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

1 Background Determinants of quit attempts and quit success: What role identity might play in smoking cessation? A study of positive smoker identity Outline

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

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

4 5 West, 2006, The Theory of Addiction, Blackwells. The PRIME theory of motivation 5 Identity Thoughts (self-labels, attributes and personal rules) and images about ourselves and feelings attached to these.

5 6 Vangeli & West, 2012, Brit J Health Psych, 17, ; 7 Brown et al., 2011, Addictive Behav, 36, ; 8 Thompson et al., 2009, Soc Cult Geogr, 10, ; 9 Johnson et al., 2003, Res Nurs Health, 26, ; 10 Levinson et al., 2007, Nicotine Tob Res, 9, ; 11 Hertel et al., 2012, Health Psych, 31, ; 12 van den Putte et al., 2009, Health Psych, 28, ; 13 Shadel & Mermelstein, 1996, Ann Behav Med, 18, Shifting between different smoker identities during smoking cessation 6. Background Discrepancies between behaviour and smoker identity 10. Making effort to distance themselves from their smoker identity 7. Those with strong non- smoker identity were more likely to remain abstinent than those with an established smoker identity 7-9. Established smoker identity associated with smoking escalation in adolescents 11. Smokers with a smoker identity were less likely to make a quit attempt 12. Smoker and abstainer self- concept at baseline predicted quit success during smoking cessation treatment 13.

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

7 Methods Cross sectional monthly survey of a representative sample of smokers (age 16 and over) in England A follow-up six months after the baseline. Measures used in this study were included June 2010 and March Representative sample of current cigarette smokers (including hand-rolled cigarettes), who smoke daily or occasionally. Provided data for all included variables. Smoking Toolkit Study Participants 14 Fidler et al., 2011, BMC Publ Health, 11(479); 15 N 6-month follow-up =2,099 N Baseline =9,456

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

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

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

11 Demographic and smoking characteristics associated with positive smoker identity* (N=9,456) Having greater nicotine dependence [OR=1.09 ( ); p<0.001] Less motivated to stop [OR=0.71 ( ); p<0.001] No quit attempt in past year [OR=0.85 ( ); p=0.025] Enjoy smoking [OR=1.65 ( ); p<0.001] Addicted to smoking [OR=1.58 ( ); p<0.001] Confidence in ability to stop [OR=1.15 ( ); p=0.054] Social Grade [OR=0.97 ( ); p=0.610] * Logistic regression, adjusted for all study variables Being male [OR=0.87 ( ); p=0.013] Being older [OR=1.11 ( ); p<0.001] Results Worries about current health [OR=1.09 ( ); p=0.284] Worries about future health [OR=1.00 ( ); p=0.988] Worries about the effects smoking has on family [OR=1.12 ( ); p=0.134] Worries about the costs of smoking [OR=1.04 ( ); p=0.509]

12 Being older [OR=1.10 ( ); p=0.005] Worries about future health [OR=1.28 ( ); p=0.031] Enjoy smoking [OR=0.71 ( ); p=0.001] Confidence in ability to stop [OR=1.53 ( ); p<0.001] Having a positive smoker identity [OR=0.69 ( ); p=0.007] Worries about the effects smoking has on family [OR=1.41 ( ); p=0.004] Predictors of quit attempts at 6-month follow up* (N=2,099) Gender [OR=0.89 ( ); p=0.251] Social grade [OR=0.98 ( ); p=0.853] Nicotine dependence [OR=0.97 ( ); p=0.300] Worries about current health [OR=1.19 ( ); p=0.143] Worries about the costs of smoking [OR=1.07 ( ); p=0.490] Addicted to smoking [OR=1.14 ( ); p=0.245] Results * Logistic regression, adjusted for all study variables

13 Greater nicotine dependence predicted the failure to quit successfully [OR=0.82 ( ); p=0.004] Positive smoker identity [OR=0.54 ( ); p=0.053] Predictors of quit success at 6-month follow up* (N=638) Predictors of quit success at 6-month follow up* (N=638) Age [OR=0.96 ( ); p=0.496] Gender [OR=0.88 ( ); p=0.524] Social grade [OR=0.73 ( ); p=0.132] Worries about current health [OR=0.91 ( ); p=0.691] Worries about future health [OR=0.79 ( ); p=0.305] Worries about the effects smoking has on family [OR=1.16 ( ); p=0.518] Worries about the costs of smoking [OR=0.97 ( ); p=0.871] Addicted to smoking [OR=1.26 ( ); p=0.295] Enjoy smoking [OR=1.03 ( ); p=0.904] Confidence in ability to stop [OR=0.90 ( ); p=0.637] Results * Logistic regression, adjusted for all study variables

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

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

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

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

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

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

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

Thank you! 21