1. Patient experience of smoking lapse and relapse back to smoking Dr Caitlin Notley SSA Research Fellow, Norwich Medical School, University of East Anglia Faculty of Medicine and Health Science Norwich Medical School

2. Background NHS Stop Smoking services are effective and cost- effective (West et al, 2013), but relapse is common (Ferguson, 2005) Insufficient evidence for any specific RP intervention (Hajek et al, Cochrane review, 2009, Agboola et al, 2010 ) Current smoking cessation guidelines do not recommend any specific interventions for smoking relapse prevention (NICE, 2008) Faculty of Medicine and Health Science Norwich Medical School

3. Faculty of Medicine and Health Science A Randomised Controlled Trial of Self- help Materials for the Prevention of Smoking Relapse (09/91/36) Investigators:F Song (PI) 1, R Holland 1, G Barton 1, M Bachman 1, P Aveyard 2, S Sutton 3, J Leonardi-Bee 4, T Brandon 5 Project coordinators: V Maskrey 1, A Blyth 1 Collaborators: M Adeney 6, K McGoldrick 6, T Dyer 7, C Slater 8 1.Norwich Medical School, University of East Anglia, UK 2.Nuffield Department of Primary Care Health Sciences, University of Oxford, UK 3.Institute of Public Health, University of Cambridge, UK 4.Epidemiology and Public Health, University of Nottingham, UK 5.Tobacco Research and Intervention Program, University of South Florida, USA 6.SmokeFree Norfolk, Norfolk Community Health and Care Trust 7.Norwich CRTU 8.NHS Norfolk Stop Smoking Services Acknowledgement: ‘This project was funded by the NIHR Health Technology Assessment programme and will be published in full in the Health Technology Assessment journal series. Visit the HTA programme website for more details www.hta.ac.uk/link to project page. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Department of Health’ ref: 09/91/36

4. Smoking lapse and relapse The Sharpish trial: “Following the Russell Standard, the primary outcome was prolonged abstinence from months four to 12, with no more than five cigarettes in total, and confirmed by CO<10ppm at the 12 month follow-up” Therefore relapse = more than five cigarettes in months 4-12 of the study Following this, lapse = less than 5 cigarettes within the last year. Faculty of Medicine and Health Science Norwich Medical School

5. Previous studies of smoking lapse and relapse Primarily quantitative – identification of relapse ‘triggers’ and high risk situations, e.g. being around smokers, stress (Brandon, 1986, Piasecki, 2006) Psychological factors – cue reactivity, attentional bias (Powell et al, 2010) Association between level of dependence and likelihood of relapse (Powell et al, 2010) Response: Focus on coping skills (ineffective coping in response to high risk situations → relapse) (Marlatt 1980, Marlatt & George, 1984; Song, 2009) Faculty of Medicine and Health Science Norwich Medical School Faculty of Medicine and Health Science Norwich Medical School

6. SHARPISH Q 43 In depth qualitative interviews Purposive sampling across trial sample Sample was representative of the study population as a whole Focus groups with participants and SS professionals Grounded theory approach to analysis. 10% coding independent verification Secondary analysis aim to explore participant experiences of lapses and relapse Faculty of Medicine and Health Science Norwich Medical School Intervention group Smoking statusInterventioncontrol abstinent1511 relapsed89

7. Findings 874/1404 (62%) trial participants relapsed at 12 months (530/1404) CO verified abstinence) 17/43 (40%) qualitative sample self reported relapse 23 ‘lapse narratives’ (within last 12 months) Faculty of Medicine and Health Science Norwich Medical School

8. Findings – the process of a smoking lapse Faculty of Medicine and Health Science Norwich Medical School Prior to lapse Lapse triggers Outlook following lapse Cognitive rationalising Lapse leading to relapse Motivation Identity feelings reflection Brief lapse only – no relapse (4) Mood Lapse quickly leads to relapse (7) Lapse slowly leads to relapse (2) Social Situational Psychological Environmental cue

9. From lapse to relapse 1.Unplanned lapse ‘before I knew it I was smoking again’ ‘I don’t know what I was thinking’ ‘that was it’ ‘I was drunk’ ‘so we were going fishing and I went to [supermarket] as it happens on the er Thursday prior to going fishing, to get some bits and pieces of food for, for going, and I went up to the tobacco kiosk to buy a lottery ticket …And er- the woman in front of me, she bought some cigarettes and (coughs), God knows what made me do it, I just- I said if you can- do us some lucky dips on that one please, oh and I said, while I’m at it, I’ll have half an ounce of one of your- (0677, male, age 75, Relapsed)

10. From lapse to relapse 1. Planned lapse, unplanned relapse ‘I thought I could just have one’ ‘I was on holiday’ Faculty of Medicine and Health Science Norwich Medical School well it was kind of outdoors like a club every night for the kids…and then the adults will stay there you know…and people were smoking around and then I was really, really craving a cigarette and I couldn’t get ??...and then the next day I found a cigarette machine in the hotel …and I bought some but I didn’t buy any to take back with me I didn’t plan to smoke when I came back…but I did (0940, female, aged 56. Relapsed but abstinent again at follow up)

11. From lapse to relapse 2. Planned lapse, and relapse ‘I couldn’t cope’ ‘what the hell’ ‘things can’t get any worse’ Faculty of Medicine and Health Science Norwich Medical School I had to walk away from the situation, my parents, and I had to say no, and it was a case of I, that’s what I’m going to do and I drove five miles, even on the way there I thought to myself why am I doing this, and it was a case of something in my brain was saying I want one (0674, female, age 49, relapsed.)

12. From lapse to abstinence 3. Unplanned lapse, avoidance of full relapse ‘I thought it would help, but it didn’t’ ‘I don’t need it anymore’ ‘I used my e cigarette instead’ Faculty of Medicine and Health Science Norwich Medical School ‘that was it… although everyone thought that I was going to go back to cigarettes, right on top of Christmas, cos we moved, and I didn’t… and they were all shocked that I didn’t because, you know ‘(NAME) has a crisis (NAME) immediately goes for a cigarette’, that’s what they assumed would happen, and it was just those two times (0728, female, age 49, abstinent) ‘and my partner and I had a bit of a to-do argument or whatever…and we were at the pub at the time…so I just asked someone I knew for a couple of ciggy’s so I did have a bit of a but I knew the next day I would go straight to not having any…because as I suspected the cigarettes didn’t really do anything at all’ (0818, female, age 37, abstinent)

13. The process of a smoking lapse – Sharpish-Q Analysis and the RP model Expectations / anticipation Mood Feelings/ reflection Physical effects rationalisin g Lapse triggers: Environmental Social Psychological Identity Socio-cultural Psychological, social, cultural and identity related factors for describing the move to relapse 2 groups: Planned vs. unplanned relapsers Mood Identity

14. Conclusions In-depth understanding of patient experience of smoking lapse/relapse Lapsing and/or relapsing back to smoking is a complex process rather than a discrete event The concept of identity appears to be important for describing the move to relapse Possible adaption of our current theoretical understanding of relapse to incorporate instances of planned relapse, and lapse situations where relapse is avoided. Importance of addressing the concept of identity within smoking relapse prevention interventions for future testing. Faculty of Medicine and Health Science Norwich Medical School

15. References Hajek P, Stead LF, West R, Jarvis M, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane database of systematic reviews (Online) 2009(1):CD003999 NICE. NICE public health guidance -Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. NICE public health guidance 10. National Institute for Health and Clinical Excellence; 2008. Piasecki, T.M. (2006) Relapse to Smoking, Clinical Psychology Review, 26:2, March 2006, p196–215 Marlatt GA, Gordon JR: Determinants of relapse: implications for the maintenance of behavior change. In: Behavioral medicine: changing health lifestyles. edn. Edited by Davidson P, Davidson S. New York: Brunner/Mazel; 1980: 410-452. Song F, Huttunen-Lenz M, Holland R. Effectiveness of complex psycho-educational interventions for smoking relapse prevention: an exploratory meta-analysis. Journal of Public Health 2009, doi:10.1093/pubmed/fdp109. Agboola S, McNeill A, Coleman T, Leonardi Bee J. A systematic review of the effectiveness of smoking relapse prevention interventions for abstinent smokers. Addiction 2010, 105(8):1362-1380. West R, May S, West M, Croghan E, McEwen A. Performance of English stop smoking services in first 10 years: analysis of service monitoring data. BMJ 2013, 347:f4921. Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: one-year outcomes. Addiction 2005, 100 Suppl 2:59-69. Brandon, Thomas H., Stephen T. Tiffany, and Timothy B. Baker. "The process of smoking relapse." Relapse and recovery in drug abuse 72 (1986): 104. Marlatt, G.A. & George, W.H Relapse prevention: Introduction and Overview of the Model. British Journal of Addiction, 79 (1984): 261-273 Marlatt, G.A. & Gordon, J.R 1985 Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. Guilford Press

16. We’ve come a long way...