Motivation to quit as a predictor of smoking cessation and abstinence maintenance among treated Spanish smokers

Highlights

• We evaluated motivation to quit smoking in a sample of Spanish smokers.

• Motivation to quit predicted cessation and maintenance abstinence.

• Among abstainers, motivation to quit post-treatment predicted continued abstinence.

• Even non-quitters maintained high cessation motivation at the end of treatment.

• Results suggest intervention opportunities throughout the cessation process.

ABSTRACT

Introduction

Although quitting motivation predicts smoking cessation, there have been inconsistent findings regarding motivation predicting long-term maintenance of abstinence. Moreover, most such research has been conducted in North America and the United Kingdom. The aim of this study was to examine motivation to quit as a predictor of smoking cessation and of abstinence maintenance in a Spanish sample.

Method

The sample comprised 286 Spanish smokers undergoing psychological treatment for smoking cessation. Motivation to quit was assessed pre-treatment and post-treatment with the Readiness to Quit Ladder. Abstinence post-treatment and at 6 month follow-up was biochemically verified.

Results

Participants with higher levels of pre-treatment and post-treatment motivation were more likely to be abstinent at the end of the treatment (OR = 1.36) and at 6 month follow-up (OR = 4.88). Among abstainers at the end of the treatment (61.9%), higher levels of motivation to quit post-treatment predicted maintaining abstinence at 6 months (OR = 2.83). Furthermore, participants who failed to quit smoking reported higher levels of motivation to quit post-treatment than they had pretreatment (p < .001).

Conclusions

Motivation to quit smoking predicted short and long-term cessation, and also predicted long-term maintenance of abstinence. These results have implications for understanding motivational processes of smoking cessation in general, while extending research to Spanish smokers. They may also help in the design of cessation and relapse-prevention interventions. Specifically, the results suggest that motivational enhancement is important throughout the cessation and maintenance periods.

Introduction

Most current smokers are interested in smoking cessation and often make multiple quit attempts (Centers for Disease Control and Prevention, 2011). Many quit attempts are unplanned and do not utilize evidence-based treatments, and it is significantly more difficult for smokers to achieve long-term abstinence from a given cessation attempt without such treatments (Hughes, Keely, & Naud, 2004). Successful smoking cessation is more likely if smokers utilize evidence-based smoking cessation treatments (Fiore et al., 2008); however, even with evidence-based treatment (consisting of behavioral counseling and/or medication), only around 10% to 30% achieve long-term abstinence; a great majority eventually relapse (Fiore et al., 2008). Therefore, identifying modifiable factors that predict long-term smoking cessation is highly relevant.

One such factor that might be associated with short and long-term abstinence is motivation to quit smoking. Commonly, motivation is conceptualized as readiness to change (Biener & Abrams, 1991) and plays an important role in the smoking cessation process (e.g., Baker, Brandon, & Chassin, 2004). In fact, accumulating evidence indicates that motivation to quit is a key factor in determining cessation success (e.g., Biener and Abrams, 1991, Jardin and Carpenter, 2012). In relapse prevention theory (Marlatt and Gordon, 1985, Witkiewitz and Marlatt, 2004), motivation is a critical ingredient to quitting smoking and maintaining abstinence because high levels of motivation are necessary to enact coping behaviors during situations with high risk for relapse. Similarly, in the Transtheoretical Model (Prochaska & DiClemente, 1983), a theory of health behavior change, motivation to quit is posited to directly increase intention to quit, facilitate cessation attempts, and increase successful abstinence rates.

There has been an increasing emphasis on distinguishing between the different phases of the quitting process (motivation, pre-cessation, cessation, and maintenance) when conducting research to develop and testing treatments (Baker et al., 2011, Schlam and Baker, 2012), and it is possible that predictors of quit attempts may differ from predictors of maintenance of abstinence (Borland et al., 2010, West et al., 2001, Zhou et al., 2009).

Prior research indicates that motivation to quit is one of example of such a predictor, in that motivation to quit is strongly related to quit attempts but not to cessation maintenance (Borland et al., 2010, West et al., 2001, Zhou et al., 2009). However, other studies have found that higher levels of motivation increase the likelihood of maintaining smoking cessation (Boardman et al., 2005, Heppner et al., 2011) and that motivation to quit predicts abstinence at 6 months (Williams, Gagne, Ryan, & Deci, 2002), suggesting that there are different results and considerations in how important motivation to quit may be to successfully quit smoking. Indeed, Borland et al. (2010) points out that motivation is a complex set of beliefs that is not fully understood, especially as it relates to long-term cessation.

Given the inconsistent findings about the role of motivation in the maintenance of smoking abstinence, it may be useful to explore this construct across populations. Indeed, motivation to quit has been studied primarily in smokers from North America and the United Kingdom. Given that Spain has a higher prevalence of smoking (24% Spanish Ministry of Health, 2013), more studies are necessary in this population to improve knowledge of the culture-specific mechanisms of change, and to identify modifiable factors that predict long-term smoking cessation. As noted by Carballo et al. (2014), more studies of the process of change are needed to a better inform the development of interventions for Hispanics across different cultures and countries.

Although motivation has been frequently examined as a predictor of cessation and as a predictor of quit attempts, less attention has been paid to motivation as a predictor of maintenance of abstinence. The present study aimed to examine the role of motivation to quit as a predictor of short-term and long-term smoking cessation and as a predictor of abstinence maintenance at 6 month follow-up among a Spanish sample of smokers who received an evidence-based psychological treatment for smoking cessation. Based on the results found in previous studies (Boardman et al., 2005, Heppner et al., 2011, Jardin and Carpenter, 2012, Williams et al., 2002) we hypothesized that higher levels of motivation to quit would predict smoking cessation at the end of the treatment and at 6 month follow-up, and maintenance of smoking abstinence at 6 month follow-up.