This study reveals the causes, underlying scenarios, and the role of personal environments regarding failure to maintain abstinence after smoking cessation. The major finding of this study is that the most important causes of a relapse are insufficient willpower and self-discipline and exposure to stress. Moreover, one’s smoking environment also plays a large role, as it is usually in the company of other smokers, while experiencing positive or negative emotions, that one relapses to smoking.
Insufficient willpower was the most commonly given reason for failure, although the participants also mentioned several other contributing factors. The former smokers needed strong willpower to overcome the initial withdrawal symptoms. After quitting smoking, former smokers experience anxiety, irritability, and a depressed mood at levels that are comparable to those experienced by psychiatric patients [42,43]. The former smokers realize that smoking a cigarette might relieve these unpleasant experiences; thus, some immediately succumb to this temptation and relapse to smoking. Of those who manage to overcome such unpleasant symptoms, some adopt an independent approach, using willpower (the so-called “cold turkey” method). Meanwhile, others use pharmacotherapy to reduce the severity of the symptoms; although such medications have various mechanisms of action, their end result comprises a reduction in physical withdrawal symptoms and a lack of reinforcing effects if one happens to smoke a cigarette during abstinence [11]. Thus, using medication increases the chances of maintaining abstinence by several times [44,45]. Through lessening withdrawal symptoms, pharmacotherapy makes it easier for former smokers to concentrate on making changes to their psychological and social behaviors. Unfortunately, however, pharmacotherapy is used too rarely in the process of smoking cessation [30,46]. Many smokers are not aware of or underestimate the efficiency of pharmacotherapy in relation to smoking cessation [47]. In general, the participants in the present study used only the cold turkey method and did not seek professional help; they also sporadically used nicotine replacement therapy; this approach has also been reported in earlier studies conducted in eight European countries [30]. Later, when the withdrawal symptoms abate, to combat cravings it remains necessary to exercise willpower in certain situations, mostly those in which the person would usually have smoked. Our results pertaining to the essential role of strong willpower in this regard are consistent with those of Shaheen et al., who examined young smokers in Pakistan, a low-income country [48].
Spending time in a smoking environment has a negative impact on former smokers as, in such environments, there is a lack of social support to abstain from smoking, high tolerance for smoking, and exposure to smoking cues [49–51]. The participants mentioned that they would not have recommenced smoking had they not spent time with smokers. Smoking cues that appear in situations in which former smokers would have previously smoked (which causes the cues to function as triggers) seem to have key meaning [20,52]. It is the response to these cues that ultimately causes one to smoke. Our respondents described experiencing such situations when they spent time among smokers. People with lower education levels and who have lower socio-economic status are more likely to smoke, meaning former smokers from these social groups are more frequently exposed to smoking cues. Previous studies have highlighted the significant influence of the smoking environment on the occurrence of relapses to smoking, particularly among former smokers with lower education levels and lower income [27,29,53].
The participants frequently emphasized that the attitude of their close social circle to smoking abstinence was a significant factor. Unfortunately, they had negative experiences in this regard, as having a spouse who smoked had a similar influence as spending time with other smokers – they were a source of stimuli to smoke. Lack of support from close social circles was listed as a reason for relapse; it also played a large role in the scenarios underlying such relapses. Similarly, several previous studies have also found that the smoking status of a former smoker’s cohabitants has a large influence on the success of the quitting attempt, as living with a smoker decreases the chance of successful smoking cessation [25,26].
On the other hand, support from non-smoking life partners and family members has been found to play a large positive role in successfully quitting smoking [54–56]. Further, living with a non-smoker or someone who has quit smoking in the past has a particularly beneficial impact [15,57].
Among our participants, a recurring problem mentioned in connection with relapsing to smoking was weight gain, which was perceived—especially by women—as a deterioration of their physical appearance. These observations are consistent with the results of studies by Memon et al., who showed that post-cessation weight gain promotes relapse. Moreover, these researchers showed that fear of unavoidable weight gain is also a barrier to attempting to cease smoking [58]. Thus, this appears to be a subject worth mentioning when preparing a smoker for smoking cessation. When there is a risk of such weight gain, an appropriate intervention should be provided, as gaining weight after smoking cessation means not only a change in one’s physical appearance, but also a higher risk of diabetes and hypertension [59].
In all interviews, the relapse scenarios mentioned involved contact with smoking environments. Social meetings were particularly frequently discussed. Prior to smoking cessation, the participants would frequently smoke during informal meetings; consequently, during the cessation attempt such meetings induced a sudden impulse to smoke. If the person did not have sufficiently strong willpower (which was occasionally weakened by alcohol consumption in such situations), relapse would occur. The connection between alcohol consumption and tobacco smoking has been known for a long time [60,61]. Specifically, drinking alcohol is connected with increased nicotine dependence, less frequent undertaking of smoking-cessation attempts, and a larger probability of relapse during smoking-cessation attempts [60,62,63]. When seeking to help smokers quit, it is worth keeping in mind that, in order to decrease the risk of a relapse, they should be advised to limit their alcohol consumption or to become temporarily entirely abstinent. Unfortunately, even after many years of abstinence a social meeting connected with alcohol consumption can constitute a relapse scenario [60].
Another finding was that stress plays a large role in unsuccessful smoking-cessation attempts. In our study, the participants frequently cited work-related stress as a trigger, which is consistent with reports from other studies [64,65] When stress is accompanied by a lowered mood, the risk of relapse increases [21,66]. For example, Cooper et al. demonstrated that the occurrence of depression in participants is connected with more frequent undertaking of smoking-cessation attempts; unfortunately, it is also a predictor of more frequent relapses [67]. Further, Zvolensky et al. also confirmed that affective factors play an important role in quitting attempts [22].
For former smokers, exposure to stress causes an urge to smoke in order to alleviate the associated unpleasant sensations, as this had been an effective strategy prior to smoking cessation. A frequent scenario underlying smoking relapse, contact with other smokers, is also associated with stress, as the urge to relapse was especially strong when the participants experienced stress while in the company of other smokers. Thus, stress at work and during critical situations can lead to a relapse, particularly when cigarettes are easily available. Interventions for improving one’s mood, especially among people with lowered mood, could be useful for preventing such a scenario [68].
Although a substantial majority of the participants did not use regular medical assistance in their smoking-cessation attempts, some discussed the role of physicians in smoking cessation. According to our participants, a physician can play a positive role, especially when they present to the smoker the consequences of tobacco smoking. However, to maximize the helpfulness of this advice, they should do so in an engaging manner, adapted for the given smoker. Wang et al. made similar observations in their studies; the respondents reported that health-care professionals who demonstrate sensitivity and true interest in helping the smoker represent notable sources of support when one is attempting to quit smoking [69]. Other studies have also highlighted the roles physicians and nurses can play in helping patients quit smoking [70–72]. This indicates that health-care professionals should seek to engage themselves in helping smokers quit, and should do so in a non-judgmental fashion, instead offering advice and support. This is particularly important when considering the effectiveness of anti-nicotine interventions and pharmacotherapy, which significantly increase the chance of successful smoking cessation [73–75]. In Poland, smokers can obtain anti-nicotine advice from general practitioners, but they have no access to smoking-cessation clinics, as no such institutions exist in many parts of the country [35]. Unfortunately, among European countries, smokers in Poland are least likely to use health professionals’ advice to quit; this especially contrasts with the situation in countries in which the smoking-reduction process began several decades ago [30]. Pharmacotherapy involving nicotine replacement therapy, bupropion, cytisine, and varenicline are available, but they are not covered by health insurance, unlike in some developed countries [30]. In practice, this means that the majority of smokers attempt unassisted cessation: the cold turkey method and reduction in cigarette use before quitting completely [76].