking course during pregnancy. Patient Education and Counseling 61(3): 467–472. West R, Walia A, Hyder N, et al. (2010) Behavior change techniques used by the English Stop Smoking Services and their associations with short-term quit outcomes. Nicotine & Tobacco Research 12(7): 742–747.
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HPQ0010.1177/1359105313512878Journal of Health PsychologyNaughton et al.
Article Journal of Health Psychology 2015, Vol. 20(11) 1427–1433 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105313512878 hpq.sagepub.com
Use and effectiveness of lapse prevention strategies among pregnant smokers Felix Naughton1, Andy McEwen2 and Stephen Sutton1
Abstract Little is known about the use of lapse prevention strategies to help smokers manage situation-triggered urges to smoke. Pregnant smokers (N = 174) participating in an intervention trial reported use of cognitive– behavioural lapse prevention strategies and smoking abstinence (biochemically verified). Participants typically enacted few strategies. Distraction strategies were most commonly used. Total number of strategies used did not predict abstinence. However, using ‘self-talk’ (odds ratio (OR) = 3.44, 95% confidence interval = 1.14–10.40) or ‘avoiding spending time with other smokers’ (OR = 4.01, 95% confidence interval = 1.34– 11.95) independently increased the odds of abstinence. The promotion of these and other under-utilised evidence-based strategies warrants further attention.
Keywords behaviour change techniques, lapse prevention, pregnancy, relapse prevention, smoking cessation
Introduction Smoking in pregnancy is one of the greatest preventable causes of pregnancy complications and infant health conditions and mortality (Cnattingius, 2004; Flenady et al., 2011; McCowan et al., 2009). While between 14% and 28% of pregnant women who smoke prepregnancy are estimated to stop smoking spontaneously on learning of their pregnancy (Owen and Penn, 1999; Solomon and Quinn, 2004), few successfully stop thereafter despite significant efforts to do so (Pickett et al., 2003). Interventions that promote abstinence during pregnancy can be effective, but the mean abstinence rate post-intervention is only 15% (Lumley et al., 2009). Lapse and relapse are therefore high during pregnancy (Pickett et al., 2005). What is not known, however, is what
action pregnant smokers take to attempt to prevent lapses from occurring to prevent subsequent relapse. A major cause of smoking relapse is the failure to manage situations that cue the individual to smoke, referred to as episodic cravings or cues (Ferguson and Shiffman, 2009). The presence of other smokers, rapid drop in mood or elevated stress and high availability 1University 2University
of Cambridge, UK College London, UK
Corresponding Author: Felix Naughton, Behavioural Science Group, Institute of Public Health, University of Cambridge, Forvie Site, Cambridge CB2 0SR, UK. Email: [email protected]
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of cigarettes all increase the risk of lapse and subsequent relapse among smokers (Ferguson and Shiffman, 2009; O’Connell et al., 2011; Shiffman and Waters, 2004). Smokers can increase their chances of preventing a lapse through enacting cognitive and behavioural lapse prevention strategies to help them cope with or avoid situations or states that might cue them to smoke (Ferguson and Shiffman, 2009). The evidence to date does not support the efficacy of smoking relapse prevention interventions (Hajek et al., 2009), and little is known about the efficacy of lapse prevention strategies. Within a recently developed behaviour change technique (BCT) taxonomy for smoking cessation interventions (Michie et al., 2011a), there are a number of behavioural techniques that relate to lapse prevention, mostly within a self-regulatory skills category. These include ‘facilitate relapse prevention and coping’, ‘advise on changing routine’, ‘advise on/facilitate use of social support’, ‘advise on avoiding social cues for smoking’, ‘facilitate restructuring of social life’ and ‘teach relaxation techniques’. There is evidence, based on an assessment of UK Stop Smoking Service (SSS) treatment manuals, that the first three of these techniques are associated with higher overall CO verified abstinence at a service level (West et al., 2010). Advising on changing routine and advising on/facilitating use of social support are also associated with increased effectiveness in smoking cessation interventions for pregnant smokers (Lorencatto et al., 2012). However, these studies do not focus on what was actually delivered or enacted by smokers, which is a current gap in knowledge. Lapse prevention strategy use has been documented for adolescent smokers (Myers et al., 2007), and the impact of cognitive and behavioural coping responses in managing tempting situations has been explored among adult smokers calling a helpline (Shiffman, 1984). However, there is a dearth of research exploring the use and efficacy of commonly recommended non-pharmacological strategies to manage cravings and to avoid lapse among any population of
smokers, besides deep breathing techniques (Shahab et al., 2012) and brief physical activity (Taylor et al., 2007). The use of lapse prevention strategies are likely to be particularly important for pregnant smokers. This is because the majority have partners who smoke (Lawrence et al., 2003), they experience significant pregnancyspecific barriers to accessing cessation support which can inhibit support access (Ussher et al., 2006), have fewer cessation medications available to them and rarely use those that are appropriate for use in pregnancy (Rigotti et al., 2008). The aim of this study is therefore to identify which commonly recommended lapse prevention strategies pregnant smokers use and to assess whether their use predicts abstinence, using participants of an intervention trial (MiQuit) as an observational cohort.
Methods Participants Pregnant smokers (N = 207) were recruited from seven UK National Health Service (NHS) Trusts between December 2008 and October 2009 to a self-help smoking cessation intervention trial. Community midwives within each Trust were asked to invite all pregnant smokers they saw at their booking visit to participate, providing they met the inclusion criteria: less than 21 weeks pregnant, 16 years of age or over, smoked seven or more cigarettes per week, owned or had regular use of a mobile phone and understood written English. Women enrolled by completing and returning by post a baseline questionnaire and consent form. A more detailed description of procedures can be found elsewhere (Naughton et al., 2012). Participants were sent a follow-up questionnaire 3 months after enrolment and were followed up by text message and telephone if it was not returned within 10 days.
Design and interventions Trial participants were randomly allocated either to a tailored self-help smoking cessation
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Table 1. Lapse prevention strategy use among sample and association with cotinine-validated abstinence. Lapse prevention strategy
Focusing on other tasks Trying not to think about smoking Keeping your mouth busy (e.g. chewing mints or gum) Going for a walk or some fresh air Avoiding spending time with other smokers Changing your routine Self-talk (e.g. I can do it) Avoiding places where you would usually smoke Deep breathing Contacting a friend/family member for support or distraction
Type
Number used (%)
Association with abstinence χ2
P
120 (69) 109 (63)
0.17 0.52
0.684 0.470
Coping-behavioural
79 (45)
0.84
0.359
Coping-behavioural
44 (25)
1.27
0.261
Avoiding-behavioural
40 (23)
9.31
0.002
Avoiding-behavioural Coping-cognitive Avoiding-behavioural
39 (22) 36 (21) 33 (19)
0.09 8.14 0.02
0.768 0.004 0.900
Coping-cognitive Coping-behavioural
20 (12) 11 (6)
0.05 0.07
0.824 0.796
Avoiding-behavioural Avoiding-cognitive
intervention (MiQuit) or to non-tailored selfhelp (control). See elsewhere for a detailed description of the interventions and sample size calculation (Naughton et al., 2012). For the purposes of this article, we are using this sample as an observational cohort.
Measures Demographic and background information and smoking-related baseline measures were collected at enrolment by questionnaire, including partner’s smoking status, previous prenatal smoking history and parity. Nicotine dependence was measured using time to first cigarette after waking and cigarettes per day (Naughton et al., 2012), and motivation to quit was measured by asking when participants planned to quit smoking (within next 2 weeks, 30 days, 3 months or not planning to quit). At 3-month follow-up, participants were asked to indicate which of 10 lapse prevention strategies they used since enrolment to help them avoid smoking. These were strategies commonly recommended in self-help materials
for pregnant smokers assessed for a systematic review (Naughton et al., 2008) and are described in terms of two dimensions of lapse prevention: avoiding or coping with high-risk situations and cognitive or behavioural strategies (Ferguson and Shiffman, 2009). These strategies and corresponding dimensions are listed in Table 1. Smoking abstinence was defined as cotininevalidated 7-day point prevalence abstinence at 3-month follow-up. Saliva samples were collected by post with a cut-off of 13 ng/ml cotinine (Hegaard et al., 2007). A sensitivity analysis removing those reporting use of Nicotine Replacement Therapy (NRT) at follow-up was undertaken in case their cotinine level erroneously classified them as smokers.
Analysis Analyses were undertaken in SPSS v15.0. Participants were withdrawn from the study if they had experienced a miscarriage/stillbirth after enrolment (Naughton et al., 2008). Descriptive statistics were run to describe strategy use at the participant level. Pearson
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correlations and chi-squared tests were run to assess the associations between strategies used and abstinence. Given the exploratory rather than confirmatory nature of the analyses, we did not adjust the α level for multiple comparisons so as to reduce the risk of a type II error. For specific strategies associated with abstinence, logistic regression analyses were run to test for trial group by strategy interactions to check whether associations were similar in the two trial groups. Hierarchical logistic regression was undertaken in which baseline characteristics (listed in the ‘Measures’ section) associated with abstinence- and trial-related variables (trial group and NHS Trust as a stratifier) were entered into the model as control variables at step 1 with individual strategies associated with abstinence entered at step 2 to assess their independent predictive ability.
Results Baseline characteristics and attrition Of those who enrolled into the trial (N = 207), 88% completed follow-up (n = 174) who formed the sample for the analyses. Participants had a median gestation of 13 weeks and a median age of 26 years at baseline, and 67% had a partner who smoked. Regarding cigarettes smoked per day, 30% smoked 5 or less, 39% smoked 6–10 and 31% smoked more than 10. The majority (91%) planned to quit at least within the next 3 months at baseline, with 9% not currently planning to quit. See elsewhere for a full breakdown of participant characteristics (Naughton et al., 2012).
Use of lapse prevention strategies The most commonly used strategies were ‘focusing on other tasks’ (69%), ‘trying not to think about smoking’ (63%) and ‘keeping your mouth busy’ (45%). The remaining strategies were used by one-quarter or less of the participants (see Table 1). The mean number of strategies used per participant was 3.1, and only 19% of participants reported using 5 or more strategies.
At follow-up, 12% of participants were abstinent. The number of strategies used was not associated with abstinence. However, when looking at individual strategies, two were associated with abstinence: the use of ‘self-talk’ (25.0% who used strategy were abstinent vs 8.0% who did not; χ2(1) = 8.1, p = 0.004) and ‘avoiding spending time with other smokers’ (25.0% who used strategy were abstinent vs 7.5% who did not; χ2(1) = 9.3, p = 0.002). No trial group by strategy interactions were found. When these strategies were entered into a logistic regression model, after the inclusion of trial variables and nicotine dependence as the only significant control variable, they independently increased the odds of abstinence: ‘self-talk’ OR = 3.44 (95% confidence interval (CI) = 1.14– 10.40) and ‘avoiding spending time with other smokers’ OR = 4.01 (95% CI = 1.34–11.95). Removing 55 participants reporting any use of NRT at follow-up as part of a sensitivity analysis resulted in an increased effect of ‘self-talk’ (OR = 7.22, 95% CI = 1.77–29.56), and the strategy ‘avoiding spending time with other smokers’ became non-significant (OR = 3.76, 95% CI = 0.94–15.07).
Discussion Lapse prevention strategies that helped participants distract themselves from smoking were most commonly used, cited by around twothirds of participants. This corresponds closely with findings from adolescents (Myers et al., 2007) although less so with findings from adults contacting a helpline, where self-talk and replacement activities were the most common strategies (Shiffman, 1984). Strategies supported by evidence for coping with the physiological effects of cravings, that is, deep breathing and brief physical activity, were among the least used. The strategies ‘changing your routine’ and ‘contacting a friend/family member for support or distraction’ that map onto BCTs associated with abstinence at a SSS level (Lorencatto et al., 2012; Michie et al., 2011b; West et al., 2010) were only used by 22% and 6% of participants, respectively.
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Naughton et al. Our findings indicate that the total number of strategies used may not be important for successful short-term abstinence, as found by Shiffman (1984), although our study may be underpowered. However, two specific strategies, ‘self-talk’ and ‘avoiding spending time with other smokers’, while only used by a minority, were associated with more than a threefold increase in the odds of being abstinent. The presence of other smokers in a smoker’s environment is a strong predictor of relapse (O’Connell et al., 2011) and continued smoking in pregnancy (Lu et al., 2001). It is consistent therefore that actively avoiding other smokers is associated with abstinence. It was not anticipated that the use of self-talk would be so strongly associated with abstinence, given that it had not previously been identified as more effective than other strategies (Shiffman, 1984). Self-talk might work by boosting determination and self-efficacy to quit, potentially as a form of self-affirmation (Steele, 1988). Knowledge of the type of selftalk used would provide valuable insight into this potential mechanism. Alternatively, the use of self-talk may be associated with individual characteristics which also predict abstinence, although we did not find any likely candidates in our analysis of demographic/ background factors. Avoiding spending time with other smokers maps onto two BCTs (‘facilitate restructuring of social life’ and ‘advise on avoiding social cues for smoking’). While ‘self-talk’ is identified as a generic BCT (Michie et al., 2013), it does not yet feature within a technique in the BCT taxonomy for smoking cessation (Michie et al., 2011b). Our results would support the inclusion of this technique into this taxonomy. Furthermore, it may be beneficial to pregnant smokers if these two strategies were more actively promoted within SSS support, although further evaluation is needed.
Limitations The cross-sectional design of this study means that we cannot rule out alternative explanations
of our findings, and retrospective self-reported strategy use may be subject to recall bias. This could have led to an overestimate or underestimate of the number of strategies reported to have been used. Recall bias could be minimised by using repeated data collection methods such as ecological momentary assessment. However, this intensive measurement approach could remind or cue participants into using the strategies, acting as an intervention in itself (Godin et al., 2008), and therefore reduce its validity for assessing typical strategy use after receiving an intervention which might be expected to form part of usual care. We did not measure the frequency of strategy use, which may be an important factor when predicting abstinence in order to distinguish between strategies tried once or twice only and those used more regularly. Furthermore, we did not provide detailed definitions of the strategies, and so some participants may have interpreted them differently. While we made efforts to include strategies commonly present in self-help materials for pregnant smokers, our list is not fully comprehensive, and we did not allow for the addition of any unlisted strategies, and therefore, we may have excluded some effective strategies commonly used.
Conclusion On the one hand, our finding that pregnant smokers do not commonly enact lapse prevention strategies other than those most easily employed, that is, distraction, suggests that they may not be benefiting from their use, especially those with an evidence base. On the other hand, our findings do not implicate the use of multiple strategies as being important in achieving abstinence. Future research assessing the frequency of strategy use in greater depth over time should help provide greater insight. Our findings do suggest, however, that self-talk and avoiding other smokers may be particularly important individual strategies to promote in clinical care. This finding warrants further attention.
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Journal of Health Psychology 20(11)
Declaration of conflicting interests F.N. and S.S. have no conflict of interest to disclose. A.M. receives a personal income from Cancer Research UK via University College London. He has received travel funding, honorariums and consultancy payments from manufacturers of smoking cessation products (Pfizer Ltd, Novartis UK and GSK Consumer Healthcare Ltd) and hospitality from North51 who provide online and database services. He also receives payment for providing training to smoking cessation specialists, receives royalties from books on smoking cessation and has a share in a patent of a nicotine delivery device.
Funding This work was supported by Cancer Research UK (CR-UK) grant number C1345/A5809.
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