1. The social dynamics of giving up smoking Caroline Smith CPHS, University of Edinburgh E-mail: C.E.Smith-3@sms.ed.ac.uk

2. Rationale Clusters of smokers quit together rather in isolation (Christakis & Fowler, 2008) Various social network features associated with lower relapse rates: ➤ presence of successful quitters (Goldade et al., 2013) ➤ ban on smoking in home (Yang et al., 2011) ➤ high levels of social support (Holahan et al., 2012) Interventions aimed at enhancing partner support within quitter’s existing network have been largely unsuccessful (Park et al., 2012; Hemsing et al. 2012)

3. Study design Longitudinal, qualitative design In-depth interviews: ~4 & 13 weeks after quit date Social networks mapping; quit experience incl. part played by family & friends Clients of NHS stop smoking services in Forth Valley

4. Participants Gender Female Male Age 25-44 45-64 65+ SIMD 1-4 (most) 5-10 (least) Quit at 4 weeks? Yes No Quit at 13 weeks? Yes No

5. Analytical approach Patient stories Broad framework Thematic analysis

6. Social network responses Making sense of SN responses Thematic framework Managing social networks Using social resources Actions People QUIT Smoking Quit role Self-protection Support Knowledge

7. Two case studies HeatherLynn 50-54 4 NHS Husband & 3 children Husband has chronic health problems; aging parents & parents-in-law need support 35 20 50-54 4 Housewife Husband Looks after two young grandchildren (aged 3 & 4) 2-3 days a week 30-35 10-15 Age: SIMD: Occupation: Lives with: Other commitments: Yrs smoked: No. smoked:

8. Social network mapping: Heather daughter son-in- law grand- daughter grandson daughter husband daughter’s partner brother sister-in- law friend + partner friend Current smoker Ex-smoker

9. Social network mapping: Lynn colleague daughterson sistermum daughterhusband father-in- law dad mother-in- law friend best friend friend work friend colleague Current smoker Ex-smoker

10. Making sense of SN responses And you go out in company, because nobody smokes, they’re not interested if you’ve stopped. “How you managing with smoking? With the no smoking?” And I said, “Och, I’m managing not too bad.” I says, “Good days and bad days.” He says to me, “I’m really proud of you for trying this.” And I thought, it’s not like him to say that. Lynn: He was sitting smoking and I says to him, “I don’t believe you’ve done this to me.” That was the first thing I went into in the kitchen… Caroline: On the very first morning. Lynn: And he went, “What? What have I done?” I said, “I don’t believe after all we’ve said that you could do this to me. I’m really, really pissed at you Mark.” And he said, “I don’t know what I’ve done. I don’t know what the hell you’re going on about.” I said, “You’re smoking.” “Oh, is it today you’re stopping?”, he said.

11. Managing SNs: regulating smoking Heather: The only person that smokes is Gillian and she doesn’t smoke in the house either. Caroline: Right, OK. Heather: Even when we did all smoke, nobody smoked in the house. Caroline: So does he still smoke in the kitchen, at the breakfast bar? Lynn: Yes, but not in front of me. Caroline: OK, yes. Lynn: Not in front of me. He’ll go outside and have one or he’ll go upstairs to the bedroom, but I can still smell it in the bedroom. Caroline: Yes. Lynn: But I’m loathe to throw him out in the rain, but maybe I should. But he won’t smoke in the same room. Definitely not. We used to go out, we go 12.00pm to 1.00pm lunch. We used to go out about 12.40pm and have a cigarette. Sometimes she goes out and has a cigarette and comes back in or sometimes she goes out maybe about 12.50pm and I just don’t see her after that.

12. Managing SNs: other strategies I never said to my husband because I thought, he’s a reformed smoker. He used to smoke, he’s been stopped for years now. But I didn’t want any pressure from anybody, I’ll do it in my time. Linda says, “And we’ll go out power walking for our holidays and we’ll get into shape.” And a bit later So she’s on Tamoxifen and I think that’s put a wee bit of weight onto her as well. And she’s not wanting to pile on a lot of weight either. But no, I’ve kind of, I’ve not said a lot about it. I think I’ve been frightened that if I did go back on it, they’ll say, “Oh, there she goes again.” Because you feel a bit of a failure when you think, “Other people can manage it, what’s wrong with me that I can’t?”

13. Using social resources But this time it’s different because I’m not wanting to let Nadia down and Nadia’s not wanting to... To be honest with you, if Nadia starts smoking I will probably fall by the wayside, or vice versa. So we’re helping each other through this. That kept us going, the discussing it, how we felt it was going. Well do you know, when I’ve felt like having one, these words have come back to me and actually they’ve been the best thing, the biggest help. To try and prove him wrong. I thought, “Bugger you, I’m going to show you that I’m going to manage it this time.” I thought, you know, this girl kept, still trying but obviously still buying… so I didn’t feel she was giving it 100%.

14. OR Who was still quit at 13 weeks?

15. Preliminary conclusions Focus on social network structure alone insufficient ➤ quitters do not react passively to SN influences ➤ but take active role in navigating their networks ➤ within constraints of their existing social relationships Various strategies used to negotiate complex social worlds: ➤ making sense of others’ responses ➤ managing social networks ➤ making use of social resources Research on social network-based interventions needs to move beyond a focus on enhancing partner support

16. The social dynamics of giving up smoking Caroline Smith CPHS, University of Edinburgh E-mail: C.E.Smith-3@sms.ed.ac.uk