Testing Social Cognitive Theory as a theoretical framework to predict smoking relapse among daily smoking adolescents☆
Introduction
Adolescents seem to undertake quit attempts frequently (Pallonen et al., 1990, Presti et al., 1992), but only few adolescents succeed in quitting (Stanton, 1995). It is estimated that 95% to 99% of all unaided quit attempts among adults end in relapses (Jarvis, 2003), most of which occur in the first few days and weeks of quitting (Doherty et al., 1995, Jarvis, 2003). Adolescent smokers even seem to relapse as much as or even more often than adults (Mermelstein, 2003, Pallonen et al., 1990, Presti et al., 1992, Stanton et al., 1996). Predictors of adolescent smoking relapse are largely unknown, since studies on smoking relapse are conducted almost invariably among adults. In addition, most studies, both among adults and adolescents, examine predictors of long-term smoking cessation, which only establishes distal relationships between predictors and outcomes over months and years. The present study focuses on incidental lapses and relapse among daily smoking adolescents who achieved at least 24 h abstinence.
A wide variety of factors, such as physiological and biological as well as cognitive factors appear to determine whether individuals successfully quit smoking or not. The present study concentrates on the role of cognitive factors in adolescent smoking relapse. Social Cognitive Theory (SCT) explains how people acquire and maintain certain behavioural patterns, for example smoking. The cognitive factors outcome expectations, self-efficacy, and intentions are important determinants of behaviour according to SCT (Bandura, 1986). In the context of smoking, outcome expectations can be operationalized as pros and cons of smoking, and intentions as motivation or readiness to quit. Pros of smoking involve the perceptions of the advantages of smoking, and cons refer to the disadvantages of smoking. Prior research on the pros and cons of smoking also used measures of the pros of quitting next to the pros of smoking (De Vries and Backbier, 1994, Dijkstra et al., 1997, Van Zundert et al., 2007). Self-efficacy is often defined as the ability to resist smoking in tempting situations, and intentions are frequently framed in terms of motivation or readiness to quit (Prochaska et al., 1991, Van Zundert et al., 2007). As such, SCT offers a theoretical framework to examine smoking behaviour.
Several studies have demonstrated that adult smokers' perceptions of the pros and cons of smoking and quitting affect their quitting behaviour (De Vries and Backbier, 1994, Dijkstra et al., 1996, Greening, 1997, Hansen et al., 1985, Prochaska et al., 1992, Rose et al., 1996). Individuals who report to attribute relatively few advantages to smoking and many benefits to quitting are more likely to achieve smoking cessation. However, relatively little is known about the influence of the pros and cons on smoking relapse specifically. It is conceivable that adolescents who perceive smoking to be highly advantageous and quitting to have relatively few advantages are the ones who will relapse and revert to smoking after embarking on a quit attempt. Another predictor which seems to play an important role in smoking relapse is self-efficacy to resist smoking. Research has consistently shown that low self-efficacy is related to smoking relapse among adults (for an overview, see Gwaltney, Metrik, Kahler, & Shiffman, in press). Among adolescents, self-efficacy has not yet been tested in association with relapse. Lastly, motivation to quit has been found to be a precursor of smoking cessation among adolescents (Engels et al., 1998, Lichtenstein et al., 1994, Osler and Prescott, 1998). Conclusively, there are some indications from both the literature on smoking cessation and from adult studies that components of the SCT can predict relapse. However, most studies that used the SCT to explain smoking cessation and relapse have focused on aspects of the SCT rather than capturing the model including outcome expectations, self-efficacy, and intentions as a whole. Moreover, to our knowledge, SCT has not yet been used to predict relapse among adolescents. In the present study, we examined whether SCT derived smoking-specific cognitions predicted adolescents' lapses and relapse after a serious quit attempt.1
Besides the influence of adolescents' smoking-specific cognitions, the effect of intensity of smoking on relapse was taken into account. Intensity of smoking refers to the number of cigarettes smoked per day. Previous research has shown mixed results regarding the relation between intensity of smoking and smoking relapse. Some adult studies have found that heavy smokers are at greater risk for relapse during a quit attempt compared to light smokers (Curry et al., 1989, Senore et al., 1998). In contrast, other studies showed that the number of cigarettes smoked per day did not predict whether persons would succeed or fail during their attempts to quit smoking (Fiore, Novotny, Pierce, Giovino, Hatziandreu, et al., 1990; Kenford, Fiore, Jorenby, Smith, Wetter, et al., 1994). Nicotine dependence is in part determined by intensity of smoking (Pierce & Gilpin, 1996), and there have been several studies that explored nicotine dependence in relation to adolescent smoking cessation (Engels et al., 1998, Horn et al., 2003), but not to relapse. Conclusively, the impact of baseline smoking on adolescent relapse has not yet been examined. Despite scarce evidence from previous research among adults and the contrasting findings above, we expected that a high intensity of smoking would predict the first lapses, as well as relapse into smoking within 3 weeks, and that high baseline levels of smoking would lower the odds that quitters would be abstinent at the 2-month follow-up.
The purpose of the present study was to provide prospective information on the effects of SCT-derived smoking-specific cognitions and intensity of smoking on relapse among adolescent daily smokers. A number of 135 daily smoking adolescents in the ages of 15 to 20 participated in an Ecological Momentary Assessment (EMA) study in which they embarked on a serious attempt to quit smoking. Participants answered daily questions about their quitting experiences three times a day over a period of 4 weeks (1 week pre-cessation, and 3 weeks post-cessation). We hypothesized that high scores on pros of smoking, low scores on pros of quitting, low self-efficacy to resist smoking, and intensive tobacco use at baseline would predict the following five outcome variables: A first lapse, a second lapse, mild and heavy relapse into smoking as observed during the 3 weeks after the quit attempt, and current smoking at the 2-month follow-up.
Section snippets
Participants
Participants were 135 daily smoking adolescents in the ages of 15 to 20 years, who were highly motivated to quit. Participants were recruited through advertisements and articles about the study that were published and displayed in newspapers, on websites, and in community centers. Being between 15 and 19 years of age, having a strong motivation to quit, and smoking at least one cigarette per day were the main selection criteria. Exclusion criteria were participation in a smoking cessation
Descriptive analyses
The majority of the participants experienced at least one lapse during monitoring (70.4%, n = 95 of 135), and 58.5% (n = 79 of 135) also reported a second lapse. ‘Mild’ relapse defined as ‘smoking at least 1 cigarette on three consecutive days’ occurred for 46 participants (34.1%, n = 46 of 135). ‘Heavy’ relapse defined as ‘smoking at least 5 cigarettes on three consecutive days’ occurred for 27 participants (20.0%, n = 27 of 135). At follow-up, 29.6% of the initial sample of 135 adolescents were still
Discussion
In the present study, smoking-specific cognitions derived from the Social Cognitive Theory (Bandura, 1986) were hypothesized to predict the outcomes of a serious quit attempt of daily smoking adolescents. The main findings show that a strong endorsement of the pros of smoking, low self-efficacy to quit, and baseline smoking status significantly predicted relapse within 3 weeks after quitting. The first and second lapses as well as abstinence 2 months later appeared to be largely unaffected by
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This research was supported by a grant from the Dutch Asthma Foundation and a fellowship grant to Rutger Engels from the Netherlands Organization of Scientific Research.