Health Education Research, Vol. 18, No. 3, 292-303,
June 2003
© 2003 Oxford University Press
‘I came back here and started smoking again’: perceptions and experiences of quitting among disadvantaged smokers
Public Health Sciences, and 1 Research Unit in Health, Behaviour and Change, Department of Community Health Sciences, Edinburgh University, Teviot Place, Edinburgh EH8 9AG, UK. E-mail: amanda.amos{at}ed.ac.uk
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Abstract |
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This paper draws upon qualitative research with 100 smokers (50 male and 50 female) in two Scottish areas of disadvantage to investigate their perceptions and experiences of quitting. The fieldwork took place between 1999 and 2000, with data collected through in-depth individual interviews and the completion of a smoking day grid. While many interviewees wanted to quit, they drew on their understandings of habit and addiction to illustrate the difficulties which quitting posed. Addiction was referenced through accounts of actual and anticipated unpleasant withdrawal symptoms, while accounts of the difficulties associated with quitting drew primarily upon habitual usage and routine aspects of their lives. Interviewees reported interacting frequently with other smokers. They also highlighted how stressful aspects of their lives perpetuated habitual smoking and prompted relapse following periods of cessation. Although the contexts inhabited by the interviewees were crucial in inhibiting successful quitting attempts, these factors acted in conjunction with and exacerbated feelings of physiological dependence on tobacco. Interviewees were sceptical about the effectiveness of nicotine replacement therapy (NRT) other than in the immediate or short term. For the most part, interviewees felt that NRT could not address aspects of their lives that appeared to support and sustain smoking in the long term. The paper concludes that in order to facilitate and sustain smoking cessation, tobacco control interventions need to tackle both nicotine addiction and the material circumstances experienced by disadvantaged smokers.
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Background |
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There is a strong and increasing association between cigarette smoking and social disadvantage (Graham, 1993
; Marsh and McKay, 1994; Jarvis, 1997a; Dorset and Marsh, 1998; Bridgewood et al., 2000). Those living in areas of social disadvantage are more likely to start smoking and less likely to quit than other groups (Acheson, 1998; Shiffman, 1993). Smoking cessation presents particular problems for disadvantaged smokers. Although, overall, 70% of smokers say that they would like to quit (Jarvis, 1997b), there has been little change in cessation levels among poorer groups across the UK (Jarvis, 1997a; Acheson, 1998; Dorsett and Marsh, 1998). The current understanding that smoking is not only patterned by social inequalities, but is also a major contributor to inequalities in health (Graham, 1998), has informed Government White Papers on tobacco and public health (Secretary of State for Health, 1999; Secretary of State for Scotland, 1999). These have identified reducing smoking among low-income groups as a priority area and a key element of Government strategy for tackling health inequalities. In particular, resources have been directed at developing community-based cessation services in areas of deprivation, such as the Health Action Zones in England and Local Health Care Co-operatives in Scotland. In order to develop effective interventions, however, a more in-depth understanding is needed of the mechanisms which bind disadvantaged smokers to smoking and the difficulties which quitting presents.
The research perspectives which constitute the broad field of smoking research (addiction, psychology, sociology) offer different and sometimes competing explanations of why some smokers find it difficult or impossible to quit. From an addiction perspective, nicotine dependence is the major barrier to quitting. Because nicotine produces lasting changes in the body’s structure, smokers develop tolerance towards and dependence upon the drug (Henningfield and Benowitz, 1995). Nicotine’s ability to stimulate neural nicotine receptors in the brain also explains its psycho-pharmacological reinforcing properties (Balfour, 1994; Gilpin et al., 1997). Nicotine deprivation causes both physiological and psychological withdrawal symptoms (Baker, 1988; Henningford, 1994; Henningfield and Benowitz, 1995). Recent research on addiction suggests that there are differences between the way in which men and women smoke (Perkins et al., 1999) which may have implications for quitting (Blake et al., 1989). For example, that social and environmental factors may be a more important influence on women than men (Rose et al., 1996; Benowitz and Hatsukami, 1998) may have implications for quitting among disadvantaged women. In addition, evidence that highlights the role of nicotine in socio-economic variation and smoking, by demonstrating how nicotine dependence increases systematically with deprivation (Bennett et al., 1996; Jarvis and Wardle, 1999), has implications for cessation among disadvantaged smokers.
Psychological approaches have traditionally seen smoking as a function of both nicotine addiction and psychological dependency. Social psychologists have tended to use social cognition models to understand the determinants of behaviour and behaviour change (Coombes and McPherson, 1997). The explanations of health-related behaviours which they provide focus on the relationship between beliefs and behaviours (Schneider, 1991; Conner and Norman, 1996). Self-Efficacy Theory (Bandura 1977), for example, is based upon the dual premise that optimistic self-beliefs predict behaviour and that individuals typically intend to perform behaviours they consider to be within their control (Schwarzer, 1992; Schwarzer and Fuchs, 1996).
Social cognition models which have attempted to explain individual differences between smokers’ behaviours have been criticized for excluding the social contexts of smoking (Conner and Norman, 1996). Sociological research suggests that social conditions and circumstances may facilitate or constrain smoking behaviour. For example, while smoking in Britain used to be an acceptable component of social behaviour among adults, in many social contexts today the reverse operates (Murray et al., 1995; Rice et al., 1996; Royce et al., 1977). Smoking used to be associated with increased frequency of social relationships, probably because smokers interacted with other smokers and such contact increased the likelihood of smoking (Ford et al., 2000). However, although cultural norms are generally more likely to support non-smoking, social contexts or subcultures where smoking is the norm rather than the exception still persist, notably in areas of disadvantage (Laurier, 1999).
Qualitative sociological research indicates how the social circumstances of disadvantage play an important part in both sustaining smoking and prompting smoking resumption after periods of abstinence (Laurier et al., 2000). This body of work illustrates how smoking is one mechanism which women use to cope with living and caring in disadvantaged circumstances (Graham, 1993), and has made an important contribution to our understanding of the difficulty of quitting for women on low incomes and to the development of new approaches to tackle this issue (Graham, 1987; Gaunt-Richardson et al., 1999).
In a previous paper, which drew on our qualitative study of smoking in two disadvantaged areas of Edinburgh, we argued that each disciplinary approach makes an important contribution to our understanding of smoking among disadvantaged smokers. In particular, we noted how smokers have a sophisticated understanding of smoking drawing on the concepts of both addiction and habit when describing their patterns of smoking across the course of a ‘typical’ day (Bancroft et al., 2003). In that paper we argued that daily contexts which smokers inhabited either constrained or facilitated smoking, and that smokers employed various strategies to maintain a ‘desired’ level of nicotine intake in the face of smoking restrictions. In this paper we draw on the same study to focus upon interviewees’ experiences and beliefs about quitting, and examine how these are informed by their understandings of smoking and the role that it plays in their lives.
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Methods |
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Fieldwork was conducted between 1999 and 2000. In order to optimize diversity among our interviewees, 100 smokers were recruited from two health centres in two areas of Edinburgh defined as socially disadvantaged using DEPCAT scores (Carstairs et al., 1991
). GPs identified smokers aged 25–40 years old from their patient lists from which a sample was randomly selected. No other information about patients was gathered, although some were excluded by GPs as not suitable for the study. Interviewees comprised 50 female and 50 male smokers aged 25–40 years. Each received a letter from their GP providing information about the study accompanied by an opt-out form. Interviewees who did not opt-out were contacted to arrange an interview and 100 of the 167 people contacted agreed to be interviewed. The study encountered problems in recruiting interviewees, mainly due to a high level of ineligible addresses. Of the 372 letters sent out, 205 of the addresses proved ineligible or were unable to be contacted. We have discussed problems around the recruitment of research participants from disadvantaged areas in a previous paper drawing on the same study (Parry et al., 2001a).
The interviews
The study used qualitative interviews which incorporated an adapted version of the ‘life grid’ (Parry et al., 1999) to collect smoking data for 1 day from each interviewee. The interviews were taped and conducted in people’s homes, lasting approximately 1 h. The interviewer was one of the authors (A. B.), a trained qualitative researcher and sociologist. Wherever possible the interviewees were interviewed alone and in a small number of instances partners were present. They sometimes interrupted the interview with their own insights and contributions. These data have been used in the paper when pertinent.
In the first part of the interview the day grid was completed by the interviewer as a joint endeavour between researcher and interviewee. The grid was used to record structured data on daily experiences and events across different life domains (home, work, leisure, family and friends), and patterns and levels of cigarette use across the day. Although anchored to events and activities of 1 day, interviewees were asked to reflect upon circumstances and events occurring on contrasting days (such as work days and days off) where smoking might vary. Information contained on the grid was used as a resource for the second part of the interview, which explored in greater depth the levels and patterns of current daily consumption, reasons and justifications for smoking, the smoking environment, wider social influences on smoking, changes in smoking behaviour (including quit attempts and relapse after periods of abstinence), experiences of quitting, and future smoking/quitting intent. The day grid helped to build rapport and assisted interviewees in focusing on the themes of the research. It was often not completed separately from the qualitative part of the interview. Rather, it was returned to at different points during the interview, allowing interviewer and respondent to reflexively refocus on the interview themes. In many instances, interviewees self-identified and commented on their smoking patterns when looking over the completed day grid. It should be noted that the interviews were conducted before the introduction of local cessation services and nicotine replacement therapy (NRT) on prescription.
Analysis
The interviews were transcribed and entered into NUDIST. Patterns and themes emerging from the day grid were identified and discussed in the interview, rather than being analysed separately. The interview transcripts were read in conjunction with the day grids and a profile of typical daily smoking was established for each interviewee. These profiles enabled changes in smoking behaviour to be contextualized within routine events and circumstances across the day. The qualitative data were analysed thematically. The transcriptions were then examined for references to quitting and the various ways in which smoking was connected with their lives. These references were organized in terms of both similarity and contrast of content. Recurrent interviewee formulations were identified and tested by reference to the individual cases, and conditions and circumstances under which smokers deployed these formulations were compared and contrasted. In this paper, extracts from both transcript and profile data are used to illustrate key points. Interviewees are identified by sex (F = female, M = male) and interviewee number.
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Findings |
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Description of the sample
Most interviewees lived in council or housing association accommodation (Table I
). Less than half were in full-time employment and many worked irregular hours, such as variable shifts. Most said they smoked between 10 and 20 cigarettes a day, with females smoking at a slightly lower level than males. Most interviewees had tried to quit smoking at least once and many described several previous quit attempts. In addition, the majority said that they had reduced the amount they smoked or were anticipating doing so, as the first step towards quitting. Only a small minority of interviewees were adamant that they did not wish to stop smoking, and several of these had previously attempted to quit and failed.
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The following sections explore interviewees’ smoking-related beliefs, behaviours and future intentions. In particular, we examine reasons for previous quit attempts, their experience of abstinence, reasons why they resumed smoking, their reasons for wanting to quit in the present or in the future and anticipatory difficulties related to quitting.
Reasons to quit
Three reasons or motivations for quitting were most often cited by the interviewees—health, cost and significant others. Although not always mutually exclusive, for the purposes of the paper we discuss these reasons/motivations separately.
Health
Issues of health and illness were not specifically raised by the interviewer. However, because the interviewees were aged between 25 and 40 years, we expected that some would raise these issues. Indeed, among interviewees who regularly visited the GP, issues of health and illness were particularly salient, and many were connected to their smoking. M26, who had started smoking at primary school, for example, felt that smoking had adversely affected his health by leaving him with a ‘chesty cough’, and M25, who smoked 30 a day, said ‘the health side of things is starting to show’. Smokers were generally aware of the health risks of smoking and only a very few expressed the opinion that they were personally exempt from these risks. A very small minority raised, unprompted, examples of family members who had experienced long life despite being smokers, in the context of the general issue of scientific and medical ambiguity.
Although illness symptoms were experienced as unpleasant they had not, however, provided a sufficient reason to quit and sustain abstinence. Some interviewees, like F49, quit cigarettes following a health scare ‘but went back on them’, when the immediate crisis had abated. In addition, some interviewees said that smoking relieved unpleasant physical symptoms (which may themselves have been caused by smoking). For example, F22, who smoked 40 a day, claimed that because her ‘bad smokers cough’ was relieved by smoking it ‘doesnae [does not] give me the incentive to stop’. In other cases, smoking was linked to interviewees’ mental health. F01, for example, said she experienced ‘a right low feeling’ when abstaining from smoking.
Cost
Many interviewees complained about the high price of cigarettes. M10, for example, calculated that he and his wife would save ‘£260 a month’ if they quit and M20 said ‘sometimes we realize we’ve been smoking 60 quid a week’. Although many like F04 recalled intending to quit if prices rose, the reality was different:
We always say, ‘if they go up to such and such a price that’s it, I’ll never buy another pack’. But you just [do]. It never makes a difference.
Although important to the interviewees, price did not provide a sufficient motivation to quit, because, like F01, many said ‘I always seem to have the money for my cigarettes’. Rather than quitting, interviewees employed a range of strategies to continue smoking despite the high prices. These included, switching to cheaper brands, cutting down and buying ‘black market’ cigarettes. These strategies have been discussed in detail elsewhere (Wiltshire et al., 2001).
Significant others
Although some interviewees described disapproval from significant others about their smoking, this had not provided a sufficient motivation to quit and maintain abstinence. However, it was often cited as a reason for modifying smoking behaviour. Hence, intolerance of smoking had in many cases served to restrict the areas where interviewees would smoke within the home and/or moderate the amount interviewees smoked at home. Some interviewees lived with partners who had never smoked and smoking was described by these interviewees as a source of relationship tension. F29, for example, said her partner ‘hates smoke’ and described having ‘a lot of arguments over smoking’. M45 talked about his partner ‘giving me a row’, especially when he smoked ‘one after the other’. Children also exerted influence over their parents’ smoking. F35 described how her 10-year-old encouraged her to quit by saying repeatedly ‘that’ll kill you’ and F27 said she no longer smoked at home because of her daughter’s disapproval.
Explanations of relapse
Two reasons or explanations for continuing to smoke and/or relapsing, which featured highly in interviewees’ accounts, related to the management of emotions and the cultures of smoking which interviewees inhabited.
Smoking, stressful lives and the management of emotions
Many interviewees described how smoking helped them to cope with stressful aspects of their lives. F47, for example, said that when she experienced difficulties coping with her young children, ‘cigarettes sort of calm you down’. Men, who were more likely than women to work outside of the home, tended to associate smoking with work-related stress. M15, for example, said he smoked because his work caused him to get ‘stressed out’.
When the interviewees talked about quitting, for the most part they focused on how different and stressful aspects of their lives prompted them to resume smoking following periods of abstinence. Once again, gender differences in the stress-related activities which interviewees associated with smoking resumption were largely related to the daily contexts, domestic and/or employment, which they inhabited. M28, for example, had given up smoking with a friend. After 18 days he had started again, claiming it was ‘the job at the time made me start again’. Women with primary responsibility for the care of young children, like F05, were more likely to cite childcare related stresses, like, ‘it just became unbearable. I was going to smack them or start smoking again’. F05 said that although she still wanted to stop smoking, she was postponing quitting until her children had ‘grown up and left the house’.
The culture of smoking
Most interviewees lived, socialized and/or worked with other smokers, and because of this smoking was deeply embedded in their lives. Although many larger Scottish workplaces have formal smoking restrictions (Parrot et al., 2000), smokers tended to navigate around these, e.g. congregating outside together at break times.
In some cases interviewees described their partners as smoking ‘more than me’ [M11], ‘like a trooper’ [F36] and ‘like a chimney’ [M5]. Despite their awareness of health risks, smoking constituted a source of pleasure for interviewees, like F47, who said, ‘I know it’s bad for me and everything like that, but I do enjoy it’. These interviewees associated smoking with relaxation and with their leisure pursuits:
I don’t see why I have to stop now, I enjoy it. It’s a part of going out that I enjoy doing, and it’s a part of relaxing that I like, so I don’t want to stop it just yet. [M85]
For these interviewees, smoking was normalized and the routine mixing with other smokers exacerbated difficulties which quitting posed. Many described similar experiences to M16, who quit and stayed off cigarettes for a week, until he socialized with smokers. Moreover, because smoking constituted the familiar and ‘taken for granted’, it was easy for the interviewees to return to smoking following a period of abstinence. Hence, F11 said, ‘I canny [can’t] even remember why I had one and that was me back on them again’ and M46 said ‘[the] packet of fags was there and I just picked it up and lit a fag and that was it’. M43, explaining why he had resumed smoking after 5 years said ‘I just thought, you know, I wonder what it would be like to start again, and I did’.
The significance of context for smoking and cessation was not underestimated by interviewees. Interviewees, like M25, felt that a change of scene was necessary in order to sustain long term quitting:
Only once in my entire life have I stopped smoking...the time I was in Australia and I managed to stop for oh like a good 5 months totally. And then I came back here and started smoking again. I think the only way to stop [smoking] is to get away from your environment.
Addiction, habit and NRT
Addiction also played an important part in the interviewees’ understandings about the difficulties of quitting. M28, who had tried to quit on two occasions talked about failure in terms of the ‘highly addictive’ quality of cigarettes. M16 resumed smoking because cigarettes were ‘a drug’ and M45 said that smoking was not only ‘a habit...it’s an addiction’. Some who had quit smoking for considerable periods of time described experiencing ‘craving’ for cigarettes, months and even years after they had stopped. M43 said that 5 years after he quit he ‘still had the craving...you learned to live with it and you learned to just ignore it’. Even those interviewees who claimed to enjoy smoking acknowledged that some cigarettes were more enjoyable than others. F40, who at one point in the interview said she enjoyed smoking, later said ‘half the time I’m sitting going this is disgusting, why am I doing it?’.
Although interviewees tended to focus upon contexts and related life circumstances when explaining the difficulties they faced when attempting to quit and/or stay off cigarettes, they also acknowledged how these difficulties were exacerbated by nicotine withdrawal symptoms. F05, like many of the interviewees, talked about successful quitting in terms of ideal (stress-free) conditions or ‘the right situation’, but also acknowledged that cigarette deprivation during quit attempts was likely to contribute to and exacerbate any feelings of stress which they experienced. Two days after quitting cigarettes, F29, described in habitual terms how she had to:
...just go back on them... I get stressed out about anything. The first thing I go for is a cigarette and once you take that one, that puts you back on.
Similarly, M19 said ‘it just takes something to go wrong’, to prompt a return to smoking.
Some interviewees said they had resumed smoking because of the effect which withdrawal symptoms had on significant others. M47, for example, said that quitting had made him short tempered, causing him to ‘snap’ at his family and M03 described becoming bad tempered with his partner when he quit during a family holiday:
I was moody, I was moaning, I was arrogant. You get these mood swings and temper and everything, because you’re craving for a cigarette. The slightest thing that she would do wrong I would shout at her.
Moreover, while stressful life circumstances were supplied by many interviewees as a justification for resuming smoking, some, like M48, acknowledged how these might be deployed as a convenient excuse to start again. Hence, ‘I think the first thing that went wrong at work and then that was it’.
Despite acknowledging the role that addiction played in the difficulties which interviewees’ experienced when quitting and staying off cigarettes, for the most part nicotine replacement products were felt to be inadequate for the task. Some interviewees, like M10, knew of smokers who were unsuccessful in their attempts to quit using NRT, but said that ‘if I’d seen it work for someone else I’d probably do it’. Others had tried NRT products themselves with little success. M38, for example, said that although NRT had helped him stop smoking, in the long term it was not effective:
[I] was off the cigarettes for about seven and a half months... on patches. I went through a bad period and started back up again, and I stopped smoking again... Once again with the chewing gum... Went through another bad patch, started back up again and I’ve not long since started back up, after going through another bad patch.
While the majority of interviewees singled out particular cigarettes (such as those smoked first thing in the morning) which they associated with dependency, for the most part cigarettes were associated with habitual and routine behaviours arising from interviewees’ life circumstances. For interviewees like F26, it was the conditions which were associated with these cigarettes which NRT was unable to address, so that ‘if you get stressed, or whatever, you have to have a cigarette’. Similarly, F21 described how her friend had tried to quit using patches:
...but she’s started smoking again... It’s a bad situation, she’s had a lot happening to her and I feel to try and stop smoking at this time was stupid.
By giving interviewees ‘something to do with your hands all the time’ [F06], smoking was used to offset periods of inactivity and boredom. Ritual aspects of smoking behaviour were not addressed by NRT and, as F37 said, ‘it’s the hand and mouth thing it [NRT] can’t handle’.
The interviews were carried out prior to the introduction of NRT on prescription, and the biggest barrier against trying NRT, for these interviewees, was cost. Given their own personal experiences of quitting and their awareness of the quitting experiences of others, some were loath to spend money on NRT products in case they failed. F06, for example, whose mother had ‘tried the patches and not stopped either’, said:
I would rather spend £15 on cigarettes, in case I had the patches and needed cigarettes as well.
F25, said that while she realized that quitting smoking would ‘save in the end’, she did not believe that the patches ‘would work anyway’. The wife of M11 claimed that although she stopped smoking for 4 weeks using patches:
...what I was paying for the patches I would have spent on cigarettes anyway. So I sort of gave up.
Despite their own experiences and the awareness of others’ experiences of patches, some interviewees, like F25, were nevertheless prepared to use NRT in future quit attempts. However, there were reservations. F25 said ‘I could try the patches again but they’re too expensive’.
Disadvantaged lives, staying off cigarettes and willpower
Interviewees lived in two disadvantaged areas of Edinburgh. The buildings were primarily a mixture of low-level and high-rise local authority housing. During fieldwork, demolition of older housing was underway and the construction of new homes in progress. There was a lack of recreational facilities and public amenities in both neighbourhoods. Interviewees spoke about living in these areas, noting the amount of housing being demolished and some of the social problems. M24, for example, said that he had to get a dog because people ‘stole my telly and went away with my stuff’. He had tried to get a house in a different area but without success. Similarly M13 talked about how he had ‘seen guys getting nearly murdered and folk just walk past’ and that the area was ‘getting a label... I saw them pulling shot guns and everything, and all of them chasing each other’.
F19 explained that her surroundings made quitting difficult. Although she and her partner had been unable to quit, she said:
The area you live in and all that kind of thing affects you as well... They’re knocking all the houses down round about here and we’re going to be getting a nice, brand new built house with a front and back door, and I think that might have an influence on both of us giving up.
M24 was unemployed and talked about how little he and his partner were able to go out socializing. This was due to lack of money and having to buy things like nappies for their children. Scarce finances had compelled M24 to reduce his smoking, but he was unable to give up completely. He complained of overcrowding, yet had noticed extensive building work in the area and had ‘got this stupid letter [from the council] asking if he wanted to buy his house...[but] how can you buy your house if you’re on the dole [unemployment benefit]?’.
M26 said the type of stress that caused him to continue to smoke was ‘being in debt, not having enough money’. Similarly, M03 said that the stress of where he lived and impoverished life circumstances played a large part in his smoking behaviour. He said that he and his partner were ‘not comfortable living here... I’m unemployed... Stress levels have been very high [and] we have noticed we smoke a lot more’. Living in areas of disadvantage were clearly felt to affect smoking behaviour and motivation to quit.
Whereas many interviewees framed their understandings about and experiences of successful quitting in terms of ‘ideal conditions’ or the ‘right time’, they spoke about sustaining cessation or ‘staying off’ cigarettes in terms of willpower. While ‘patches’ might be used to initially stop smoking, like many interviewees, F35 felt that without ‘the willpower I don’t think they’re going to help you’ and M19 said ‘I think it’s more the willpower’. Because the everyday contexts and conditions of the interviewees’ lives appeared to support smoking, willpower was seen by most interviewees as necessary to maintain quitting in the long term:
It’s willpower. A lot of people smoke if they’re stressed. They’ve got family that stress them out or they’re not working or things like that... I mean say you [were] an MP or that [and] you had no worries in the world. If you had plenty of money you could do what you wanted. [M07]
Willpower was seen as an effective resource in quitting in conjunction with sufficient motivation to quit. M46, for example, described friends who stayed off cigarettes through:
...sheer willpower—you know [they] can’t afford it, or most of the guys I know have just got new babies in the house. They’ve got good reasons for stopping. I find it really hard.
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Discussion |
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Interviewees’ accounts of quitting were marked by ambivalence. We acknowledge that in all research, interviewees present a take on the social world which they wish to promote and, as Blaxter (Blaxter, 1997) notes, many assume a moral obligation to be healthy when reporting health-related behaviour. This is a particularly poignant issue for those conducting research upon smoking. The topic of quitting may well have disposed these interviewees to justify their behaviour in a way which they considered most appropriate for the researcher and least damming to themselves. Interviewees were asked whether they had ever attempted to quit (or reduce their level of smoking) and what their future intentions were in regard to smoking. On many occasions they contradicted themselves during the course of the interview. For example, they might claim to have no intention to quit at one point in the interview, yet assert their intention to quit at another. While such contradictions are a normal feature of ordinary conversation and interviews (Potter and Wetherell, 1997), it is possible that a marked tendency towards contradiction in interviewee accounts in this study may reflect the area of research interest.
The data suggested that whilst many interviewees wanted to stop smoking, they experienced and/or anticipated quitting as extremely challenging. Wider social understanding that smoking is a highly addictive behaviour has been described by discourse analysts as both deterministic and disempowering, and has been blamed for encouraging fatalism among smokers (Gori, 1996; Gillies and Willig, 1997; Gillies, 1999). In other words reticence to quitting among some smokers is understood as partly a function of the widespread understanding that quitting smoking is a difficult, if not impossible, endeavour (Chapman, 1995; Laurier, 1999). The belief that smoking is caused by addiction may portray it as hopeless for people to try and give up (Peele, 1990), and the more convinced an individual is about being addicted, the less likely they may be to quit. However, our interviewees understood the difficulties of quitting as a function of both nicotine dependency and their social/personal circumstances. Although the real and anticipated symptoms of nicotine withdrawal presented a barrier for interviewees when quitting, life circumstances were cited as a greater barrier to both accomplishing quitting in the short term and remaining off cigarettes in the long term. Addiction was described more in terms of the ways in which it contributed to and exacerbated the problems associated with quitting rather than the major source of these problems.
The conditions and circumstances of the interviewees’ lives supported smoking in two important ways. First, smoking was used routinely as a tool for emotional management by interviewees. Interviewees associated smoking with the high levels of stress that characterized their lives and in many cases stress-related experiences prompted a resumption of smoking following a period of abstinence. Although we found gender-related differences in stress-associated activities and experiences, this appeared to be largely a function of the different daily contexts (employment versus domestic) which men and women characteristically inhabited.
Second, interviewees routinely mixed with other smokers (at work, home and socially) and smoking was a deeply embedded in their daily lives. Smoking for these interviewees, who appeared largely unaffected by wider societal shifts in the cultural climate towards smoking, was the norm. In many contexts which they inhabited it was easier to be a smoker than a non-smoker. The lack of alternative ‘no-smoking’ contexts provided these interviewees with few choices and facilitated cessation relapse.
Resources and support which interviewees could draw on when quitting were differentiated between those which were felt to assist with the immediate quitting event and those which helped to sustain quitting in the long term. Few interviewees had used NRT and some could only recall unsuccessful use of NRT by others. The interviews were carried out before NRT was available on prescription in the UK and the cost implications had deterred many interviewees from trying NRT. Despite this, some interviewees said they would be willing to use NRT if it was free and felt it might assist quitting in the short term. However, overcoming nicotine withdrawal symptoms was not the only perceived problem associated with the actual quit event. Material and personal circumstances were described as equally important, with interviewees stressing that that the quit attempt should be timely and the context/conditions appropriate.
Despite the evidence from clinical trials that using NRT increases quit rates (Bond et al., 1994; Silagy et al., 2002), many interviewees were sceptical about the contribution that NRT could make to sustaining quitting in the long term. Whereas NRT products were felt by some to be potentially useful for combating immediate withdrawal symptoms, overcoming the long-term experience of being a non-smoker required extraordinary levels of willpower. Willpower was described as a personal resource necessary to sustain non-smoking in the face of disadvantaged circumstances. Willpower was understood as an effective resource for quitting, particularly when fuelled by positive life circumstances. These findings to some extent reflect survey evidence that, at least in 1995 in England, smokers who had used NRT (bought over the counter) were less likely to have quit than those using no aids or formal support (Buck and Morgan, 2001). Indeed willpower was the most commonly cited reason for successful quitting. While these findings might seem to go against the clinical evidence on the effectiveness of NRT, they were in part explained by the fact that users of NRT prior to 1995 were more addicted to nicotine than non-users of NRT. This is likely to have masked the true impact of its effectiveness.
Since the study was carried out, as part of the Government’s strategy to address smoking and disadvantage, NRT has been made available on prescription. Because the cost had discouraged many interviewees in this study from trying NRT, it is likely that NRT use among these smokers will therefore increase. It also anticipated that removal of the financial barrier may encourage disadvantaged smokers to persevere with the therapy. However, it is important that smokers become more aware of others who have quit successfully using NRT, perhaps through media campaigns, because this will assist in challenging beliefs among disadvantaged smokers that NRT is inadequate for the task, thereby affecting feeling of self-efficacy.
The data have demonstrated, however, that combating nicotine addiction in isolation is likely to be insufficient. While NRT products assist quitting in the short term, they cannot fully compensate for those conditions and contexts that sustain smoking in circumstances of disadvantage. Our data suggest that ex-smokers who work, live and socialize in contexts where the smoking is the norm face extraordinary difficulties when they quit. In Scotland, 32% of men in social class 5 who have ever smoked have quit compared to 65% of ever smokers in social class 1. Among Scottish women the difference is even more marked with only 20% of ever smokers in social class 5 having quit compared to 66% in social class 1 (Shaw et al., 2000).
Quitting difficulties are not only associated with the quitting event or the period immediately following the attempt, but also the long-term experience of being an ex-smoker in a smoking ‘world’. It is important, therefore, that interventions on smoking among disadvantaged smokers comprise a combination of measures to address not only nicotine addiction, but also other aspects of lives that support smoking. Indeed, smokers may lack motivation to access such cessation services unless they perceive that they will get help with dealing with the routines and stresses that are enmeshed with their daily smoking patterns (Gaunt-Richardson et al., 1999). It is therefore encouraging to note the recent development of innovative approaches to addressing smoking in areas of disadvantage in the UK which have been made possible through extra resources provided by the Government to local health services for smoking cessation (Raw et al., 2001). Pilot studies have found that more broadly based initiatives which address smoking in its wider social context can be attractive to disadvantaged smokers (Gaunt-Richardson et al., 1999; Health Promotion Agency for Northern Ireland, 1996). However, it is too early to tell whether the new cessation initiatives and services being provided in areas of deprivation are being effective in both attracting disadvantaged smokers and increasing cessation rates. However, what does seem clear is that without an increase in the wider availability of treatment (Raw et al., 2001), guaranteed sustainable cessation services and implementation of measures aimed at reducing poverty, high smoking levels and low levels of cessation will remain a feature of disadvantaged areas.
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We would like to thank the interviewees who participated in this study. Also, we would like to thank the GPs (Penny Watson, Mandy Allison and Carl Bickler) for their contribution. Gratitude is also expressed to Ruth Scott for her secretarial support. The views expressed in this paper are those of the authors and do not necessarily reflect the views of the funding body. The research was funded by the Chief Scientist Office, Scottish Executive Health Department.
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