“Like you are fooling yourself”: how the “Stoptober” temporary abstinence campaign supports Dutch smokers attempting to quit

We conducted a qualitative study shortly after the 2016 Stoptober program in the Netherlands ended. We retrospectively interviewed a sample of participants to understand the campaign’s working mechanisms [10], including how the program’s components had or had not brought about the intended effects based on the three key theoretical principles. We held semi-structured interviews and performed a thematic analysis [11]. We followed the criteria for reporting qualitative studies (COREQ).

More than 53,000 individuals subscribed to the 2016 Dutch Stoptober. Respondents for our study were recruited by convenience sampling through both the program’s Facebook page and email at the end of October and the beginning of November to avoid interference with the simultaneous effect study [6]. Participants were asked to contact the first author [ST] if they were willing to take part in an interview about their experiences during campaign and if so, they would receive a gift voucher of 20 euro. Participants were approached in an open, non-normative way, especially with regard to their success or failure in the campaign. In general, 20 to 25 interviews are sufficient to reach information saturation [12]. Therefore, we stopped recruitment after 24 interviews were scheduled. Most respondents had approached us via the Facebook solicitation. Since one interview was cancelled due to logistics, the final sample included 23 Stoptober participants.

The first author [ST], a female doctoral student with a Master of Science degree trained in qualitative research methods, conducted the interviews in November (n = 17) and December 2017 (n = 6), at a location of the respondent’s choice: participant’s home (n = 18) or workplace (n = 3), researcher’s office (n = 1), or a café (n = 1). Before the start of each interview, the interviewer tried to establish rapport by making small talk and having a coffee. The interviewer did not have a prior relationship with the participants. No third persons were present during the interviews. Most respondents were female, 30–60 years old, and first-time participants in Stoptober (Table 2). Before the campaign, respondents typically smoked about a one pack of cigarettes a day. Two respondents relapsed during Stoptober and two others relapsed after Stoptober. About half of the sample had used additional support to stop smoking (e.g. varenicline, nicotine replacement therapy, e-cigarettes).

Semi-structured interviews were chosen to allow participants to express their experiences and ensure the main research themes were addressed [13]. The interview guide included topics such as current smoking status, Stoptober’s role in the attempt to quit, experiences with specific program components, changes in psychosocial determinants of smoking (i.e., attitude, social norms, social support, self-efficacy, habit and identity), expectations regarding future smoking status, and ideas for improving Stoptober. An English version of the interview guide is provided in Additional file 1. Interviews lasted between 20 and 60 min (average 45 min). The interviews were audiotaped after receiving consent from the respondents and were transcribed verbatim.

The interviews were thematically analyzed [11] in MAXQDA [14]. First, ST and JH individually coded two “rich” interviews. They used the interview guide as a foundation for the analysis, but open coding was also allowed. Based on their findings, codes were added for program components and coping strategies. Second, ST systematically coded all other interviews with the final coding scheme (Table 3). All coding by ST was checked by JH. Third, ST summarized the main findings per theme. Finally, ST and JH categorized these findings into the three key theoretical principles of Stoptober (i.e., social contagion theory, SMART goals, and PRIME theory). Additional file 2 reflects the categorization part of the data analysis. Disagreements were discussed until consensus was reached.

The Stoptober message was spread throughout the Netherlands with high intensity through various traditional and new mass media channels. Our respondents typically explained how this social contagion strategy had familiarized them with the program and motivated them to participate.

Before the campaign you frequently saw commercials on the television with the announcement that Stoptober was coming up. And [ … ] because I saw it so often, I thought: “This might be something, should I participate or not?” And eventually, after seeing it several times, I thought: “Let’s just try it, I will do it.” [R02]

It makes you think about it. [ … ] I saw that many people had registered. It would be a nice stimulus, a good moment. [ … ] So many smokers are going to quit, so I should be able to succeed again too. [R07]

These accounts also indicate how the mass media approach may have contributed to the normalization of smoking cessation and strengthened the respondents’ social support and self-efficacy to quit.

Many respondents explained how the SMART goal set by Stoptober had assisted them in their current attempt to quit. For instance, they mentioned that appointing October as the month to stop smoking collectively had made it easier for them to set a quit date and the defined quit period of 28 days had made their attempt look more achievable.

And the date. You often try to set a date. Most people do it [try to quit] at New Years. But we just didn’t have a date anymore because we’d tried so many times already. [ … ] With New Years, you don’t participate together with so many others. [R18]

Look, you can always give it a try. It’s a month, it is not like you are quitting entirely, because then you would dread it. You would feel stressed and think: CIGARETTE!!!. This is ideal. [R02]

Although experienced as improving their self-efficacy at the start, respondents also stated that at some point in time, they had realized their temporary quit goal was only a trick to distract themselves from the ultimate goal of quitting for good.

It’s just like you are fooling yourself, actually. It is quitting for 28 days, with the idea: “After 28 days I can smoke again”, and that is what makes you hold on. [ … ] [But] eventually you realize that quitting for 28 days, well, you don’t accomplish anything with that. [Because] it’s temporary. [R19]

The respondents’ reports clearly illustrate how the variety of support offered by Stoptober (in line with PRIME theory) had supported them in their attempt to quit by allowing them to make an individual selection based on their personal needs and preferences. “You use whatever suits your needs.” [R12] For example, while some respondents thought the Stoptober app had been most supportive, others found that the Stoptober Facebook page had offered the best help.

I have to say, that [the app] really works. You get notifications like “you saved this much [money]”, “you have received this badge” or “you can taste better now”. [ … ] And it was true and it made me think: “YES, let’s go for the next one. For me, that was a great tool”. [R15]

For me the stories on Facebook were of greater use. So, they [Stoptober] posted a message [on the Facebook page]. Many people reacted to this, and from that you could read: “Well, they are also going through a difficult time”. [ … ] And when some said: “I smoked a cigarette”, others would say [ … ]: “Don’t worry, never mind, just keep on going”. [ … ] It is really nice, because you can share [experiences]. [R14]

These accounts indicate that the Stoptober app primarily served as a self-monitoring tool, while Facebook mainly provided a platform for exchanging experiences, making social comparisons, and providing and receiving social support.

Respondents frequently made use of additional pharmacological, behavioral or social support during the campaign (Table 2), however they still reported a need for further support from Stoptober during and after the campaign.

The respondents reported that their needs changed over time and the support did not adapt accordingly. For instance, some respondents explained that the frequent posts from Stoptober that had been helpful at the start, gradually became counterproductive to their attempt to quit, since the posts reminded them too much of smoking.

At a certain point, I felt that it [the Stoptober posts] worked negatively. [ … ] In the beginning you are always thinking of smoking. You don’t want that anymore. And when you think of smoking less and less, you receive messages on smoking cessation once in a while. So [ … ] after three weeks, I thought: “No, [..] not all those pop-ups and notifications.” I switched them all off. [R03]

Another incongruity was reported when about halfway into the campaign, Stoptober started to communicate through the app that the participants had (almost) achieved cessation, while the respondents stated that for most of them, this was not yet the case.

But, after that I realized that Stoptober was like: “Yes, you did it, already two weeks!” [ … ] I saw that people were quite angry about this. [ … ] The addiction is gone, but if I think of how strong that thing is what’s still in your head. That is real too. I think that maybe people, [ … ] maybe also Stoptober [ … ], underestimate how strong that part still is. [R17]

The respondents reported a need for adjusted support, for instance by offering a broader variety of announcements, feedback messages and role-model stories, or including more interactive and personal elements.

A bit more interaction. [ … ] That [Stoptober] will make itself heard a bit more, except for posting a message. Also replies on all responses. Will enter into debates. [ … ] That they will react with positive feedback or advice. [R08]

Yes [the emergency button of the app], did not help very much. But, I wouldn’t know how to change it. That’s really difficult right? I would prefer having someone [a real person] jump out and saying: “DON’T DO IT!” [laughter]. [R21]

Respondents also referred to additional social network components. While some suggested connecting Stoptober to other online social networks (e.g. Instagram), more prominent were the respondents’ desires for additional offline social networks.

Find people within Stoptober with whom you can talk before or after. [ … ] I think that this will also be a motivation for people to remain abstinent. [ … ] I would have liked it if there was an activity nearby for people who had also quit smoking. [ … ] In that way, you get to know someone and can support each other. [R05]

I participated last year too, then I did not succeed. [ … ] So, I went looking, beforehand. [ … ] How nice would it be to quit together with others? [ … ] A colleague of mine, [ … ] was also thinking about it [quitting]. I thought, well then, let’s just organize it collectively for all coworkers. That went really well. We have all quit smoking. [R20]

This need for offline social networks was explained by the lack of social support and the strong pro-smoking social norm that respondents mostly experienced from their personal social networks.

I’m far away from my family here. I don’t speak to them daily or weekly. Also, with friends, [ … ] I told them I quit, but many of them still smoke and they don’t think of stimulating, motivating or supporting me. It’s more like they think, well … [ … ] So, something is lacking from my direct environment. [R02]

I don’t have someone close to me that makes me think: “That one is going to pull me through it.” You understand? Intensive counselling or something. I really need someone. [R06]

Respondents typically expressed the need for continued support after the campaign. This need manifested once they realized that the trick of Stoptober’s SMART goal was no longer effective, given their personal goal of quitting for good.

I believe that those 28 days, those were the starting point, also for me. But well, you cannot expect it all to be gone afterwards. But, it is true that the physical part is over then, all discomforts, that is true. [R17]

But, afterwards it feels like going into the deep end. [ … ] Why don’t they continue? Why that month? That is just not smoking for a month and lighting your cigarette again afterwards. And hoping that people won’t do that. No, you have to push through then! [R08]

These accounts indicate that the SMART goal had indeed contributed to the respondents’ self-efficacy, but it was not sufficient for most of them to continue as a non-smoker on their own.

Respondents suggested three types of continued smoking cessation support. First, the current Stoptober support could be prolonged, for example by continuing with the app, Facebook and related activities after the campaign.

The Stoptober app should continue. I have another app like that and that one keeps counting how long you have been abstinent, how many cigarettes, how much money you saved. [ … ] I would certainly do that. [R08]

Second, respondents illustrated how Stoptober participants could continue to support each other after the campaign through the online or offline social networks they had established during the campaign.

Someone started a private [Facebook] group: We quit smoking 2016. 539 members. There are also posts. Well, then you read those messages. It just helps. It is really useful. [R03]

Third, respondents thought Stoptober could connect to regular smoking-cessation services and stimulate participants to make use of available follow-up support, such as individual counseling or group support.

And I think that if you, at that moment, use a powerful tool, like: “Listen everyone, well done, keep holding on”. That you give a good follow up. [ … ] That you get some more advice: “Here you can sign up for this training”. Very practical tools. [R20]

Despite their critical remarks and suggestions for improvement, in general, respondents believed that in line with social contagion theory, Stoptober could play an important role in the normalization of smoking cessation.

I think the initiative is good, because [smoking] is a problem and it is good that there is an official organization stepping forward that helps people [with smoking cessation], because if it is just constantly tolerated and accepted [ … ]. It is good to have this wake-up call. [ … ] [R20]

Our retrospective interviews with Stoptober participants indicate that the temporary abstinence campaign largely functioned according to its theoretical principles. Program components built on social contagion theory familiarized respondents with Stoptober and motivated them to participate, the SMART principle points embedded in the program assisted them to set an achievable intermediate goal, and the variety of support offered in line with PRIME theory helped them to succeed with their temporary attempt to quit. However, once Stoptober was over, follow-up support was needed to overcome the enduring challenge of smoking cessation and becoming a permanent non-smoker.

The main limitation of this study is the selectiveness of the study sample. Most respondents managed to remain abstinent during Stoptober and only two relapsed after the campaign had ended. Although the high abstinence rates in our sample seem to contrast with real life smoking cessation attempts [15], they most likely reflect the high three-month quit rates in our quantitative evaluation of Stoptober [6]. The high number of successful quitters in our study sample could have caused our respondents’ accounts to be overly positive towards Stoptober and the support they had received. However, we observed that our respondents were willing to express criticism about the campaign and the available program support, regardless of their current smoking status. Nonetheless, using quota sampling to include additional respondents who had not remained abstinent during or shortly after Stoptober could have revealed other information on campaign limitations.

Second, in correspondence with the quantitative evaluation of Stoptober [6], most of our respondents were female (20 females out of 23 respondents). Male participants may have had other perspectives on Stoptober. Literature indicates that females are generally less successful in quitting smoking compared to males [16]. It is suggested that females might need additional behavioral counselling to address mood variability, environmental cues and social support [16]. This may have caused our female respondents to express a relatively high need for these types of support.

Third, respondents were primarily recruited via a call on the Stoptober Facebook page. This may have caused an overrepresentation of participants who used Facebook as their main source of support. Nonetheless, our sample also included a number of respondents who admitted not being frequent Facebook users and who preferred the Stoptober app or other measures as a way to receive support and remain abstinent.

Our results indicate that the Stoptober campaign functioned largely according to its theoretical principles. In theory-based evaluations, illustrating an intervention’s working mechanisms may count as additional support for its effectiveness [10]. This type of evidence can be especially important for national programs, such as Stoptober, that cannot be properly evaluated in controlled study designs. Added to available evidence [5, 6], our results support the continuation and wider implementation of the Stoptober campaign.

Our results illustrate how Stoptober’s SMART principle supported smokers to stay abstinent for a defined period of time. This is in accordance with Bandura’s theory [18], which explains that behavior change can be facilitated through increased self-efficacy by setting achievable goals for a graded task over a graded time interval. Hence, Stoptober may be seen as a valuable first step in becoming a non-smoker, since accomplishing a temporary attempt to quit has been found to noticeably increase both self-efficacy [6] and the chance of quitting for good [5]. However, after the campaign, our respondents tended to regard Stoptober’s temporary quit goal as “fooling yourself”, since they were confronted once again with their (still difficult) personal goal of quitting for good. Since permanent abstinence is typically the reason smokers participate in the campaign [17], and longer term support is generally needed to achieve that goal [19], we present the respondent’s suggestions for how to strengthen the impact of Stoptober below.

A first suggestion builds on social network theory. So far, Stoptober successfully applied this principle to create a mass quit attempt [5] and create an online platform for social comparison and social support (this study). In line with our respondents, studies on online smoking cessation support suggest that face-to-face contacts may have added value for remaining abstinent [20, 21], especially for smokers who lack social support in their own social circle [22]. To establish such contacts, Stoptober could encourage participants to use their current social networks to stop smoking collectively (e.g. together with work colleagues) or facilitate participants building an additional social network (e.g. through local Stoptober meetings).

Two other suggestions are built on PRIME theory. In line with our respondents, studies on online or smartphone based smoking cessation interventions [22‐26] suggest that improving the interactivity and tailoring of support could further increase Stoptober’s effectiveness. Our respondents also suggested that promoting local smoking cessation services could help Stoptober participants to overcome barriers to using these services [27] and increase the likelihood of taking advantage of professional support.