Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
The International Journal of the Addictions, 27(9), 1079- 1086, 1992
Relationships between Mood around Slip-Up and Recovery of Abstinence in Smoking Cessation Attempts Ron Borland, Ph.D. Centre for Behavioural Research in Cancer, Anti-Cancer Council in Victoria, 1 Rathdowne Street, Carlton South, Victoria 3053, Australia. Telephone: (03) 662 3300.
ABSTRACT Data are presented from 201 slip-up episodes in attempts at smoking cessation. Analysis as a function of whether the person recovered and resumed abstinence broadly confirmed previous findings. Emotions immediately before and after the slip-up episode were assessed, as were feelings about having slipped-up. Feeling bad prior to the slip-up cigarette was associated with reduced recovery. By contrast, reporting that the slip-up cigarette made the person feel worse was associated with increased recovery. Feeling bad about slipping-up was not associated with relapse, contrary to predictions from Marlatt and Gordon’s theorizing about the Abstinence Violation Effect. Key words. Smoking control; Relapse; Smoking cessation; Mood
RESOURCE TABLE “Affect prior to slip-up/relapse: Selected studies, parameters and processes,” R. Borland, 1991, Australia, tobacco smoking, smokers calling a mass marketted smoking cessation advice service in 1988, 297 subjects-201 reporting slip-up episodes; telephone survey; retrospective recall of specific events; collected by trained interviewers in Melbourne, Australia. Results 1079
Copyright @ 1992 by Marcel Dekker, Inc.
I080
BORLAND
Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
show outcome of slip-up (recovery vs relapse) related to mood before slip-up and the immediate affective consequences of the cigarette, but not secondary negative affect. The results identify limitations in Marlatt and Gordon’s concept of the Abstinence Violation Effect. The major limitation is the retrospective self-report of all measures.
INTRODUCTION There is an increasing focus on slip-ups and relapse in research on smoking cessation (Shiffman, 1982; Brownell et al., 1986). Marlatt and Gordon’s (1985) theory of relapse gives a central place to affect in determining the probability of relapse, through what Marlatt calls the Abstinence Violation Effect. When a slip-up leads to cognitive attributions about causes that are internal, stable, and global, this leads to the experience of negative emotions, guilt, and feelings of inadequacy, which reduce the capacity of the individual to recover. This is because their addictive habit is postulated to be an important component of the person’s affect-regulating mechanism and, thus, to control and regulate the negative affect, smokers feel a need to engage in the addictive habit. The focus of this paper is on the relationships between affect at the time of slip-up and subsequent recovery or relapse. Negative affect at the time of slipup (or temptation to smoke) has been associated with greater relapse (Shiffman, 1982; O’Connell and Martin, 1987; Borland, 1990). These findings are as would be expected from Marlatt’s theory. However, none of these studies differentiated the feelings immediately prior to the slip-up from those engendered by the effects of smoking the cigarette, and those that resulted from attributions following having slipped-up. Negative affect resulting from attributions of causation for the slip-up is the component that is centrally related to the Abstinence Violation Effect, and thus should be the best predictor of relapse, according to Marlatt and Gordon’s theory. Curry et al. (1987) found that guilt about slip-ups was associated with relapse, and thus provided some support for the importance of this aspect of negative affect. Similarly, Baer et al. (1989) found that guilt about a slip-up was associated with relapse, but only for one of the three periods they studied. This study further explores the relationship between different aspects of mood around slip-ups and the likelihood of subsequent relapse.
METHOD Participants in the study were 297 smokers who called a smoking cessation service in Victoria, Australia, in June 1988, and who agreed to be followed up 3 months later, as they were. The sample consisted of 59% women and 41% men of mean age 34. Only 5% were professionals or managers, 47% were
Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
SMOKING CESSATION ATTEMPTS
1081
clerical and other white-collar workers, 12% were skilled tradespeople, 10% were semiskilled or unskilled blue-collar workers, 17% were engaged in home duties, and 10% were unemployed or retired. There were proportionately more clerical and other white-collar workers than in the community. Eighteen percent had tertiary qualifications, which is close to community levels. They had smoked for an average of 16.2 years, and reported smoking an average of 24.4 cigarettes a day. We collected no data on history of cessation attempts, but studies of previous studies of callers to the service (Borland and Hill, 1990) found that few had taken formal smoking cessation treatments and they had been less likely to have tried to quit before than smokers in general. At the 3 month follow-up, respondents were asked if they were prepared to answer some questions and, if they agreed, were then asked whether they had made a cessation attempt, its outcome, and whether they had any slip-ups and the outcome of these, either relapse or return to cessation within 24 hours (recovery). Respondents who had had slip-ups were questioned further about their first slip-up by open-ended questions (with pre-coded response options) concerning how they were feeling immediately before having the slip-up cigarette, any effects the cigarette may have had on how they felt, and how they felt about themselves after the slip-up. Where the respondents did not immediately comprehend the differences between the three affect variables, they were explained to them. Interviewers classified responses into the pre-coded categories listed in Table 1. Interviewers were naive to the research questions. Respondents were also asked how many cigarettes they smoked, how long they had been stopped at the time of the slip-up, the reason for the slip-up, where they were, and what they were doing when the slip-up occurred. Other questions were asked concerning the smoking control campaign of which the telephone service was a part, and about other aspects of the slip-up situation. These data are reported elsewhere (Borland and Schofield, 1990). Of the sample, 21% were not smoking at follow-up, another 57% had stopped but had relapsed at the time of contact, and the remaining 22% had either not tried to stop or had not succeeded in stopping for 24 hours. This study reports on the initial slip-up of the 201 cases who reported a slip-up.
RESULTS Of the 201 initial slip-up episodes, 43 (21.4%) were recovered from and the remaining 158 resulted in relapse. Recovery was defined as a return to abstinence within 24 hours. In three cases of relapse the respondent had subsequently quit again and was not smoking at follow-up. Similarly, 21 of the recoverers had relapsed subsequently and were smoking at follow-up. The results are presented as a function of initial recovery.
BORLAND
1082
Table 1. Mood around Slip-Ups and Its Relationship to Recovery and Relapse
Recoverers Relapsers
Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
Mood
N
(%)
(%)
51 150
37.3 16.0
62.7 84.0
54 51 20 73
14.8 15.7 5.0 34.2
85.2 84.3 95.0 65.8
x2 = 12.82 df=3 p = ,005
55 92
20.0 17.4
80.0 82.6
x2 = 3.63 df = 2
52
30.8
69.2
p = . l 6 . N.S.
Significance
Before: Positive/neutral Negative
x2 =
10.22, df = I
p = .001
After: Effect of cigarette'
None Felt good Felt less bad Felt worse
Feelings about slip-uph Very bad Disappointed Transient Disappointment/OK Missing data in three cases. Missing data in two cases.
Most slip-ups (69.5%) occurred within a week of stopping, with 11.5% after 1 day, 34.5% from 2 to 4 days, and 23.5% from 5 days to a week. The remaining 30.5% of slip-ups occurred after more than 1 week. Recoverers were more likely to slip-up after being stopped for longer (x2 = 15.1, df = 3, p = .003). Those people who smoked no more than one cigarette at the time of the slip-up (35%) were more likely to recover than those 65 % who smoked more than one cigarette ( x 2 = 7.08, df = 1, p = 0.01). Reasons given for slip-ups were coded into four categories: addictiodhabit (34%),coping with stress (38%), reducing negative emotions (9%), and social pressure (20%). Recovery was best following social pressure and worst when coping with stress (x2 = 18.1, df = 3, p = .OOO4). Places of slip-ups were work (25%), home (45%), at social venues (19%), and other (including outdoor and in a car; 11 %). Recovery was more likely after slipping-up at social venues compared to the other three places (x2 = 27.2, df = 3, p = .OOOl; see Fig. 1). Activities at slip-up were drinking coffee (14%), alcohol (14%), relaxing (25%), working (25%) and other (e.g., walking, waiting, and outdoor activities; 22%). Activity was related to outcome ( x 2 = 22.37, df = 4, p = .0002), with drinking alcohol and relaxing being associated with recovery, and the others, particu-
Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
SMOKING CESSATION ATTEMPTS
Work
1083
Home S o c i a l Other
Place o f s l i p - u p Fig. 1.
Relapse and recovery as a function of place of slip-up.
larly working, being associated with not recovering. These findings basically replicate findings of earlier studies (Borland, 1990; Shiffman, 1982). In response to the question about how they were feeling immediately before the slip-up, most respondents reported negative affect (75%) while 10% reported positive emotions and 15 % reported “neutral” or no particular emotion, the latter two being combined for analysis. As can be seen from Table 1 , those respondents who reported having felt positive or neutral prior to slip-up were more likely to recover than those who reported negative affect (X* = 10.2, df = 1 , p = 0.001). When asked what effect the slip-up cigarette had, 37% reported they felt worse, 26%said they felt better, 10%felt less bad, and 27% reported no effect on mood. Those individuals who reported feeling worse following the cigarette were more likely to recover than those who reported feeling better, less bad, or who reported no effect of the cigarette (x2 = 12.8, d f = 3, p = . 0 0 5 ) . Respondents were then asked how they felt about themselves after they slipped-up. Most respondents reported feeling bad about having had the cigarette with 28% feeling very bad, 46% feeling disappointed, and 26% feeling no more than transient disappointment or “OK.” Feelings about self after the slip-up were not significantly related to eventual outcome (x2 = 3.6, df = 2, p = .16, N.S.). To explore any interaction between the three mood variables and recovery, a logit analysis was performed. It revealed that the two sample effects identified
BORLAND
Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
I084
above were the only significant contributions to predicting recovery from the slip-up episode, and that there were no higher order interactions. Interactions between the affect variables with the other variables reported above were also explored. The two post-slip-up affect measures were largely independent of the pre-slip-up context, and although moderately related to the number of cigarettes consumed in the slip-up episode, this relationship did not interact with the likelihood of relapse. Affect before the slip-up was related to reasons for the slip-up, but this is because some of the reasons were defined, at least in part, in terms of affect. Before slip-up affect was also related to place of slip-up (x2 = 35.8, df = 3, p < .0001) and activity (x2 = 25.2, df = 3, p < .OOOl). There was evidence of an interaction between place of slip-up, mood before slip-up, and relapse. In the logit analysis, the main effect for mood before slip-up was marginal (2 = 1.94), while the effects for place and the place by mood interactions were significant for at least one parameter. Consideration of the four places separately revealed chat negative mood was most predictive of relapse at work with negative affect being associated with greater relapse ( x 2 = 9.9, df = 1 , p = 0.002; Yates correction used due to small numbers who recovered), but for social venues there was a reverse trend ( x 2 = 2.0, df = 1 , p = .16).
DISCUSSION This study has basically replicated the findings of others (e.g., Shiffman, 1982; Borland, 1990) insofar as they overlap. It has also extended the understanding of the relationship between mood and slip-ups. The study is based on retrospective recall, so as in all such studies it is not possible to differentiate real effects from those due to selective recall. The results need to be interpreted with this limitation in mind. The finding that negative mood before the slip-up was associated with greater relapse confirms previous research (Shiffman, 1982; O’Connell and Martin, 1987; Borland, 1990). The finding that this relationship does not hold following negative affect in social situations is of interest. Social situations leading to relapse are typically not associated with negative affect (Baer and Lichtenstein, 1988; Shiffman et al., 1985). It may be that the negative affect is not seen as a persisting cause of relapse in this context. Other studies have found that situations where the attributed causes of slip-up were potentially modifiable result in greater recovery of abstinence (Borland, 1990; Schoenman et al., 1988). The possibility that the negative affect will not recur in future social situations may thus encourage recovery. The finding of increased recovery when the respondents reported that the slip-up cigarette made them feel worse may not be surprising as it is generally easier (except for some neurotic behaviors) to give up something when it produces immediate negative outcomes.
Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
SMOKING CESSATION ATTEMPTS
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The finding of no relationship between feelings about having slipped-up and outcome is contrary to what would be expected by Marlatt and Gordon’s theory. This study only considered one aspect of Marlatt and Gordon’s theory and is consistent with findings of Brandon et al. (1990). It did not consider the direct role of casual attributions for slip-ups on subsequent relapse. Other studies have found clear effects for attributions (O’Connor and Martin, 1987; Curry et al., 1987). However, it is apparent from this study that feeling bad about oneself after slipping-up is not necessarily related to full relapse, as the theory would predict. Indeed, the Curry et al. (1987) study which found an association between guilt following slip-ups and relapses found that this effect was smaller than the effect directly attributable to cognitive attributions. Further, the failure of Baer et al. (1989) to find consistent associations between guilt and relapse suggests that guilt is not always an important factor in relapse. Associations between relapse and negative emotion may relate more to the context prior to slip-up (including the prevailing emotion) and to the effects of the cigarette on feelings, rather than to negative emotions that result from an appraisal of failure. This suggests the need for a modification of Marlatt and Gordon’s ( 1985) theory to give priority to negative cognitive attributions about the reasons for a slip-up as determining the likelihood of relapse, rather than postulating that this is mediated through the negative mood states that follow the attributions. Such a theory is conceptually simpler and better fits the available data, at least for the case of smoking. The findings have importance for interventions in that they show that affect plays a complex role in relapse. It may be that therapists need to focus more on the possible attributions for causality that clients make and the likelihood of these changing or being changed, rather than to assume that affect and other factors will necessarily be important.
ACKNOWLEDGMENTS This research was funded by the Victorian Smoking and Health Program and the Anti-Cancer Council of Victoria.
BAER, J. S., KAMARCK, T., LICHTENSTEIN, E., and RANSOM, C. C. JR. (1989). Prediction of smoking relapse: Analysis of temptations and transgression after initial cessation. J. Cons u l ~ Clin. . Psychol. 51: 623-627. BAER, J . S. and LICHTENSTEIN, E. (1988). Classification and production of smoking relapse episodes: An exploration of individual differences. J. Cansulr. Clin. Psychol. 56: 104-1 10. BORLAND, R . (1990). Slip-ups and relapse in attempts to quit smoking. Addicr. Behav. 15: 235245. BORLAND. R., and HILL, D. (19%). Two-month follow-up on callers to a telephone quit smoking service. Drug AlcoholRev. 3: 21 1-218.
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BORLAND, R., and SCHOFIELD, P. (1990). Follow-up of callers to the DIRECT Line counselling service. In Victorian Smoking and Health Programs; Quit: Evaluation Studies, No, 4. Melbourne: VSHP. BRANDON, T. H., TIFFANY, S. T.. OBREMSKI, K. M., and BAKER, T. B. (1990). Post cessation cigarette use: The process of relapse. Addict. Behav. 15: 105-1 14. BROWNELL, K. D., MARLATT, G . A., LICHTENSTEIN, E., and WILSON, G. T. (1986). Understanding and preventing relapse. Am. Psycho/. 41 : 765-782. CURRY, S., MARLATT, G. A , , and GORDON, J. R. (1987). Abstinence violation effect: Validation of an attributional construct with smoking cessation. J . Consult. Clin. Psychol. 55: 145149. MARLATT, G . A , , and GORDON, J. R. (1985). Relapse Prevention. New York: Guilford Press. O'CONNELL. K . A., and MARTIN, E. J. (1987). Highly tempting situations associated with abstinence, temporary lapse, and relapse among participants in smoking cessation programs. J . Consult. Clin. Psychol. 55: 367-37 I . SCHOENMAN, T. J., HOLLIS, I . F., STEVENS, V. J., FISCHER, K., and CHECK, P. R. (1988). Recovering stride versus letting it slide: Attributions for "slips" following smoking cessation treatment. Psychol. Health 2: 335-347. SHIFFMAN, S. (1982). Relapse following smoking cessation: A situational analysis. J . Consulr. Clin. Psycho/. 50: 71-86, SHIFFMAN, S., READ, L., and JARVIK, M. E. (1988). Smoking relapse situations: A preliminary typology. Int. J . Addict. 20: 311-318.
THE AUTHOR Ron Borland, Ph.D., is Deputy Director of the Centre for Behavioural Research in Cancer, Melbourne, Australia. His original training in psychology was from Monash University. Following that, he worked in clinical and occupational psychology in Australia and Papua New Guinea. He completed a Ph.D. in Psychology at the University of Melbourne (1987) while teaching there. His main research interests are in the areas of smoking relapse, the impact of workplace smoking bans, and on factors influencing the adoption of sun-protection behaviors. He is also involved in the evaluation of major health promotion campaigns on smoking and skin cancer control.
The International Journal of the Addictions, 27(9), 1079- 1086, 1992
Relationships between Mood around Slip-Up and Recovery of Abstinence in Smoking Cessation Attempts Ron Borland, Ph.D. Centre for Behavioural Research in Cancer, Anti-Cancer Council in Victoria, 1 Rathdowne Street, Carlton South, Victoria 3053, Australia. Telephone: (03) 662 3300.
ABSTRACT Data are presented from 201 slip-up episodes in attempts at smoking cessation. Analysis as a function of whether the person recovered and resumed abstinence broadly confirmed previous findings. Emotions immediately before and after the slip-up episode were assessed, as were feelings about having slipped-up. Feeling bad prior to the slip-up cigarette was associated with reduced recovery. By contrast, reporting that the slip-up cigarette made the person feel worse was associated with increased recovery. Feeling bad about slipping-up was not associated with relapse, contrary to predictions from Marlatt and Gordon’s theorizing about the Abstinence Violation Effect. Key words. Smoking control; Relapse; Smoking cessation; Mood
RESOURCE TABLE “Affect prior to slip-up/relapse: Selected studies, parameters and processes,” R. Borland, 1991, Australia, tobacco smoking, smokers calling a mass marketted smoking cessation advice service in 1988, 297 subjects-201 reporting slip-up episodes; telephone survey; retrospective recall of specific events; collected by trained interviewers in Melbourne, Australia. Results 1079
Copyright @ 1992 by Marcel Dekker, Inc.
I080
BORLAND
Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
show outcome of slip-up (recovery vs relapse) related to mood before slip-up and the immediate affective consequences of the cigarette, but not secondary negative affect. The results identify limitations in Marlatt and Gordon’s concept of the Abstinence Violation Effect. The major limitation is the retrospective self-report of all measures.
INTRODUCTION There is an increasing focus on slip-ups and relapse in research on smoking cessation (Shiffman, 1982; Brownell et al., 1986). Marlatt and Gordon’s (1985) theory of relapse gives a central place to affect in determining the probability of relapse, through what Marlatt calls the Abstinence Violation Effect. When a slip-up leads to cognitive attributions about causes that are internal, stable, and global, this leads to the experience of negative emotions, guilt, and feelings of inadequacy, which reduce the capacity of the individual to recover. This is because their addictive habit is postulated to be an important component of the person’s affect-regulating mechanism and, thus, to control and regulate the negative affect, smokers feel a need to engage in the addictive habit. The focus of this paper is on the relationships between affect at the time of slip-up and subsequent recovery or relapse. Negative affect at the time of slipup (or temptation to smoke) has been associated with greater relapse (Shiffman, 1982; O’Connell and Martin, 1987; Borland, 1990). These findings are as would be expected from Marlatt’s theory. However, none of these studies differentiated the feelings immediately prior to the slip-up from those engendered by the effects of smoking the cigarette, and those that resulted from attributions following having slipped-up. Negative affect resulting from attributions of causation for the slip-up is the component that is centrally related to the Abstinence Violation Effect, and thus should be the best predictor of relapse, according to Marlatt and Gordon’s theory. Curry et al. (1987) found that guilt about slip-ups was associated with relapse, and thus provided some support for the importance of this aspect of negative affect. Similarly, Baer et al. (1989) found that guilt about a slip-up was associated with relapse, but only for one of the three periods they studied. This study further explores the relationship between different aspects of mood around slip-ups and the likelihood of subsequent relapse.
METHOD Participants in the study were 297 smokers who called a smoking cessation service in Victoria, Australia, in June 1988, and who agreed to be followed up 3 months later, as they were. The sample consisted of 59% women and 41% men of mean age 34. Only 5% were professionals or managers, 47% were
Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
SMOKING CESSATION ATTEMPTS
1081
clerical and other white-collar workers, 12% were skilled tradespeople, 10% were semiskilled or unskilled blue-collar workers, 17% were engaged in home duties, and 10% were unemployed or retired. There were proportionately more clerical and other white-collar workers than in the community. Eighteen percent had tertiary qualifications, which is close to community levels. They had smoked for an average of 16.2 years, and reported smoking an average of 24.4 cigarettes a day. We collected no data on history of cessation attempts, but studies of previous studies of callers to the service (Borland and Hill, 1990) found that few had taken formal smoking cessation treatments and they had been less likely to have tried to quit before than smokers in general. At the 3 month follow-up, respondents were asked if they were prepared to answer some questions and, if they agreed, were then asked whether they had made a cessation attempt, its outcome, and whether they had any slip-ups and the outcome of these, either relapse or return to cessation within 24 hours (recovery). Respondents who had had slip-ups were questioned further about their first slip-up by open-ended questions (with pre-coded response options) concerning how they were feeling immediately before having the slip-up cigarette, any effects the cigarette may have had on how they felt, and how they felt about themselves after the slip-up. Where the respondents did not immediately comprehend the differences between the three affect variables, they were explained to them. Interviewers classified responses into the pre-coded categories listed in Table 1. Interviewers were naive to the research questions. Respondents were also asked how many cigarettes they smoked, how long they had been stopped at the time of the slip-up, the reason for the slip-up, where they were, and what they were doing when the slip-up occurred. Other questions were asked concerning the smoking control campaign of which the telephone service was a part, and about other aspects of the slip-up situation. These data are reported elsewhere (Borland and Schofield, 1990). Of the sample, 21% were not smoking at follow-up, another 57% had stopped but had relapsed at the time of contact, and the remaining 22% had either not tried to stop or had not succeeded in stopping for 24 hours. This study reports on the initial slip-up of the 201 cases who reported a slip-up.
RESULTS Of the 201 initial slip-up episodes, 43 (21.4%) were recovered from and the remaining 158 resulted in relapse. Recovery was defined as a return to abstinence within 24 hours. In three cases of relapse the respondent had subsequently quit again and was not smoking at follow-up. Similarly, 21 of the recoverers had relapsed subsequently and were smoking at follow-up. The results are presented as a function of initial recovery.
BORLAND
1082
Table 1. Mood around Slip-Ups and Its Relationship to Recovery and Relapse
Recoverers Relapsers
Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
Mood
N
(%)
(%)
51 150
37.3 16.0
62.7 84.0
54 51 20 73
14.8 15.7 5.0 34.2
85.2 84.3 95.0 65.8
x2 = 12.82 df=3 p = ,005
55 92
20.0 17.4
80.0 82.6
x2 = 3.63 df = 2
52
30.8
69.2
p = . l 6 . N.S.
Significance
Before: Positive/neutral Negative
x2 =
10.22, df = I
p = .001
After: Effect of cigarette'
None Felt good Felt less bad Felt worse
Feelings about slip-uph Very bad Disappointed Transient Disappointment/OK Missing data in three cases. Missing data in two cases.
Most slip-ups (69.5%) occurred within a week of stopping, with 11.5% after 1 day, 34.5% from 2 to 4 days, and 23.5% from 5 days to a week. The remaining 30.5% of slip-ups occurred after more than 1 week. Recoverers were more likely to slip-up after being stopped for longer (x2 = 15.1, df = 3, p = .003). Those people who smoked no more than one cigarette at the time of the slip-up (35%) were more likely to recover than those 65 % who smoked more than one cigarette ( x 2 = 7.08, df = 1, p = 0.01). Reasons given for slip-ups were coded into four categories: addictiodhabit (34%),coping with stress (38%), reducing negative emotions (9%), and social pressure (20%). Recovery was best following social pressure and worst when coping with stress (x2 = 18.1, df = 3, p = .OOO4). Places of slip-ups were work (25%), home (45%), at social venues (19%), and other (including outdoor and in a car; 11 %). Recovery was more likely after slipping-up at social venues compared to the other three places (x2 = 27.2, df = 3, p = .OOOl; see Fig. 1). Activities at slip-up were drinking coffee (14%), alcohol (14%), relaxing (25%), working (25%) and other (e.g., walking, waiting, and outdoor activities; 22%). Activity was related to outcome ( x 2 = 22.37, df = 4, p = .0002), with drinking alcohol and relaxing being associated with recovery, and the others, particu-
Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
SMOKING CESSATION ATTEMPTS
Work
1083
Home S o c i a l Other
Place o f s l i p - u p Fig. 1.
Relapse and recovery as a function of place of slip-up.
larly working, being associated with not recovering. These findings basically replicate findings of earlier studies (Borland, 1990; Shiffman, 1982). In response to the question about how they were feeling immediately before the slip-up, most respondents reported negative affect (75%) while 10% reported positive emotions and 15 % reported “neutral” or no particular emotion, the latter two being combined for analysis. As can be seen from Table 1 , those respondents who reported having felt positive or neutral prior to slip-up were more likely to recover than those who reported negative affect (X* = 10.2, df = 1 , p = 0.001). When asked what effect the slip-up cigarette had, 37% reported they felt worse, 26%said they felt better, 10%felt less bad, and 27% reported no effect on mood. Those individuals who reported feeling worse following the cigarette were more likely to recover than those who reported feeling better, less bad, or who reported no effect of the cigarette (x2 = 12.8, d f = 3, p = . 0 0 5 ) . Respondents were then asked how they felt about themselves after they slipped-up. Most respondents reported feeling bad about having had the cigarette with 28% feeling very bad, 46% feeling disappointed, and 26% feeling no more than transient disappointment or “OK.” Feelings about self after the slip-up were not significantly related to eventual outcome (x2 = 3.6, df = 2, p = .16, N.S.). To explore any interaction between the three mood variables and recovery, a logit analysis was performed. It revealed that the two sample effects identified
BORLAND
Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
I084
above were the only significant contributions to predicting recovery from the slip-up episode, and that there were no higher order interactions. Interactions between the affect variables with the other variables reported above were also explored. The two post-slip-up affect measures were largely independent of the pre-slip-up context, and although moderately related to the number of cigarettes consumed in the slip-up episode, this relationship did not interact with the likelihood of relapse. Affect before the slip-up was related to reasons for the slip-up, but this is because some of the reasons were defined, at least in part, in terms of affect. Before slip-up affect was also related to place of slip-up (x2 = 35.8, df = 3, p < .0001) and activity (x2 = 25.2, df = 3, p < .OOOl). There was evidence of an interaction between place of slip-up, mood before slip-up, and relapse. In the logit analysis, the main effect for mood before slip-up was marginal (2 = 1.94), while the effects for place and the place by mood interactions were significant for at least one parameter. Consideration of the four places separately revealed chat negative mood was most predictive of relapse at work with negative affect being associated with greater relapse ( x 2 = 9.9, df = 1 , p = 0.002; Yates correction used due to small numbers who recovered), but for social venues there was a reverse trend ( x 2 = 2.0, df = 1 , p = .16).
DISCUSSION This study has basically replicated the findings of others (e.g., Shiffman, 1982; Borland, 1990) insofar as they overlap. It has also extended the understanding of the relationship between mood and slip-ups. The study is based on retrospective recall, so as in all such studies it is not possible to differentiate real effects from those due to selective recall. The results need to be interpreted with this limitation in mind. The finding that negative mood before the slip-up was associated with greater relapse confirms previous research (Shiffman, 1982; O’Connell and Martin, 1987; Borland, 1990). The finding that this relationship does not hold following negative affect in social situations is of interest. Social situations leading to relapse are typically not associated with negative affect (Baer and Lichtenstein, 1988; Shiffman et al., 1985). It may be that the negative affect is not seen as a persisting cause of relapse in this context. Other studies have found that situations where the attributed causes of slip-up were potentially modifiable result in greater recovery of abstinence (Borland, 1990; Schoenman et al., 1988). The possibility that the negative affect will not recur in future social situations may thus encourage recovery. The finding of increased recovery when the respondents reported that the slip-up cigarette made them feel worse may not be surprising as it is generally easier (except for some neurotic behaviors) to give up something when it produces immediate negative outcomes.
Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
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The finding of no relationship between feelings about having slipped-up and outcome is contrary to what would be expected by Marlatt and Gordon’s theory. This study only considered one aspect of Marlatt and Gordon’s theory and is consistent with findings of Brandon et al. (1990). It did not consider the direct role of casual attributions for slip-ups on subsequent relapse. Other studies have found clear effects for attributions (O’Connor and Martin, 1987; Curry et al., 1987). However, it is apparent from this study that feeling bad about oneself after slipping-up is not necessarily related to full relapse, as the theory would predict. Indeed, the Curry et al. (1987) study which found an association between guilt following slip-ups and relapses found that this effect was smaller than the effect directly attributable to cognitive attributions. Further, the failure of Baer et al. (1989) to find consistent associations between guilt and relapse suggests that guilt is not always an important factor in relapse. Associations between relapse and negative emotion may relate more to the context prior to slip-up (including the prevailing emotion) and to the effects of the cigarette on feelings, rather than to negative emotions that result from an appraisal of failure. This suggests the need for a modification of Marlatt and Gordon’s ( 1985) theory to give priority to negative cognitive attributions about the reasons for a slip-up as determining the likelihood of relapse, rather than postulating that this is mediated through the negative mood states that follow the attributions. Such a theory is conceptually simpler and better fits the available data, at least for the case of smoking. The findings have importance for interventions in that they show that affect plays a complex role in relapse. It may be that therapists need to focus more on the possible attributions for causality that clients make and the likelihood of these changing or being changed, rather than to assume that affect and other factors will necessarily be important.
ACKNOWLEDGMENTS This research was funded by the Victorian Smoking and Health Program and the Anti-Cancer Council of Victoria.
BAER, J. S., KAMARCK, T., LICHTENSTEIN, E., and RANSOM, C. C. JR. (1989). Prediction of smoking relapse: Analysis of temptations and transgression after initial cessation. J. Cons u l ~ Clin. . Psychol. 51: 623-627. BAER, J . S. and LICHTENSTEIN, E. (1988). Classification and production of smoking relapse episodes: An exploration of individual differences. J. Cansulr. Clin. Psychol. 56: 104-1 10. BORLAND, R . (1990). Slip-ups and relapse in attempts to quit smoking. Addicr. Behav. 15: 235245. BORLAND. R., and HILL, D. (19%). Two-month follow-up on callers to a telephone quit smoking service. Drug AlcoholRev. 3: 21 1-218.
Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/18/14 For personal use only.
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BORLAND, R., and SCHOFIELD, P. (1990). Follow-up of callers to the DIRECT Line counselling service. In Victorian Smoking and Health Programs; Quit: Evaluation Studies, No, 4. Melbourne: VSHP. BRANDON, T. H., TIFFANY, S. T.. OBREMSKI, K. M., and BAKER, T. B. (1990). Post cessation cigarette use: The process of relapse. Addict. Behav. 15: 105-1 14. BROWNELL, K. D., MARLATT, G . A., LICHTENSTEIN, E., and WILSON, G. T. (1986). Understanding and preventing relapse. Am. Psycho/. 41 : 765-782. CURRY, S., MARLATT, G. A , , and GORDON, J. R. (1987). Abstinence violation effect: Validation of an attributional construct with smoking cessation. J . Consult. Clin. Psychol. 55: 145149. MARLATT, G . A , , and GORDON, J. R. (1985). Relapse Prevention. New York: Guilford Press. O'CONNELL. K . A., and MARTIN, E. J. (1987). Highly tempting situations associated with abstinence, temporary lapse, and relapse among participants in smoking cessation programs. J . Consult. Clin. Psychol. 55: 367-37 I . SCHOENMAN, T. J., HOLLIS, I . F., STEVENS, V. J., FISCHER, K., and CHECK, P. R. (1988). Recovering stride versus letting it slide: Attributions for "slips" following smoking cessation treatment. Psychol. Health 2: 335-347. SHIFFMAN, S. (1982). Relapse following smoking cessation: A situational analysis. J . Consulr. Clin. Psycho/. 50: 71-86, SHIFFMAN, S., READ, L., and JARVIK, M. E. (1988). Smoking relapse situations: A preliminary typology. Int. J . Addict. 20: 311-318.
THE AUTHOR Ron Borland, Ph.D., is Deputy Director of the Centre for Behavioural Research in Cancer, Melbourne, Australia. His original training in psychology was from Monash University. Following that, he worked in clinical and occupational psychology in Australia and Papua New Guinea. He completed a Ph.D. in Psychology at the University of Melbourne (1987) while teaching there. His main research interests are in the areas of smoking relapse, the impact of workplace smoking bans, and on factors influencing the adoption of sun-protection behaviors. He is also involved in the evaluation of major health promotion campaigns on smoking and skin cancer control.
