Consistent with hypotheses, nicotine dependence was associated with decreased rates of initial cessation, and higher risk of transitioning from lapse to relapse, independent of demographic and life context factors. This is consistent with Edwards' (1975) theory that rapid reinstatement of drug use is a hallmark of dependence.60
Nicotine dependence was related to lapse risk when tested alone, but not in multivariate models. This suggests that nicotine dependence has some relationship to the lapsing process (e.g., perhaps indexing conditioned responses to smoking cues), but does not have unique predictive validity (). Thus, the data suggest that dependence influences ultimate cessation outcome because it affects withdrawal, which in turn thwarts initial abstinence, and because lapses deliver priming doses of nicotine, which reinstate important dependence processes and spur relapse.52,61
Demographic and contextual variables
While not predicted, many of the demographic and contextual variables predicted the achievement of initial abstinence, with ethnicity and smoking in the home making unique contributions. Consistent with predictions, all of the demographic and contextual variables were significantly related to lapse risk with the exception of smoking in the home and life stress. Smoking in the home, however, was found to have a very strong relationship with initial abstinence. Therefore, it is possible that those at greatest risk due to smoking in the home failed to quit and were unavailable to lapse. Stress may have been unrelated to lapse risk because the measure of stress (SSRS57
) was retrospective, and therefore insensitive to stress during the quit attempt.7
To the extent that the demographic and contextual variables coded for greater exposure to high-risk contexts and phasic events (e.g., smoking cues, stressors, negative affect), the current findings are generally consistent with previous research that characterizes the episodic and contextual nature of such risk.7
The results also show that contextual and demographic variables tend to decrease the likelihood of initial abstinence. The current data do not suggest a mechanism for these effects, but candidates could be cue-induced conditioned reactions, which might be exacerbated by withdrawal.4,5,9,62
Surprisingly, gender was the only demographic or contextual variable to make a significant and unique contribution to risk of relapse (with women having a 29% greater risk of relapse than men; ). Gender effects on long-term abstinence have been reported frequently, but little is known about how or when such effects are manifested. These results suggest that women quit at the same rate as men, but are more likely than men to sample cigarettes and thereafter escalate their use. It was predicted that social support would predict relapse risk. While social support was related to initial abstinence and lapse risk, it was significantly associated with relapse risk only during treatment. Marital status, a less direct measure of social support, failed to predict relapse.
There could be several reasons for the failure of contextual and demographic factors to predict relapse. It may be that the motivational forces unleashed by a lapse dwarf the importance of contextual and demographic influences. Previous research has found that the vast majority of individuals who lapse eventually relapse; perhaps severe dependence renders relapse, given a lapse, almost inevitable.51
It could also be that contextual and demographic predictors of the risk of progressing from lapse to relapse exist, and were not adequately sampled in this research.
Summary and Implications
Nicotine dependence appeared to affect all cessation milestones, and especially initial abstinence and the transition from lapse to relapse. Thus, the treatments most likely to reduce lapse–relapse transitions might be those that counter dependence-related mechanisms unleashed by lapse cigarettes (e.g., increasing nicotine replacement dose after lapse).
Most demographic and contextual variables appeared to affect early milestones such as achievement of initial abstinence and lapse, but not the lapse–relapse transition. This may explain why the two most effective counseling elements are cue avoidance/coping training and intratreatment support,63
as these treatment elements may address threats to initial abstinence and lapse occurrence. These treatments may be less effective for relapse prevention,3
, to the extent that the nature of the risks changes after a lapse being more associated with gender and dependence.
These findings identify populations at risk for failure at each of the cessation milestones. Contextual and demographic variables reflecting environmental smoking exposure (smoking in the home), life stress and low levels of social support seem particularly detrimental for individuals trying to achieve initial abstinence and avoid lapsing. Therefore, treatments focusing on such risk variables could be offered to these populations at elevated risk24
Finally, amongst the demographic and contextual variables, gender was uniquely and strongly related to lapse–relapse transition. This should encourage research to uncover causes or mediators of the extra risk experienced by women.27
Limitations and future directions
One limitation of this research is that contextual variables were measured via retrospective questionnaires rather than real-time data acquisition methods. Future research could use these methods to examine whether stronger relationships are found between context and milestones when contextual features are measured in real time (but this would lack some clinical utility for risk assessment). In addition, real-time data could be used to test the mechanisms by which smoker characteristics affect milestone outcomes. Second, the method of examining milestones for only those individuals who reached a previous milestone certainly affects the variables that are related to later milestones. For instance, the rate of lapsing affects the type of smoker who is “available” for relapse, which no doubt affects patterns of relationships with relapse predictors. In addition, this group is somewhat unrepresentative of the general population, limiting generalizability.