Staying a smoker or becoming an ex-smoker after hospitalisation for unstable angina or myocardial infarction

Abstract

The aim of our study was to better understand processes of ongoing smoking or smoking cessation (quitting) following hospitalisation for myocardial infarction or unstable angina (acute cardiac syndromes). In-depth interviews were used to elicit participants’ stories about ongoing smoking and quitting. In total, 18 interviews with smokers and 14 interviews with ex-smokers were analysed. Our findings illustrate the complex social nature of smoking practices including cessation. We found that smoking cessation following hospitalisation for acute cardiac syndromes is to some extent a performative act linked to ‘doing health’ and claiming a new identity, that of a virtuous ex-smoker in the hope that this will prevent further illness. For some ex-smokers hospitalisation had facilitated this shift, acting as a rite of passage and disrupting un-contemplated habits. Those participants who continued to smoke had often considered quitting or had even stopped smoking for a short period of time after hospitalisation; however, they did not undergo the identity shift described by ex-smokers and smoking remained firmly entrenched in their sense of self and the pattern of their daily lives. The ongoing smokers described feeling ashamed and stigmatised because of their smoking and felt that quitting was impossible for them. Our study provides an entry point into the smokers’ world at a time when their smoking has become problematised and highly visible due to their illness and when smoking cessation or continuance carries much higher stakes and more immediate consequences than might ordinarily be the case.

Keywords

chronic illness and disability experiencing illness and narratives illness behaviour

Introduction

This article presents findings from an Australian study of smoking cessation or continuance after hospitalisation for myocardial infarction or unstable angina. These conditions are often referred to as acute cardiac syndromes (ACSs). For smokers who have been hospitalised due to a serious smoking-related illness such as ACSs, stopping smoking is now viewed as the single most effective behavioural change to prevent a recurrent, more serious event. Individuals who stop smoking after cardiac surgery or a heart attack reduce their risk of death by at least one-third (Critchley and Capewell, 2003). The beneficial effects of smoking cessation for patients who have had a heart attack may be as great or even greater than major non-behavioural interventions such as taking lipid-lowering medication (Shah et al., 2010).

Despite the significantly improved prospects for people who quit smoking and the fact that the majority of smokers are receptive to the idea of quitting after a hospitalisation, many individuals hospitalised because of heart disease appear to be unable or unwilling to stop smoking (Dawood et al., 2008). Between 50 and 70 per cent of people who smoked before their heart attack will resume a regular smoking habit within a year (Quist-Paulsen and Gallefoss, 2003; Rea et al., 2002).

Our research contributes to two sometimes neglected issues in the smoking cessation literature: these are smoking and cessation practices among people diagnosed with a tobacco-related illness and research that explores the smoker’s perspective. Ongoing smoking and smoking cessation among cardiac patients and others with established tobacco-related disease is under-researched . Parry et al. (2001) provide a rare and exemplary example of the value provided by research that does investigate this issue. Research in the area of smoking cessation also tends to emphasise the physical and behavioural aspects of smoking while neglecting the experiences of smokers and ex-smokers (EXSs) and the social context of smoking (Poland et al., 2006).

Smoking cessation

There are several different professional perspectives about smoking and smoking cessation currently in widespread use. By far, the most dominant are medical and psychological understandings. These are closely inter-related, and in both approaches smoking is viewed as a risk factor for future disease, an addiction and increasingly as a chronic and relapsing illness requiring treatment. Smoking is understood at least in part as an individual behaviour, and solutions to the ‘problem’ of smoking are targeted at individuals, for example, behavioural interventions such as counselling and pharmaceutical treatment such as nicotine replacement therapy (NRT) (Rigotti et al., 2012). Many writers have argued that smoking/smoking cessation has become medicalised and that the increased use of medication to assist with smoking cessation is evidence of this process (Chapman and Mackenzie, 2010; Rooke, 2013).

The medicalisation of smoking, like the medicalisation of alcoholism, carries with it advantages and disadvantages for the individuals directly affected (smokers). Viewing smoking as an illness at least theoretically reduces the likelihood that smokers will be viewed as either ignorant or wilfully negligent (if they continue smoking) or as lacking in willpower and moral fibre (if they want to quit but are unable to do so). Medicalisation may reduce the stigma of ongoing smoking and the use of medications may result in more people successfully stopping smoking (Rigotti et al., 2012). Trials of NRT and other medications suggest that appropriate use of pharmacotherapy increases the likelihood of successful quitting, and it is often recommended as an adjunct to other strategies such as counselling, particularly for people with a smoking-related disease (NICE, 2006).

The increasing medicalisation of smoking cessation has been criticised by sociologists and public health practitioners, who argue that it is unwarranted because the majority of people who successfully stop smoking do so without medication (Chapman and Mackenzie, 2010). Furthermore, the effectiveness of NRT (with or without professional counselling) has been challenged (Alpert et al., 2013). Despite this, the medicalisation of smoking cessation seems likely to continue. It is supported by several factors including ongoing encouragement from the pharmaceutical industry, moves to apply NRT at a population level through government subsidies in some countries such as Australia and the increasing uptake of genetic models of nicotine dependence.

Public health and policy perspectives on smoking apply a structural approach to smoking cessation. Legislative restrictions on smoking and taxation of cigarettes are standard practices in Western industrialised countries. Such strategies aim to reduce the availability and use of cigarettes and to protect non-smokers from the potential harm of breathing ‘second-hand smoke’ (World Health Organization (WHO) FCTC, 2003). Other public health and policy strategies to reduce smoking uptake and to encourage individuals to reduce or cease their smoking draw on the fields of health education and marketing, for example, ‘nudging’ (Marteau, 2011). Behavioural economics is focused on the actions of individuals and draws on a model of the smoker where individuals are driven less by agency and rational decision-making (as in health education) and more by ‘inherent impulsivity and need for instant gratification’ (McNaughton et al., 2012: 459).

Sociology of smoking and smoking cessation

In contrast to medical/psychological and public health/policy perspectives on smoking cessation, sociological approaches to understanding smoking and smoking cessation focus on the social patterning of smoking and the strong link between smoking and social disadvantage. Smoking is patterned by age, gender, ethnicity, types of employment and areas of residence, with the strongest pattern related to material disadvantage (Harman et al., 2006; Rahkonen et al., 2005). Disadvantaged people are more likely to take up smoking and less likely to stop. Various explanations have been put forward to help explain this pattern, such as lay epidemiology (Lawlor et al., 2003), lifecourse explanations (Graham et al., 2010), area effect (Levin et al., 2014; Miles, 2006) and conceptualising smoking as a coping mechanism (Bancroft et al., 2003). Smoking is viewed as a social practice with detrimental effects on health that is often indicative of other factors such as poverty or marginalisation. Recommendations for strategies to reduce smoking focus on the importance of reducing social and income disparities and tend to advise against individualised interventions or health education approaches.

The sociological literature on smoking and smoking cessation also gives attention to the cultural, historical and experiential aspects of smoking and cessation. This body of work often explores smoking from the perspective of the smoker. It is informed by the social structural approach outlined above; however, smoking is again explored in terms of individuals. But unlike medical and psychological perspectives, the individual is understood as a socially situated actor and thus life chances are seen as impacting their actions related to smoking and the resources and supports available for smoking cessation. Smoking is not viewed as an illness nor is it always viewed as an entirely negative act. Rather, smoking is viewed as a health-related social practice that carries with it advantages and disadvantages. Viewing smoking (and cessation) in this way is helpful as it acknowledges that smoking and cessation like other every day practices are ‘locally situated and composite … [they] emerge out of the actions and interactions of individuals in a specific context’ (Cohn, 2014: 4).

As with other forms of social action, smoking and cessation are meaningful and they vary in terms of their meaning and practice at different points across an individual’s lifecourse (Laurier et al., 2000). The meaning of smoking (or not smoking) also varies according to place and time and is closely tied with age, gender and class-based identities (Katainen, 2010; Pampel, 2006). Practices such as smoking, smoking refusal and smoking cessation play a part in identity formation and display. This may be conscious, for example, both smoking and smoking refusal can be part of performing ‘coolness’ among adolescents (Plumridge et al., 2002). It may also be largely taken for granted and un-contemplated. For regular smokers, the act of smoking is woven into their everyday lives: ‘it forms part of the recursive embodying which weaves their actions and contexts together’ (Laurier et al., 2000: 294).

As the meaning of smoking changes over time and across different social contexts, what it means to smoke (or refuse or quit) also changes and this can alter the relationship between smoking and identity. For example, in contemporary Western cultures, the pursuit of health through practices viewed as ‘healthy’ is associated with virtue and a valued social identity (Crawford, 2006: 402). Smoking is now widely viewed as unhealthy and thus as increasingly socially unacceptable (Bell et al., 2010; Stuber et al., 2008). Dilemmas arising from being seen as unhealthy and thus discreditable are likely to be particularly concerning for people diagnosed with a tobacco-related disease such as cardiovascular disease. They carry a double burden of chronic illness and smoking. This type of relationship between two discrediting characteristics has been described as double or dual stigma (Frohlich et al., 2012; Thompson et al., 2007). For people who have just been diagnosed with heart disease or those whose condition has resulted in a life-threatening incident, the meanings of ongoing smoking or cessation, and the relationship between their smoking practices and health, are at a critical juncture. Our study provides an entry point into the smokers’ world at a time when their smoking has become problematised and highly visible due to their hospitalisation and smoking cessation or continuance carries much higher stakes and more immediate consequences than might ordinarily be the case.

The study

Aim and approach

The aim of our study was to better understand processes of ongoing smoking or smoking cessation following hospitalisation for ACSs in recognition of the importance of smoking cessation for secondary prevention of cardiovascular disease. Secondary prevention refers to slowing the progression of existing disease and reducing the risk of a subsequent acute cardiac event. We wanted to apply a sociological perspective to an issue that has previously been addressed from medical and psychological perspectives. The sociological perspective used in our study focuses on eliciting the perspectives of smokers, the social context of smoking practices and the relationships between meaning, identity and practice. We used an inductive qualitative design and our chosen method of analysis (iterative thematic analysis) is derived from the grounded theory tradition. Our research used qualitative interviews to investigate how people ‘create, enact, and change meanings and actions’ around smoking, quitting and hospitalisation for ACSs (Charmaz, 2006: 7). Because our research investigates cigarette smoking, we also remained aware of material and structural issues. To assist us with this aim, our research used a relational concept of health practices where health practices are seen as being interconnected with ‘dispositions of mind and body and supra-individual contexts defined by relations of power’ (Veenstra and Burnett, 2014: 31).

Participant recruitment

After gaining ethical approval from the combined hospital/university ethics committee (approval number H8641), a database in a large Australian public hospital was searched for patients who were recorded as tobacco users and who had a discharge diagnosis of acute angina or myocardial infarction (ACSs) in the 2 years prior to recruitment (recruitment and interviews occurred in 2007/2008). We mailed 685 letters inviting ongoing smokers (OSs) to participate in an interview. We received a 3% (N = 22) response rate, and 21 people were recruited for an interview. We then sent a new invitation asking for people who had stopped smoking after their hospital admission (known in this study as ‘EXSs’). After known deaths were removed, 477 letters were sent inviting people who had stopped smoking for at least 12 months since their hospitalisation to participate in our study. We received an 8% response rate (N = 39). Of these, 22 were ineligible for the study (it had been less than 12 months since they stopped smoking or they were currently smoking). A total of 14 EXS participants were recruited for interview. Although the sample achieved was sufficient to pursue our research aims, it is worth noting the low response rate for both groups. The low levels of recruitment are likely to be at least partially related to the use of a single letter as a method for recruiting.

Semi-structured interviews

Each participant engaged in an in-depth interview where the interviewer used a short list of open ended questions (e.g. ‘Tell me about your smoking’) and topics as a guide for discussion (Rice and Ezzy, 1999: 54). Interviews focused on eliciting participant stories about smoking and cessation and their discussion of events and experiences leading up to and after their hospitalisation. Interviews were conducted in participants’ homes with the exception of three interviews conducted by telephone. Interviews ran for between 40 and 70 minutes, all were audio-recorded. In all, 21 OSs were interviewed; however, only 18 of these interviews were analysed and included in the analysis as three digital audio files were lost due to a damaged audio recorder (males, N = 11 and females, N = 7). A total of 14 EXSs were interviewed (males, N = 12 and females, N = 2).

Questionnaires

A brief demographic questionnaire was also administered prior to the interview to collect information on place of residence (postcode), age, sex, education level and income.

Data analysis

Qualitative data were analysed using an iterative thematic approach (Grbich, 2013). The analysis aimed to identify major themes about smoking, hospitalisation, the ACS, heart disease, smoking cessation and the role of doctors in smoking cessation. We also compared the ways that ongoing and EXSs spoke about smoking cessation, smoking and hospitalisation. Audio-recordings of interviews were fully transcribed and summaries of each participant’s questionnaire data and any field notes were added to the transcripts. Initial codes were developed from the data (a type of open coding) and included many in vivo codes (codes that were labelled using terms used by participants, see Charmaz, 2006: 55). Following a process of compare and contrast, the codes were then sorted, refined and regrouped into higher order conceptual categories. These categories reflect the higher level of abstraction achieved at this stage in the analysis and helped to show how earlier codes were related to each other and how previous and current smoking status shaped smoking and quitting practices. For the purpose of investigator triangulation and to encourage reflexivity, the first author met regularly with the second author to reflect on data and the analysis (Finlay, 2002). Following this process of review, the first author refined and completed the analysis. Themes relevant to the conceptual category ‘processes of ongoing smoking or quitting after hospitalisation’ are presented in this article. Themes related to how participants spoke about the role of health professionals when quitting smoking after hospitalisation have been published elsewhere (see Hansen and Nelson, 2011).

Findings

Thirty-two interviews were analysed (18 OS and 14 EXSs). Participant ages ranged from 40 to 74 years with the median age of 57 years. All participants reported very low to low incomes (disability benefits or ‘old age’ pensions or annual incomes equal to or less than the state median income). Seven of the participants were employed and the others relied on disability or aged pensions for their income. Most participants had co-morbidities, many of them severe. These included arthritis, diabetes, kidney disease, peripheral arterial disease, back injuries, workplace injuries of longstanding duration, post-heart surgery pain/impairment and chronic obstructive pulmonary disease.

The themes presented in this article all sit under the conceptual category ‘processes of ongoing smoking or quitting after hospitalisation’. The thematic titles used are ‘Views on smoking, quitting and heart disease’, ‘The ACS (myocardial infarction or acute angina) and quitting’, ‘Fear and fate’, ‘Hospitalisation and cessation’, ‘Smoking status and identity: ex-smokers’ and ‘Smoking status and identity: ongoing smokers’. Individual participants are represented by a number and a prefix indicating whether they are an OS or an EXS.

Views on smoking, quitting and heart disease

EXSs and OSs all described feeling worried about smoking and the impact of smoking on their health and financial circumstances prior to the ACS. Participants from both groups described smoking as something that has a detrimental effect on health which had contributed to them developing heart disease. However, they were unsure about how exactly smoking might contribute to heart disease. They often engaged in a process of lay epidemiology (Lawlor et al., 2003) where they spoke about various factors that might explain why they had developed heart disease, for example, stress, family history, work, diet, ‘bad luck’. Participants often questioned the strength of the link between smoking and heart disease; is it really as important as doctors say?

Well if you believe what the doctors say smoking caused it. I’m not really personally convinced that smoking does cause it. (OS3)

I had a heart attack at the age of 40 and um, had a double bypass which, um I believe was due more to my job than smoking … I think it was my attitude, my stress levels that probably brought it on. (EXS7)

Part of it I’m sure is hereditary, … I believe part of the problem is a hereditary one. The other cause is maybe smoking. I don’t know if it’s a cause I’ve been smoking on and off for sixty years or so, I assume that wouldn’t be good for me. (EXS8)

The ACS (myocardial infarction or acute angina) and quitting

While not always convinced that smoking was the key reason they had developed heart disease, EXSs seemed very confident that stopping smoking would prevent another hospitalisation and/or serious cardiac event. All fourteen EXSs described deciding to quit while they were in hospital or very soon afterwards. Most were able to sustain abstinence. Two started smoking again in the months after the ACS and then were subsequently able to quit and maintain this for longer than 12 months. Many of the EXSs told very similar often highly dramatic stories of quitting ‘cold turkey’ at the time of the ACS admission:

The day I had my heart attack was the day I stopped smoking. And I’ve tried to give up smoking for years. … I was only in there five days after I had the heart attack, and after that never once have I picked up a cigarette. (EXS10)

I walked out of hospital and I’ve never even looked like touching a cigarette. (EXS12)

For the majority of OSs, the ACS and subsequent hospitalisation resulted in a desire to quit or actual quit attempts. OSs also described reducing their smoking after the ACS (sometimes this only lasted a short period of time), and several saw this as a first step leading up to quitting at some time in the near future. For those participants who had stopped smoking when in hospital, and then resumed some time afterwards, their accounts often described a stressful event that resulted in their resuming smoking or beginning to smoke again when they resumed normal habits and routines:

I was in hospital for 2 or 3 days while they performed all these tests. That’s been the longest. I tried to hang off when I got home, and no. Not even half an hour when I was at home. (OS9)

After my heart attack I gave up for about 5 months, and then I just, some sort of stress started happening … I’ve been smoking ever since then. (OS7)

Fear and fate

Participants from both groups spoke about their fear of dying and further illness. While not always convinced that smoking had led to their heart disease, participants from both groups were sure that continuing to smoke would impact negatively their health, something which now seemed precarious. Among the EXSs, a common element in their stories was that this hospitalisation had been particularly frightening or a big shock:

It was the scare of having my heart attack that pulled me into line. You sort of think well, if I keep smoking I’m in danger, you’re dicing with your life really. (EXS11)

Among the EXSs, many of the participants described a pivotal moment when they were told by a doctor that if they kept smoking they would die or at least be back in hospital with another heart attack. They found this frightening, and it was often the key event in their stories about deciding to stop smoking. When many of the EXSs spoke about quitting, it became apparent that stopping smoking ‘cold turkey’ at the time of the ACE and never smoking again was viewed as an act that would protect them from future illness or premature death:

I’d be dead now if I was still smoking. (EXS7)

If I smoke a pipe again I think it would kill me. So that’s the story. (EXS2)

Quitting allowed participants to regain the moral high ground after the heart attack. As a smoker they were judged and they felt judged by those around them in the hospital and the wider community. The stigma of being a smoker with heart disease was something that many of the participants had experienced. Quitting and thus being morally ‘good’ was a powerful motivation for smoking cessation. After some time had passed other reasons to stay an EXS also came to the fore (not wanting to let people down, the smell, the cost, etc.).

Conversely, the stigma experienced by OSs due to their smoking status and in some cases ‘failed’ attempts to quit merely added to their distress. In contrast to the views expressed by many EXSs that they were able to prevent future illness by quitting smoking, many of the OSs expressed fatalistic views about illness, heart disease, death and smoking. They often described a history of illness, injury, unfairness and ‘bad luck’ (e.g. workplace accidents and illness among close family members) that ran through their life stories, and the ACS was seen as an extension of this:

I tend to believe if my number is up it’s up! there’s nothing you can do about it. (OS1)

I’ve already stuffed up this body so it won’t make much of a difference if I stuff it up even more. (OS6)

Participants who were OSs were also much more likely to describe experiencing previous serious illness and other hospitalisations despite making lifestyle changes such as changing their diet, reducing or giving up alcohol and exercising (and in two cases lengthy periods of quitting in their 20s or 30s before resuming smoking). This had contributed to their view that illness cannot be manipulated. Many stated that they didn’t think there was any way to prevent another heart attack or death; others told the interviewer that they were not afraid of death.

Hospitalisation and cessation

Hospitalisation itself seemed to help some participants to stop smoking. It disrupted smoking routines, and surgery, feeling unwell and being bed-bound made it impossible to smoke:

Well I was in hospital for 10 days, 4 days in intensive care [without any cigarettes]. Then I was going downstairs to a general ward. The wife came in and the kids and she said what are you going to do and I said well I’m going to give up smoking, I’ve got to. (EXS4)

I didn’t really want to smoke while I was in there. I didn’t have the urge to get up, it was probably the morphine. (EXS5)

Several EXSs described how going several days or longer without cigarettes increased their confidence in their ability to cope without cigarettes. Being an inpatient also made it impossible to adhere to their usual routines which had the effect of disrupting un-contemplated habits (Laurier et al., 2000) related to smoking such as starting the day with a cigarette or stopping for a smoke at certain points in the working day. This disruption often continued for some time after they went home because life didn’t go ‘back to normal’ immediately. For example, participants described being less mobile, making other changes such as diet and later exercise, deciding to retire due to ill-health or having a family member staying in their home to help them recover when they usually lived alone.

The role of routine and habit was also demonstrated in accounts by OSs who described stopping smoking while in hospital but starting again when they returned home or resumed their usual activities:

I came out on a Sunday and I definitely didn’t have a cigarette for a full fortnight … And then I reckon I was feeling better. I didn’t even sort of think about it. Just went down to the shops on Saturday morning and got the local papers and a packet of cigarettes and away I went. (OS13)

I thought I’ve gone a week [in hospital], so I might as well give it up. But I didn’t last long after that week and a week here [at home] with them, I went back on again. (OS2)

Smoking status and identity: EXSs

Accounts from the EXSs made it clear that becoming an EXS involved a change in identity. Being a smoker had been a significant part of who they were; many spoke about the pleasure of smoking and how smoking had been embedded in their daily lives:

I used to love them, I could not get enough of them. Everything used to revolve around having a fag, like if I was going to eat my tea, I’d have a fag first. If I was going to walk to the shop I’d have a fag first. Everything revolved around having a fag first because when I stopped all of a sudden it dawned upon me that I didn’t do nothing unless I had a fag. Like everything revolved around this packet of cigarettes. (EXS4)

The new identity of an EXS was a triumphant one forged at a time of adversity (illness and hospitalisation) that was viewed by participants (and according to participants, health professionals) as being virtuous and responsible in contrast to the increasingly discreditable identity of being a smoker with a serious smoking-related illness. EXSs and OSs were very aware of the stigmatised nature of smoking, particularly when smoking was known to have resulted in illness. Several EXSs described the satisfaction they felt when they were praised by doctors, family members and friends because they had stopped smoking but also that they didn’t want to disappoint the people who were so proud of them for quitting:

And I say to myself, I’m like an alcoholic one more drink and you’re off again, one more fag and I’d be off again. And look at all the people you’re going to disappoint as well as yourself. (EXS7)

Being an EXS meant more than stopping smoking. Being an EXS meant that participants had changed who they were and what they did with their time. Maintaining their ex-smoking status required new daily routines. Several participants made a point of describing themselves as EXSs or reformed smokers rather than non-smokers: ‘Um, well I class a non-smoker as that they’ve never touched it and they’ve never tried it’ (EXS10).

Smoking status and identity: OSs

Unlike the EXSs, the OSs had not changed their smoking identity because of the ACS and hospitalisation. They had entered hospital as a smoker and remained a smoker afterwards (even if they had tried to quit or had actually quit for a short period of time). Smoking had remained an integral part of who they saw themselves to be. Some of the OSs in our study told us that they had always been a rebel and an outsider and that smoking had been and still was part of this. Others described working class occupations where cigarette breaks were the norm, jobs that entailed shift work or potentially dangerous tasks where cigarettes operated as a reward and an opportunity to ‘calm down’ after technically difficult tasks.

Several participants described themselves as stressed anxious people, and they told the interviewer that smoking helped them cope with stress or feelings of anxiety. Smoking was both part of ‘doing’ stressed or anxious jobs and a way or coping with being stressed or anxious:

It’s sort of the depressive state that I go back to when I try and give up [smoking] that is the problem. and I don’t know how you can overcome that, I really don’t. (OS18)

I said before, about the giving up smoking and, you know … previously I have had depression, I’ve had post-traumatic stress disorder, I have hyper vigilance, and I disassociate under extreme trauma or stress. (OS6)

For others, smoking was part of their embodied self and daily life that just happened. Outside of times such as the interview or hospitalisation when smoking became visible and problematic, smoking wasn’t something that they thought about very much, it was just something they did:

Now that I’m alone, the evening is so early dark, you sit here on your own because everybody is going home, so you sit here on your own. I read and read and read, so automatically I take a cigarette, and it’s like a comfort. (OS10)

This quote also illustrates how smoking can be an act of self-care and nurturing. For some participants, it was one of their few remaining sensual pleasures and a link to their younger and healthier selves. Several male OSs spoke about the sadness they felt because they were now unable to have sex or to work in their gardens or enjoy movement without pain or breathlessness. They described lives of sitting and watching rather than doing:

[doctors say] ‘give up smoking, it causes you trouble’, oh I think possibly it does, But they don’t take into account what you’ve given up; already … you’ve given up just even the simple little things. (OS11)

What else have I got? I’ve got no other pleasures in life. This is the last thing I’ve got left. (OS8)

While nearly all OSs expressed a desire to stop smoking, many also stated that they felt as though quitting was impossible for them. Repeated failed quit attempts in the past were seen as further proof of the strength of their smoking identity. OSs were concerned about being a ‘smoker’, not only because of worries about future ill-health but also because they considered they were at risk of being discriminated against in terms of future medical care:

I saw a specialist but he’s not going to operate because of the smoking. He said if it’s getting worse and you stop smoking we will do something about it, so in other words he wasn’t going to do it. My [own GP] says that ‘he won’t touch you if you are smoking’. (OS17)

I don’t like being told the only reason [my health is poor] is because I smoke. They are using smoking as an excuse for everything. (OS1)

When OSs told us that they had been refused surgery until they stopped smoking, it was apparent that they viewed this as a moral judgment rather than a reflection of anaesthetic risk or their surgeon’s attempt to improve the likelihood of a successful surgical outcome. Trying to quit and being unable to do so added to the stigma felt by the OSs. Quitting smoking was viewed by participants from both groups as a test of virtue and willpower. Because they had tried to stop smoking and been unable to do so they worried that others would see them as a bad person and some viewed their ongoing smoking as a personal failing. They described feeling like a failure or as a weak person:

If I try to give up smoking, within twenty four hours I’m a blithering idiot basically, because it’s been a big part of my life, as much as I want to, I know I shouldn’t, I just can’t handle it mentally. (OS18)

Discussion

Our findings demonstrate the complex nature of smoking and smoking cessation. Quitting and ongoing smoking involve more than biochemistry, instant needs gratification or easily made ‘choices’. They are social acts that occur within a broader social context and which are closely tied to identity. Our findings also illustrate the importance of life events (in this case hospitalisation and in some cases diagnosis of cardiovascular disease) and sustaining conditions in smoking cessation (see Ogden and Hills, 2008).

Smoking and smoking cessation are linked with identity construction in several different ways. The meanings given to the act of smoking can help to signify membership of a group or a certain type of social status, for example, young adult or ‘rebel’ (Pampel, 2006). Smoking is an ‘action which is embodied and contextually meaningful and therefore certainly habitual but also helpful in self fashioning through ritualization’ (Laurier et al., 2000: 291). It is a performative act that helps a person to know themselves and others to know them (Butler, 1990). For example, participants spoke about smoking as a practice that is undertaken during stressful events; in this context, smoking is both a coping strategy and a demonstration of ‘being stressed’. Smoking was also viewed by participants as an appropriate practice for people who view themselves as being anxious or worried types of people.

It was clear that giving up smoking meant becoming in some ways a new person, constructing a new identity through the development of new routines, practices and habits. In the case of our participants, this process was linked with the ACS and hospitalisation. Smoking-related illness provides a powerful motivation for smokers to quit (McKenna and Higgins, 1997). The shock of being so unwell and in some cases receiving a diagnosis of heart disease for the first time operated as a trigger event for some participants that motivated them to seriously consider quitting now. Hospitalisation and in many cases surgery also offered an opportunity for change by disrupting un-contemplated habits, and in some cases, introducing new routines related to medication and diet.

For some participants, hospitalisation also seemed to act as part of a rite of passage marking the transition from apparently healthy to being seriously unwell and then from smoker to EXS. A rite of passage is a ritual that marks a change in a person’s social status indicative of a transition from one life stage to another, as from adolescence to adulthood. They occur at times of ‘life crisis or when major changes in status occur in an individual’s life’ (Banwell and Young, 1993: 382). In the accounts of many of the EXSs, their hospitalisation for a heart attack (more often than for angina) was a major point in their life that marked a transition from the person they saw themselves to be before the event to the person they became afterwards. Linked with this was a transition from a smoker to an EXS possibly related to a shift from being ‘healthy’ to being ‘ill’ or ‘mortal’. Even participants with an existing diagnosis of heart disease or other serious conditions such as chronic obstructive pulmonary disease had been shifted to a state where their sickness was now characterised as life-threatening. Rites of passage are characterised by a loss of social power (Hockey and James, 1993). Disease and illness on their own are associated with a reduction in social power, ‘a combination of social and organic distress’ (Shilling, 2008: 113) that has a profound impact on identity.

While the ritualised and performative aspect of smoking is often acknowledged (Laurier et al., 2000; Plumridge et al., 2002), we found that ritual practice and performance also played a large role in smoking cessation for some of our participants. Both OSs and EXSs questioned whether smoking was the most important causal factor for their illness, while EXSs were at the same time very certain that ongoing smoking would result in further illness or even death. We had initially been puzzled by this apparent contradiction. However, we now consider that for the EXSs who spoke with such certainty about the importance of smoking cessation for their ongoing well-being that in the context of hospitalisation for ACSs, smoking cessation can be understood as a ritual act. Williams described the pursuit of health as an ‘embodied act and moral performance’ (Williams, 1998: 437). For many of the EXSs in this study, the act of quitting smoking ‘cold turkey’ could be understood as a ritual performance of health in addition to being part of a rite of passage that shifted them from a discrediting identity. Smoking cessation and the new identity of an EXS meant that they were moving from the morally culpable identity of critically ill smoker (‘sick role’) to the far preferable role of a virtuous EXS who is hopefully on the road to health (‘health role’) (Shilling, 2008: 107).

In contrast to the EXSs, the OSs largely retained the identity and smoking practices from before their hospitalisation. This was acknowledged by many of the OSs as a discrediting identity that seemed at times to be the focus for health professionals to the extent that they were no longer visible as people who were suffering and in need of comfort and support. It is worth noting that, in some cases, ongoing smoking may be an attempt to retain or regain a ‘healthy’ identity, if being healthy means to be the way a person was before hospitalisation, to regain their ordinary lives after the unpleasant deviation of hospitalisation and illness. Resuming routines is an important aspect of the process of re-establishing ‘coherent embodied identities’ after serious illness (Shilling, 2008: 118). Ongoing smoking can also be an act of resistance or escape from increasingly unpleasant daily lives that were now characterised by increased medicalisation and in some cases pain and disability. When physical limitations were making it difficult for participants to engage in enjoyable or valued activities, smoking was a sensual and pleasurable practice that could still be undertaken.

For others, ongoing smoking had come to symbolise failure and their inability to pursue health despite a desire to do so. This was most apparent in the accounts of OSs who described unsuccessfully trying to quit smoking, many of whom also described feeling as though they had little or no control over illness and misfortune. Lawlor et al. (2003) in their argument about lay epidemiology and the failure of smoking cessation programmes among deprived populations make note of the relationship between higher rates of premature morbidity and mortality among disadvantaged populations and a reduced incentive to stop smoking. Our results suggest that in addition to reduced incentive, a lifetime of ‘hard knocks’ is likely to reduce an individual’s sense of agency related to smoking cessation.

We found that EXSs were less likely to have previously been hospitalised due to heart disease than the OSs. Research that compares smoking and quitting practices among people after their first admission with those who have previously been diagnosed and hospitalised for cardiovascular disease is needed. In future studies, it would also be useful to interview participants very soon after their hospitalisation and then follow them over time in a longitudinal interview design. Our data collection occurred in 2007/2008, and there have been several legislative changes in Australia relating to smoking such as the introduction of plain paper packaging that have occurred since that time. However, it seems unlikely that these changes would significantly alter the experiences of ongoing smoking or smoking cessation for long-term smokers such as those in our study apart from providing further evidence of the increased stigmatisation of smoking. Our sample made it difficult to explore gender differences, and as gender and identity are so closely tied, this is also likely to be fruitful area for future research.

Our findings are valuable because they successfully demonstrate the complex and highly social nature of smoking continuance and cessation among people with a tobacco-related disease. They also illustrate the importance of performance, identity and a desire to become healthy again for quitters and some of the ways that smoking is embedded in daily routines making smoking cessation difficult for many OSs. Research that allow smokers and EXSs to explain and reflect on their smoking practices reminds us of the complex and multifaceted aspects of smoking and cessation that are often missing in medical and public health research (McNaughton et al., 2012). Our findings also support existing research that shows the importance of significant health-related life crises and reinvention in processes of sustained behaviour change such as smoking cessation (Ogden and Hills, 2008).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Author biographies

Emily Christine Hansen is a sociologist whose areas of specialisation are medical sociology and qualitative research methods. She is a senior lecturer in sociology in the School of Social Sciences at the University of Tasmania.

Mark Raymond Nelson is Professor and Chair, Discipline of General Practice, and Senior Professorial Fellow, Menzies Research Institute, both at the University of Tasmania, and an Honorary Associate, Department of Epidemiology and Preventive Medicine, Monash University.

References

Alpert

Connolly

Biener

(2013) A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation. Tobacco Control 22(1): 32–37.

Bancroft

Wiltshire

Parry

et al . (2003) ‘It’s like an addiction first thing afterwards it’s like a habit’: Daily smoking behaviour among people living in areas of deprivation. Social Science & Medicine 56(6): 1261–1267.

Banwell

Young

(1993) Rites of passage: Smoking and the construction of social identity. Drug and Alcohol Review 12(4): 377–385.

Bell

McCullough

Salmon

et al . (2010) Every space is claimed: Smokers’ experiences of tobacco denormalisation. Sociology of Health & Illness 32(6): 914–929.

Butler

(1990) Performative acts and gender constitution: An essay in phenomenology and feminist theory. In: Case

S-E

(ed.) Performing Feminisms: Feminist Critical Theory and Theatre. Baltimore, MD: Johns Hopkins University Press, pp. 270–282.

Chapman

Mackenzie

(2010) The global research neglect of unassisted smoking cessation. PLoS Medicine 7(2): e1000216. DOI: 10.1371/journal.pmed.1000216.

Charmaz

(2006) Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. London: SAGE.

Cohn

(2014) From health behaviours to health practices: An introduction. In: Cohn

(ed.) From Health Behaviours to Health Practices: Critical Perspectives, Foundation for the Sociology of Health and Illness. Chichester: Blackwell Publishing. pp. 1–6.

Crawford

(2006) Health as a meaningful social practice. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine 10(4): 401–420.

10.

Critchley

Capewell

(2003) Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: A systematic review. Journal of the American Medical Association 290(1): 86–97.

11.

Dawood

Vaccarino

Reid

et al . (2008) Predictors of smoking cessation after a myocardial infarction: The role of institutional smoking cessation programs in improving success. Archives of Internal Medicine 168(18): 1961–1967.

12.

Finlay

(2002) ‘Outing’ the researcher: The provenance, process and practice of reflexivity. Qualitative Health Research 12(4): 531–545.

13.

Frohlich

Mykhalovski

Poland

et al . (2012) Creating the socially marginalised youth smoker: The role of tobacco control. Sociology of Health & Illness 34(7): 978–993.

14.

Graham

Hawkins

Law

et al . (2010) Lifecourse influences on women’s smoking before, during and after pregnancy. Social Science & Medicine 70(4): 582–587.

15.

Grbich

(2013) Qualitative Data Analysis: An Introduction. 2nd ed. London: SAGE.

16.

Hansen

Nelson

(2011) How cardiac patients describe the role of their doctors in smoking cessation: A qualitative study. Australian Journal of Primary Health 17(3): 268–273.

17.

Harman

Graham

Francis

et al . SWS Study Group (2006) Socioeconomic gradients in smoking among young women: A British survey. Social Science & Medicine 63(1): 2791–2800.

18.

Hockey

James

(1993) Growing up and Growing Old. London: SAGE.

19.

Katainen

(2010) Social class differences in the accounts of smoking: Striving for distinction? Sociology of Health & Illness 32(7): 1087–1101.

20.

Laurier

McKie

Goodwin

(2000) Daily and lifecourse contexts of smoking. Sociology of Health & Illness 22(3): 289–309.

21.

Lawlor

Frankel

Shaw

et al . (2003) Smoking and ill health: Does lay epidemiology explain the failure of smoking cessation programs among deprived populations? American Journal of Public Health 93(2): 266–270.

22.

Levin

Fundas

Miller

et al . (2014) Socioeconomic and geographic inequalities in adolescent smoking: A multilevel cross-sectional study of 15 year olds in Scotland. Social Science and Medicine 107: 162–170.

23.

McKenna

Higgins

(1997) Factors influencing smoking cessation in patients with coronary artery disease. Patient Education and Counseling 32: 197–205.

24.

McNaughton

Carro-Ripalda

Russell

(2012) ‘Risking enchantment’: How are we to view the smoking person? Critical Public Health 22(4): 455–469.

25.

Marteau

(2011) Judging nudging: Can nudging improve population health? British Medical Journal 342: 263–265.

26.

Miles

(2006) Neighbourhood disorder and smoking: Findings of a European urban survey. Social Science & Medicine 63(9): 2464–2475.

27.

NICE (2006) Smoking: Brief interventions and referrals. NICE Guidelines, March. Available at: https://www.nice.org.uk/guidance/ph1

28.

Ogden

Hills

(2008) Understanding sustained behaviour change: The role of life crises and the process of reinvention. Health 12(4): 419–437.

29.

Pampel

(2006) Socioeconomic distinction, cultural tastes, and cigarette smoking. Social Science Quarterly 87(1): 19–35.

30.

Parry

Fowkes

FGR

Thompson

(2001) Accounts of quitting among older ex-smokers with smoking-related disease. Journal of Health Psychology 6(5): 481–493.

31.

Plumridge

Fitzgerald

Abel

(2002) Performing coolness: Smoking refusal and adolescent identities. Health Education Research 17(2): 167–179.

32.

Poland

Frohlich

Haines

et al . (2006) The social context of smoking: The next frontier in tobacco control? Tobacco Control 15(1): 59–63.

33.

Quist-Paulsen

Gallefoss

(2003) Randomised controlled trial of smoking cessation after admission for coronary heart disease. British Medical Journal 327(7426): 1254–1257.

34.

Rahkonen

Laaksonen

Karrvonen

(2005) The contribution of lone parenthood and economic difficulties to smoking. Social Science & Medicine 61: 211–216.

35.

Rea

Heckbert

Kaplan

et al . (2002) Smoking status and risk for recurrent coronary events after myocardial infarction. Annals of Internal Medicine 137(6): 494–500.

36.

Rice

Ezzy

(1999) Qualitative Research Methods: A Health Focus. Melbourne, VIC, Australia: Oxford University Press.

37.

Rigotti

Clair

Munafo

et al . (2012) Interventions for smoking cessation in hospitalised patients. Cochrane Database of Systematic Reviews (5): CD001837. DOI: 10.1002/14651858.CD001837.pub3.

38.

Rooke

(2013) Harm reduction and the medicalisation of tobacco use. Sociology of Health & Illness 35(3): 361–376.

39.

Shah

Pfeffer

Hartley

et al . (2010) Risk of all-cause mortality, recurrent myocardial infarction, and heart failure hospitalisation associated with smoking status, following myocardial infarction with left ventricular dysfunction. American Journal of Cardiology 106(7): 911–916.

40.

Shilling

(2008) Changing Bodies: Habit, Crisis, Creativity. London: SAGE.

41.

Stuber

Galea

Link

(2008) Smoking and the emergence of a stigmatized social status. Social Science & Medicine 67(3): 420–430.

42.

Thompson

Pearce

Barnett

(2007) Moralising geographies: Stigma, smoking islands and responsible subjects. Area 39(4): 508–517.

43.

Veenstra

Burnett

(2014) A relational approach to health practices: Towards transcending the agency-structure divide. In: Cohn

(ed.) From Health Behaviours to Health Practices: Critical Perspectives, Foundation for the Sociology of Health and Illness. Chichester: Blackwell Publishing. pp. 31–42.

44.

Williams

(1998) Health as moral performance: Ritual transgression and taboo. Health 2(4): 435–457.

45.

World Health Organization (WHO) FCTC (2003) WHO Framework Convention on Tobacco Control. Geneva: WHO.