Do predictors of smoking relapse change as a function of
duration of abstinence? Findings from the United States,
Canada, United Kingdom and Australia
, Ron Borland
, K. Michael Cummings
& Timea Partos
Nigel Gray Fellowship Group, Cancer Council Victoria, Melbourne, Australia,
Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina,
Charleston, SC, USA
and Department of Addictions, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, UK
To estimate predictors of time to smoking relapse and test if prediction varied by quit duration.
Longitudinal cohort data from the International Tobacco Control Four-Country survey with annual follow up
collected between 2002 and 2015.
Canada, United States, United Kingdom and Australia.
total of 9171 eligible adult smokers who had made at least one quit attempt during the study period.
Time to relapse was the main outcome. Predictor variables included pre-quit baseline measures of
nicotine dependence, smoking and quitting-related motivations, quitting capacity and social inﬂuence, and also two
post-quit measures, use of stop-smoking medications and quit duration (1–7 days, 8–14 days, 15–31 days,
1–3months,3–6months,6–12 months, 1–2 years and 2+ years), along with socio-demographics.
were predictive of relapse within the ﬁrst 6 months of quitting but only wanting to quit, quit intentions and number of
friends who smoke were still predictive of relapse in the 6–12-month period of quitting [hazard ratios (HR) = 1.20,
P < 0.05; 1.13, P < 0.05; and 1.21, P < 0.001, respectively]. Number of friends smoking was the only remaining predic-
tor of relapse in the 1–2 years quit period (HR = 1.19, P = 0.001) with none predictive beyond the 2-year quit period. Use
of stop-smoking medications during quit attempts was related negatively to relapse during the ﬁrst 2 weeks of quitting
(HR = 0.71–0.84), but related positively to relapse in the 1–6-month quit period (HR = 1.29–1.54). Predictive effects of
all factors showed signiﬁcant interaction with quit duration except for perceiving smoking as an important part of life, pre-
maturely stubbing out a cigarette and wanting to quit.
Among adult smokers in the United States, Canada,
United Kingdom and Australia, factors associated with smoking relapse differ between the early and later stages of a quit
attempt, suggesting that the determinants of relapse change as a function of abstinence duration.
Keywords Adult smokers, duration of abstinence, predictors, smoking relapse, survival analysis, time-varying effects.
Correspondence to: Hua Yong, Nigel Gray Fellowship Group, Cancer Council Victoria, 615 St Kilda Road, Melbourne VIC 3004, Australia.
Submitted 14 June 2017; initial review completed 10 October 2017; ﬁnal version accepted 29 January 2018
Tobacco control efforts have been remarkably successful
at encouraging smokers to try to quit , but have been
far less successful in helping them to maintain
abstinence. The most recent Cochrane review concluded
again that there is little that prevents longer-term
relapse from attempts to quit smoking, although some
behavioural interventions and long-term use of a nicotine
replacement show promise . Most past research has fo-
cused upon encouraging smokers to make quit attempts.
Based on the now well-established understanding that
factors associated with making quit attempts are not
necessarily the same as those associated with quit main-
tenance [1,3], recent efforts have shifted towards under-
standing what might prevent smoking relapse among
those who try. Identiﬁed predictors of relapse include nic-
otine dependence , smoking and quitting-related moti-
vations [1,5], low self-efﬁcacy , social inﬂuences 
and not using smoking cessation aids . It is estimated
that even with help approximately 85% who quit suc-
cessfully will relapse to smoking within a year , and
even after prolonged periods of abstinence relapse is still
possible, underscoring the need to understand not just
© 2018 Society for the Study of Addiction Addiction, 113,1295–1304