A Longitudinal Analysis of Unaided Smoking Cessation

Journal of Consulting and Clinical Psychology 1988, Vol. 56, No. 5,715-720 Copyright 1988 by the American Psychological Association, Inc. 0022-006X/88/S00.73 A Longitudinal Analysis of Unaided Smoking Cessation G. Alan Marlatt, S. Curry, and L R. Gordon University of Washington A sample of 15 3 smokers who attempted to quit smoking without treatment was followed for 2 years. Follow-up assessments occurred at 1 month, 4 months, 1 year, and 2 years postquit. A subsample of 69 individuals was also interviewed prior to their quit date. The majority of participants (77%) achieved at least 24 hr of abstinence by the 1-month follow-up. However, subsequent relapse rates were high: Only 13% of the sample was abstinent at 1 year, and 19% reported abstinence at the 2-year follow-up. Variables related to short-term outcome were generally unrelated to long-term outcome. Individuals who succeeded at initial cessation were more likely to be men and to be lighter smokers. Among those who initially quit, abstainers at 1 month were less likely to have participated in prior treatment, to report smokers among their friends, and to live with other smokers. At 2 years, abstainers were younger and had smoked for fewer years. The use of multiple strategies for cessation was associated with abstinence at the 2-year follow-up. A strong motivation to quit was found to be important for both initial success and long-term maintenance. Over 90% of the estimated 37 million people who have stopped smoking in this country since the Surgeon General's first report linking smoking to cancer have done so unaided (American Cancer Society, 1986). Survey data show that about one third of all current smokers make a quit attempt at least once per year and that only about one fifth of these succeed in any single attempt (Harris, 1980). Despite the preponderance of self-quitters, research on smoking cessation has typically focused on the evaluation of clinic-based treatment procedures (Lichtenstein, 1982). In a comprehensive review of smoking cessation studies published between 1959-1985, Schwartz (1987) reported that people who quit on their own appeared to succeed 16-20% of the time (success defined as abstinence at 1 year, based on 11 studies with a median 18% 1-year quit rate). Par treatment-aided subjects, the 1-year quit rates ranged from 5% to 88%; the median (for 405 studies reviewed) was 26% abstinent at 1 year (Schwartz, 1987). As Schachter (1982) argued, however, the treatment-aided cessation rate may be lower than the self-quit rate because those seeking formal treatment programs are often those who have made unsuccessful prior quit attempts. Perri was among the first to identify the self-control strategies (e.g., stimulus control and self-reward techniques) used by individuals who succeeded in their self-initiated attempts to stop smoking or to modify other addictive behaviors (Perri, 1985; Perri, Richards, & Schultheis, 1977). Similarly, Shiftman (1984) highlighted the exsmoker's method of coping with temptation and urges as a critical factor in maintaining abstinence. In addition, Prochaska and colleagues have postulated that unaided exsmokers use a variety of change processes (e.g., consciousness raising and self-liberation) as they pass through This research was supported by National Institute on Drug Abuse Grant RO1 DA02572 to G. Alan Marlatt. Correspondence concerning this article should be addressed to G. Alan Marlatt, Department of Psychology, NI-25, University of Washington, Seattle, Washington 98195. stages in the self-change process (DiClemente & Prochaska, 1985; Prochaska, DiClemente, Velicer, Ginpil, & Norcross, 1985). Until recently, the literature on unaided smoking cessation has been characterized by relatively small-scale studies, many with methodological weaknesses such as reliance on retrospective self-reports and the use of small and unrepresentative samples (e.g., Baer, Foreyt, & Wright, 1977; Guilford, 1972; Pederson & Baskerville, 1983). However, two recent studies have used a prospective follow-up design. Glasgow, Klesges, Mizes, and Pechacek (1985), who followed participants in a communitywide stop-smoking contest, showed that 37-41% of the subjects reported abstinence throughout the month-long contest. Discriminant function analyses showed that the only variable that prospectively predicted success was degree of perceived stress, which was assessed prior to quitting. Gritz, Carr, and Marcus (in press) conducted a 1-year follow-up study of over 500 smokers who either made a New Year's resolution to quit or who quit in response to the Great American Smokeout sponsored by the American Cancer Society. Results showed the proportion of subjects abstinent at each follow-up period to be relatively stable over time, with a 1-year rate of 25% (although continuous abstinence rates gradually declined to 11% by 1 year). Compared with relapsers, those who were successful at 1 year were less dependent smokers who were highly motivated to stop, were confident of their ability to do so, and were committed to quitting. The present study also used New Year's resolutions as a naturalistic arena for assessing self-initiated attempts to quit smoking (cf. Marlatt & Kaplan, 1972; Norcross, Ratrin, & Payne, in press). All participants were assessed following an attempt to quit and at periodic intervals during a 2-year follow-up period; a subsample of participants was also assessed prior to their quit attempts. Subject Recruitment Method In the month before New Year's Day, public service newspaper and radio ads were used to recruit smokers who planned to quit smoking as 715

716 G. MARLATT, S. CURRY, AND J. GORDON a New Year's resolution. A total of 227 individuals responded to the recruitment ads. Because staff and time constraints prevented us from contacting all prospective subjects, 40% (n = 95) were contacted before their quit date, and the remaining 60% (n = 132) were contacted approximately 1 month after their quit date. For the first group, 69 individuals were interviewed prior to their quit date. Of the 26 individuals in this group who were not enrolled in the study, 14 could not be reached, 3 wanted treatment, 3 were ineligible because they smoked a pipe or cigars, 4 individuals had already quit smoking, and 2 were uninterested after the study was described to them. Of the 132 subjects in the latter group, 84 actually enrolled in the study. The remaining 48 individuals were not enrolled because 30 people could not be reached, 11 were not interested after the study was described to them, 4 had quit prior to December 31,2 smoked a pipe or cigars, and 1 had enrolled in a treatment program. Thus, the final longitudinal sample consisted of 153 subjects (69 assessed before and 84 assessed after quitting). The sample, which was 44% male, averaged 38.22 years of age (SO = 18.85). A majority (90%) of the sample were high school graduates, and 76% had attended college. Seventy-five percent of the sample were employed, 14% reported incomes under $10,000 per year, and 34% reported incomes over $30,000 per year. Subjects reported that they had smoked for an average of 19.13 years (SD = 13.17), with an average smoking rate of 27.17 cigarettes per day (SD = 12.80). Twenty-seven percent of the sample had participated in prior treatment, and an average of 3.15 prior quit attempts (SD = 6.28) were reported by the sample as a whole. Assessment of Smoking Outcomes Smoking status was obtained 1 month, 4 months, 1 year, and 2 years after the January 1 quit date. Collateral verification of reported abstinence was obtained at the 1-month follow-up. The 1-month structured interview was conducted by phone. At 4 months, all subjects were mailed questionnaires to ascertain their smoking status. More detailed, structured telephone interviews, during which descriptions of specific high-risk situations and coping strategies were obtained, were conducted only with subj ects who were abstainers or who had changed their smoking status since the 1-month follow-up. The 1- and 2-year followups were sent by mail, and nonresponders were subsequently contacted by telephone. All telephone interviews were standardized and were conducted by senior-level undergraduate research assistants who were trained and supervised by the investigators. Assessment of Predictor Variables Demographic, smoking history, and social smoking environment data were obtained from all subjects at the start of their participation. Demographic variables included age, sex, education, employment status, and income. Smoking history variables included baseline smoking rate, number of years of continuous smoking, number of prior quit attempts, participation in prior treatment for cessation, longest period of prior abstinence, and reasons for wanting to quit smoking. In addition, subjects were asked whether they lived with any smokers and what percent of their friends and acquaintances were smokers. Descriptions of the characteristics of high-risk situations and of the strategies used to cope with those situations were obtained at the 1- and 4-month follow-ups. These data describing the characteristics of highrisk situations, coping strategies, and the relation of coping to outcome have been reported elsewhere (Curry & Marian, 1985). Additional predictor variables were assessed at the following time intervals. Prequit. Motivational, self-efficacy, and outcome expectancy variables were assessed for the subsample of subjects who were interviewed prior to their quit date. Ratings (on a 10-point scale) were obtained for the following variables: desire to quit, expected difficulty quitting, expected difficulty maintaining nonsmoking, confidence in being abstinent in 3 months, confidence in being abstinent beyond 3 months, and confidence for being able to smoke a single cigarette postquit without relapsing. One-month follow-up. At 1 month, all subjects were assessed for the number of techniques used for quitting smoking, the number of highrisk situations reported, and the number of strategies used for coping with high-risk situations (asked only of subjects reporting one or more high-risk situations). Equivalence of Samples The sample of subjects recruited prior to their quit date was compared with the sample recruited 1 month after their quit date on several dimensions. There were no significant differences between the two samples on age, education, income, number of years of smoking, number of prior attempts to quit smoking, and longest length of prior abstinence. The samples differed significantly on two variables: sex and participation in prior treatment for smoking cessation. There was a larger percentage of women (65%) than men in the prequit sample, whereas men and women were more evenly represented in the postquit sample (48% women). A larger percentage of the prequit sample (39%) had participated in prior treatment compared with the postquit sample (17%). Analytical Strategies Results The results examine two general issues: (a) outcomes, including subject attrition, initial outcomes of quit attempts, and short- and long-term outcomes and (b) the quit process, including the stability of outcomes over time and factors predictive of outcomes. Prequit and postquit samples were combined only for comparisons that were unlikely to be influenced by the postquit interview. For data on outcome expectancies and confidence, analyses were confined to the sample interviewed prior to their quit date. Smoking outcomes were obtained by summarizing frequencies for various outcome categories (all subjects with missing smoking outcome data were conservatively coded as regular smokers). A stepwise discriminant analysis was used to explore factors predictive of outcome, including the variables of age, sex, income, employment, education, baseline smoking rate, number of years having smoked, prior treatment, number of previous quit attempts, percentage of friends who smoke, number of cohabitating smokers, number of techniques used for cessation, and number of high-risk situations reported. In all analyses, the maximum number of variables eligible to enter the discriminant function was preset to ensure a 5:1 ratio of the number of subjects in the smallest group to predictors, thus ensuring a minimum 10:1 ratio of total subjects to predictors (Tabachnick & Fidell, 1983). Separate discriminant analyses were conducted with the subset of subjects interviewed prior to quitting in order to assess the relation between prequit motivations, expectations, and outcome. Hierarchical stepwise regression analyses were used, with predictors identified in the entire sample entered first, followed by the motivation and expectancy variables assessed for the prequit subsample; this analysis was designed to assess whether cognitive variables provided predictive power beyond that of demographic and smoking history variables for both pre- and postquit subjects. For all discriminant analyses reported, minimization of Wilks's lambda was the selection criterion; no additional variables were entered into

UNAIDED SMOKING CESSATION 717 the analysis when F ratios to enter the equation failed to exceed 1.00 for each remaining variable. Subject Attrition Of the 153 subjects who enrolled in the study, all subjects (100%) provided data at the first follow-up, 142 (93%) responded to the first two follow-ups, 1 1 5 (75%) responded to the first three follow-ups, and 8 5 (55%) responded to all four assessments over the 2-year follow-up periods. Subjects who did not complete all follow-ups were compared with those who did on demographic, smoking history, and smoking outcome data. Overall, the two groups differed only in age. Subjects who completed all of the follow-ups were significantly older than those who did not (mean ages = 41.36 and 34.27 years, respectively), 3.24,p=.001. 36 25 23 16 1-MONTH FOLLOW-UP 55 51 16 12 4-MONTH FOLLOW-UP Outcome of Quit Attempts At each follow-up, subjects were classified into four categories: (a) abstainers included subjects who had not smoked any cigarettes for at least 30 days prior to the present follow-up (for the 1-month follow-up, abstainers were subjects who had not smoked any cigarettes from their quit date); (b) slippers included subjects who were primarily abstinent but had smoked no more than one or two cigarettes since the previous followup; (c) relapsers included subjects who had quit smoking for at least 24 hr but subsequently returned to regular smoking or who were unable to maintain abstinence for at least 30 days; and (d) never quitters included subjects who did not quit smoking for at least 24 hr. Figure 1 summarizes the percentages of subjects in each category for the four follow-ups. As noted previously, at the I- and 2-year follow-ups, smoking status data were obtained both by mail and by telephone. Telephone interviews were conducted only with subjects who did not return the mailed questionnaires. Comparisons of the ratios of abstainers to relapsers in the mail versus telephone responders indicated that abstainers were more likely to respond quickly by mail and that nonresponders were more likely to report regular smoking in the subsequent telephone interviews. For example, at the 2-year follow-up, 56 responses were mailed and 40 were obtained by telephone. A total of 38% of the subjects who responded by mail reported abstinence compared with 20% of those who responded by telephone. Initial outcome. Of the 153 subjects who intended to quit smoking, 35 (23%) were unable to quit for at least 24 hr by the 1 -month follow-up and were thus assigned to the never-quitter category. Short-term maintenance. Despite findings that over 75% of the participants quit for at least 24 hr, the majority relapsed within 4 months following initial cessation. As Figure 1 indicates, a 15% increase in the percentage of relapsers occurred between the 1- and 4-month follow-ups, along with a corresponding decrease in the percentages of abstainers and slippers. After subjects were eliminated who had never quit smoking, 53% of remaining subjects were abstainers (33%) or slippers (20%) at 1-month compared with 34% (19% abstainers, 15% slippers) at 4-months. After subjects with missing data were excluded, 48% were abstainers or slippers at 4-months. Collateral verification of abstinence at 1 -month provided 13 1-YEAR FOLLOW-UP 19 1 2-YEAR FOLLOW-UP Figure 1. Percentage of subjects in four outcome categories at followups (AB = abstainer; RE = relapser; SL = slipper; NQ = never quitter). strong support for subjects' self-reports. There was only one discrepancy between collateral and subject reports; this subject was reclassified as a smoker. Long-term maintenance. At the end of 1 year, 24% of all participants were classified as abstainers or slippers compared with 20% at 2 years. When subjects who never quit smoking were eliminated from the calculations, 31% of the participants were abstainers (17%) or slippers (14%) at 1 year compared with 24% (22% abstainers, 2% slippers) at 2 years. When subjects with missing data were excluded, 48% were abstainers or slippers at 1 year and 62% were abstainers or slippers at 2 years. Stability of outcome over time. We explored two questions regarding the stability of outcome over time. First, we were interested in the disposition of slippers over time, particularly in whether they ultimately stabilized as abstainers or relapsers. Second, we were interested in whether the similarities in outcome percentages between the 4-month and 1-year follow-ups indicated that smoking outcome had stabilized during that period. Table 1 summarizes the proportion of initial quitters who changed smoking status between consecutive follow-ups and from the 1-month to 2-year follow-ups. These percentages are also partitioned by the direction of the status change: positive (i.e., from slipper or relapser to abstainer and from relapser to slipper) or negative (i.e., from abstainer or slipper to relapser and from abstainer to slipper). Decomposition of the negative category shifts indicated that slippers were more likely than abstainers to report regular smoking at subsequent follow-ups. The relative proportions of abstainers and slippers who became relapsers between consecu-

718 G. MARLATT, S. CURRY, AND J. GORDON Table 1 Percentage of Subjects Changing Smoking Status for Selected Intervals Interval 1 month to 4 months 4 months to 1 year 1 year to 2 years 1 month to 2 years Proportion changing status 29.6 31.3 25.5 47.3 Negative" 27.1 16.1 18.7 38.0 Direction 8 Positive" 2.5 15.2 11.9 9.3 Note. Percentages are presented for all subjects who achieved initial cessation (n 118); those with missing data were classified as relapsers. When the percentages were calculated only for subjects who provided data at all four follow-ups (n = 85), the percentages were very similar. For example, between the 1-month and 2-year follow-ups, 45.9% of subjects who provided complete data changed status, 34.8% in a negative direction and 11.1 % in a positive direction. ' Details on the composition of these percentages can be obtained from the first author. b Includes transitions from abstainer or slipper to relapser and from abstainer to slipper. Includes transitions from slipper or relapser to abstainer and from relapser to slipper. live intervals were 28.2% versus 67.5% (from 1 to 4 months), 31.8% versus 66.4% (from 4 months to 1 year), and 30% versus 50% (from 1 to 2 years). Overall, 59% of the abstainers and 91 % of the slippers at the 1 -month follow-up were classified as relapsers at the 2-year follow-up. Table 1 also indicates that the similarities in category percentages between the 4-month and 1-year follow-ups were due not to stabilization of smoking outcome during that interval but rather to equivalent proportions of subjects reporting positive and negative status changes. The positive category changes during this interval primarily comprised relapsers becoming slippers (11%); small proportions of the total sample also moved from relapsers to abstainers (1.7%) and from slippers to abstainers (2.5%). Factors Related to Outcome To explore factors predictive of smoking outcome, we first looked for variables that discriminated subjects who initially quit smoking for at least 24 hr from never quitters. Second, we explored relations between smoking outcome status at each follow-up and variables assessed prior to the follow-up. Quitters versus never quitters. Initial quitters (n = 118) and never quitters (n = 35) were compared on demographics (age, sex, income, employment, education) and smoking history (baseline smoking, number of prior quit attempts, prior treatment for cessation, longest prior abstinence, percentage of smoking friends, cohabiting smokers). A significant discriminant function was obtained (canonical R =.361), x 2 (5, N = 153) = 18.24, p <;.003, that correctly classified 69% of the cases (K =.261, p <,.007). Men were more likely to quit than women (82% of the men quit compared with 73% of the women). In addition, quitters were significantly more likely to be college graduates (43% of the quitters graduated from college compared with 23% of the never quitters) and to have incomes greater than $20,000 per year (66% quitters vs. 41 % never quitters). On the average, the quitters were older and smoked fewer cigarettes per day than the never quitters (mean age = 39.38 vs. 37.31 years; mean number of cigarettes per day = 23.27 vs. 27.04). In addition, quitters and never quitters who were interviewed prior to their quit date («= 69) were compared on rating scales for desire to quit and expected difficulty quitting. These variables entered the discriminant analysis after the five predictors discussed previously (sex, education, income, age, and baseline smoking), accounting for a 10% increment in variance and classifying 81 % of the subjects correctly. Quitters expressed a higher desire to quit and expected less difficulty quitting than never quitters (mean desire to quit = 8.81 vs. 7.67), Z(67) = 2.07, p =.042 (mean difficulty expected = 7.38 vs. 8.83), <(67) = -2.67, p =.011. Abstainers versus nonabstainers. Participants who initially quit smoking were categorized as either abstainers or nonabstainers at each follow-up. The abstainer category included subjects who had quit smoking and maintained abstinence for at least 30 days prior to the follow-up. Nonabstainers included all smokers, both slippers and relapsers. Separate discriminant analyses for smoking outcomes yielded significant functions for each follow-up period. Because the predictors of the 1- and 4-month and of the 1- and 2-year follow-ups were virtually identical, findings are summarized only for the 1 -month and 2-year outcomes. At 1 month, it was found that a smaller percentage of abstainers than smokers had participated in prior treatment for smoking cessation (12% vs. 32%). Compared with nonabstainers, abstainers were significantly more likely to report that less than 25% of their friends and acquaintances smoked cigarettes (80% vs. 54%), and a significantly smaller proportion of abstainers lived with other smokers (26% vs. 72%). On the average, abstainers had smoked slightly longer than nonabstainers (19.07 vs. 18.06 years). The function (canonical R =.337), x 2 (4, N = 118)= 14.551, p 2,.006, correctly classified 67% of the cases (K =.250, p A.01). None of the motivation or expectancy variables for subjects interviewed prior to their quit date predicted outcome at 1 month. At the 2-year follow-up, abstainers were significantly younger (35.78 vs. 42.00 years) and averaged fewer years of smoking than smokers (15.52 vs. 24.27 years), and abstainers reported significantly lower incomes (32% vs. 42% reported incomes greater than $30,000 per year). In addition, at the 1-month interview, abstainers reported using more strategies to quit smoking (mean strategies = 2.00 vs. 1.46). The function (canonical =.436),x 2 (5,W = 118)= 14.90,/><;. 01, correctly classified 68% of the cases (K =.30, p <:.01). Abstainers at 2 years had reported a significantly higher desire to quit smoking than had nonabstainers (Ms = 9.70 and 8.43, respectively), «(45) = 2.05, p =.047, for subjects who were interviewed prior to their quit date. Prequit motivation accounted for 12% more of the variance, and 78% of subjects were correctly classified when it was entered into the analysis after the five other predictors. Discussion This study shows that individuals who attempt to quit smoking on their own are reasonably successful. The outcome percentages compare favorably with existing quit-rate data. The 26% median success rate for aided quitters reported by

UNAIDED SMOKING CESSATION 719 Schwartz (1987) is similar to what we found for unaided quitters (24%) at 1 year. This figure must be considered conservative, moreover, because we included never-<]uitters in our study sample. The outcome percentages were considerably lower than those obtained for a series of attempts over a longer time period (Schachter, 1982). Various characteristics of our self-quitter group may have contributed to these smoking outcomes. In our study, 26% of the total sample indicated that they had participated in prior treatment for smoking cessation compared with less than 10% who have sought treatment according to national figures (Raw, 1975). Smokefs with a past history of treatment may constitute a more difficult or recalcitrant sample than those without a treatment history. Our data clearly indicate that smoking cessation and maintenance are fluid processes, with many subjects moving in and out of abstinence. Only 53% of the subjects maintained the same smoking status from the first to the last follow-up. As Table 1 indicates, many participants changed smoking status. Between the 4-month and 1-year follow-ups, almost the same percentage switched from relapser to abstainer or slipper (15%) as those who switched from abstainer or slipper to relapser (16%). There does not appear to be a discrete threshold period for successful quitting during the first year, although the relapse rate appears to stabilize to some extent dijring the second year (12% switched from abstainer to relapser; 5% switched from relapser to abstainer). These findings indicate that "dipstick" follow-ups, in which the overall percentage of abstainers and relapsers is assessed at fixed intervals following cessation, provide limited insight into individual differences in the maintenance process (cf. Marlatt, 1983). In our analysis of predictors of outcome, variables related to short-term outcome were generally unrelated to long-term outcome and vice-versa, suggesting separate short- and longterm processes in the cessation process (DiClemente & Prochaska, 1985). The importance of motivation associated with initial cessation is highlighted by the finding that participants who were successful in initial quitting reported a significantly higher desire to quit than that reported by never quitters. In addition, among those who were successful in initial quitting, those who remained abstinent at the 2-year follow-up indicated a significantly higher desire to quit than those who relapsed. These results suggest that motivational screening or interventions to enhance self-efficacy may be a helpful adjunct for selfquitters in the prequit stage. Our findings of factors that predict outcome for self-quitters concur with the factors outlined by Pechacek and Danaher (1979) in their summary of retrospective studies of unaided smoking cessation. These findings show that (a) individuals who succeed at initial cessation are more likely to be men and to be light smokers; (b) individuals who are able to maintain abstinence are less likely to have participated in prior treatment and have made fewer prior attempts to quit; and (c) individuals who are abstinent at the second year of follow-up report using significantly more coping strategies than do relapsers (in line with earlier findings that successful quitters use more techniques for cessation). This study is exploratory and was designed to provide preliminary data about the process and outcome of unaided smoking cessation. Only some of the data were collected in a fully prospective design because we interviewed some subjects before quitting and some after quitting. It is possible, therefore, that the willingness of postquit subjects to participate was influenced by their success or failure at initial cessation. Choosing an arbitrary quit date (New Year's Day) may also have been a biasing factor because it excluded the study of individuals who quit as a result of a more salient event (e.g., being told by a physician to quit smoking). Another potential drawback is that smoking data were based on self-reports by subjects. Because of the high level of agreement between self-reports and collaterals at the 1 -month followup and our desire to be as unobtrusive as possible, we did not require collateral verification at subsequent follow-ups. Because a large proportion of initial abstainers reported subsequent smoking, there did not appear to be an attempt to fabricate continued abstinence during the study. We chose not to include a biochemical measure of smoking (e.g., saliva test) because we felt that advance knowledge by the subjects concerning the administration of such a test might provide an additional motive to quit, which would be a motivational boost not experienced by the typical self-quitter. Of course, simply being part of a university-based study with multiple planned follow-ups may have had a selective impact on subjects' motivation to succeed (Glasgow etal., 1985). Prospective outcome data from unaided quitters provide a natural history of smoking cessation that can provide normative data against which treatment outcomes can be compared. For a treatment program to be shown effective, it should show a success rate that is at least as effective (or significantly more effective) than the rate for unaided quitters. These data may also provide an empirical basis for determining the dividing point between the cessation and maintenance stages of habit modification. 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