p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e6
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Heavy dependent nicotine smokers e Newfound lifestyle appreciation after quitting successfully. Experiences from inpatient smoking cessation therapy €hm a,c, Y. Schroeder b,d R. Schoberberger a,*, G. Bo a b
Institute of Social Medicine, Center of Public Health, Medical University of Vienna, Vienna, Austria Department of Finance, Faculty of Business, Economics and Statistics, University of Vienna, Vienna, Austria
article info
abstract
Article history:
Objectives: This is an evaluation of an ongoing inpatient smoking cessation program
Received 1 April 2014
available in Austria and aims to show to what extent even heavy nicotine dependent
Received in revised form
smokers can benefit from a three-week inpatient therapy.
12 January 2015
Study design: A particular focus lies on analyzing the benefits and changes in lifestyle and
Accepted 1 February 2015
sense of well-being.
Available online xxx
Methods: 270 initially heavy nicotine dependent smokers are observed for a one year period consisting of recruitment, therapy and two post-therapy follow-up visits; post program
Keywords:
smokers are compared to post program ex-smokers.
Nicotine dependence
Results: 12 month post-therapy, 42.6% of participants are identified by carbon monoxide-
Inpatient smoking cessation
verifications as ex-smokers, 34% as smokers and the remaining did not attend follow-up
Lifestyle
visits. Significant changes in lifestyle satisfaction are reported by ex-smokers compared
Quality of life
to still smokers. Conclusions: Convincing heavy dependent nicotine smokers that significant changes in lifestyle satisfaction can be expected as part of a successful cessation process should lead to enough motivation for these individuals to seek such inpatient smoking cessation program. © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Smoking leads in 70e80% of cases to nicotine dependence1 and is a risky behavior jeopardizing one's health. It is
estimated that annually in Austria 11,000 people die prematurely due to smoking related illnesses.2 The degree of nicotine dependence and level of addiction,3 experience of withdrawal symptoms as well as personal
* Corresponding author. Tel.: þ43 1 40160 34887; fax: þ43 1 40160 934886. € hm), E-mail addresses: [email protected] (R. Schoberberger), [email protected] (G. Bo [email protected] (Y. Schroeder). c Tel.: þ43 1 40160 34888; fax: þ43 1 40160 934889. d Tel.: þ43 1 4277 38267; fax: þ43 1 4277 838267. http://dx.doi.org/10.1016/j.puhe.2015.02.011 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Schoberberger R, et al., Heavy dependent nicotine smokers e Newfound lifestyle appreciation after quitting successfully. Experiences from inpatient smoking cessation therapy, Public Health (2015), http://dx.doi.org/ 10.1016/j.puhe.2015.02.011
2
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e6
characteristics differs from individual to individual. Many smokers want to quit, but the irritability, anxiety and depression they feel when not having smoked for a while pose a major barrier.4 For some, this psychological distress experienced as part of the quitting process might be a challenge.5 Often the more determining factor in the continuation of smoking is the strong dependence to nicotine itself.6 In spite of experiencing tobacco associated diseases or their own committed, genuine effort to quit, some nicotine consumers are unable to stop smoking on their own.7 In addition smokers with heavy nicotine dependence show additional unhealthy behaviors: they tend to consume unhealthy food and alcohol more frequently, are less physically active and experience more challenges when trying to quit.1,8 As a result and to accommodate particularly heavy dependent nicotine smokers, an inpatient smoking cessation program was started over 10 years ago in Austria.9 Although such therapies are not available on a nationwide basis, they are seen as an important option in becoming smoke free particularly for this group of smokers.10
based on patients having completed the program at Kuranstalt Linzerheim, the additional therapeutic and in-patient services offered at this location are listed in Table 1.13 Then, after completing the three week program, patients have to attend two follow-up (f/u) meetings at six months intervals; voluntary monthly (jour fixe) meetings are also available. The same standardized questionnaire as in the recruitment step is used at both f/u's which allows capturing possible changes. Thus, analysis of these questionnaires is the basis for assessing program successes. The program is only available to a special group of tobacco consumers, to those who require focused, specialized attention due to their pronounced nicotine dependence and resulting poor health. Although inpatient smoking cessation programs are rather rare they tend to treat heavy nicotine dependent smokers more frequently.14 In fact, such programs cater to the specific needs of this group of smokers. Moreover the effect of treatment on smoking cessation depends on nicotine dependency levels meaning that heavy smokers are most successful with comprehensive interventions than minimal ones.15,16
Sample
Methods Inpatient smoking cessation therapy The inpatient smoking cessation therapy starts with a specific selection process in which participants are identified based on their personal situation, health and level of nicotine dependence. Essential inclusion factors for the three week inpatient € m Test for smoking cessation program are a FTND (Fagerstro Nicotine Dependence)-Score 5, a CO-value 20 ppm and the earnest desire to quit smoking completely. Exclusion criteria are an ongoing treatment for a psychiatric disorder or an existing dependence on alcohol or other drug. In addition, parts of the FEG questionnaire by Dlugosch and Krieger11 are utilized to capture participants' satisfaction with their own lifestyle as well as lifestyle choices, attitude and behavior concerning health and diseases.12 In particular, questions concerning satisfaction and consequences for health with respect to nutrition, physical activity, alcohol consumption, smoking, medication, sleep and well-being are included. Additionally, the questions to ‘Dealing with health and disease’ and ‘Physical complaints’ are utilized. Week one focuses on behavior based elements; smoking is still permitted. Nicotine replacement therapy is available upon request. The smoke free period starts with week two. At this point patients have to undergo carbon monoxide (CO) testing to confirm nicotine abstinence. Teaching and exposing participants to existing alternatives to smoking and analyzing triggers most likely to occur in daily life are a focus of this week. Strengthening the positive image of oneself as a nonsmoker is the goal of week three. Two institutions in Austria offer such a program, the Grazer Gesundheitseinrichtung ‘Josefhof’ belonging to the insurance company for Austrian Railways and Mining Industry and the Kurheim Linzerheim in Bad Schallerbach, an institution of the Sick Fund of Upper Austria. As this program evaluation is
Between October 2003 and December 2011, 270 participants completed the inpatient smoking cessation program at Kurheim Linzerheim. Description of the sample is shown in Table 2. In most aspects gender differences were not found because this was not the main interest of the study there is only a short descriptive comparison between men and women in Table 2. Based on recruitment process and aim of program, participants attending the inpatient smoking cessation program differ significantly from the average Austria population (AP) in terms of nicotine dependence, resulting smoking behavior and smoking related illnesses. Inpatient program participants smoke on average 31.9 cigarettes per day (AP ¼ 18.3 cigarettes per day).17 23.7% started to smoke at very young age - prior to the age of 15 years (AP ¼ 10%). Moreover, in terms of heavy nicotine dependence inpatient smoking cessation program participants reach high CO-values (average of 24.9 ppm) and FTND values (average 7.25). In contrast, an Austrian representative study reports a FTND value of 3.59 in smokers.3 63% of participants have been diagnosed with diseases to the respiratory system, 47.4% to the cardiovascular system, 28.9% show metabolic diseases, and 28.9% show other illnesses (multimorbidity occurring).
Table 1 e In-patient services. Additional care available Medical care Psycho-social care Psycho-social one-on-one counseling Cardiovascular training (such as Nordic walking, ergometer training, gymnastics) Breathing exercises Relaxation training & stress management Nutritional advise & cooking classes Physical therapy & massages Biofeedback
Hours Based on need 21 h >1 h 21 h 7.5 h 10 h 3h 1h Based on need
Please cite this article in press as: Schoberberger R, et al., Heavy dependent nicotine smokers e Newfound lifestyle appreciation after quitting successfully. Experiences from inpatient smoking cessation therapy, Public Health (2015), http://dx.doi.org/ 10.1016/j.puhe.2015.02.011
3
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e6
Table 2 e Description of the sample. Average age in years Average body mass index in % Occupation in % Employed (active workforce) AMS (Public Employment Services Austria) Household/housewife Pension/retired No information available
Men
Women
50.67 27.31
53.16 25.68
52.0 8.0 0 27.3 12.7
33.3 7.5 5.0 45.8 8.4
Table 3 e Inpatient smoking cessation program: Comparing carbon monoxide (CO)-values of successes and failures at three different time periods.
Recruitment CO-value 6 month follow-up CO-value 12 month follow-up CO-value
Post program ex-smoker
Post program smoker
No data available
N
24.3 ppm
25.9 ppm
44.8%
28.9%
26.3%
199
2.7 ppm 42.6%
21.4 ppm 34.0%
23.4%
207
1.4 ppm
18.5 ppm
270
Analysis/evaluation Data collection occurred at three different time periods (recruitment and f/u visit six months and 12 months post program completion) utilizing the same standardized questionnaire which were analyzed using SPSS (version 20.0). Averages and frequencies were measured via descriptive analysis. Comparison between ex-smokers (successful participants) and smokers (less successful participants) of factors such as lifestyle, as well as physical ailment was done via a non-parametric Wilcoxon signed-rank test. BMI, FTND and number of smoked cigarettes were analyzed via t-test and Chi-square test. Additionally, to evaluate program success results from the Vienna Standardized Smokers Inventory,18 the FTND as well as the CO-measurements were utilized.
Results Data availability for analysis: of the 270 participants who had completed the program, 199 attended the first f/u visit six months post program completion and 207 the second f/u 12 months post program completion. Important results are shown in Table 3. Based on the standardized FEG questionnaire11 utilized, participants' satisfaction with their own lifestyle and the anticipated impact or effect of certain lifestyle choice on health are presented in Figs. 1 and 2. Prior to the start of the inpatient smoking cessation program, almost all participants (86.4% of post program exsmokers and 88.7% of post program smokers, P ¼ 0.781) reported to be unhappy or dissatisfied with their tobacco consumption. This reduced significantly in ex-smokers to 5.1% at f/u 1 and 2.4% at f/u 2 (P ¼ 0.000). Throughout observation no significant change in such attitude was observed in smokers. Moreover, at recruitment participants also reported to be aware of the negative consequences smoking had on their health and well-being (96.6% of ex-smokers and 98% of smokers, P ¼ 1.000). This changed to 14.6% at f/u 1 (P ¼ 0.000) and 12.5% at f/u 2 (P ¼ 0.000) in ex-smokers who still felt negative consequences of their former smoking behavior. In smokers - the perceived effect of tobacco consumption on health remained rather high (82.3% at f/u1 and 87% at f/u 2). Moreover, many of the participants, although less exsmokers than smokers, reported at recruitment to be dissatisfied with their sense of well-being (50.9% vs 70.2%, P ¼ 0.068) and that such posed further challenges to their health (62.5%
of ex-smokers, 60.8% of smokers, P ¼ 0.193). 12 months post program completion, ex-smokers expressed a higher sense of well-being; significantly fewer patients reported to feel dissatisfied (16.7% at f/u 1 and 15.7% at f/u 2; P ¼ 0.000). These results are in line with the findings that 12 months after therapy only 10.4% (f/u 1) and 8.7% (f/u 2) of ex-smokers believed in the negative effects an inpatient smoking cessation therapy can have on their health (P ¼ 0.000). No statistically significant changes were observed in the group of post program smokers. Similar results are available in terms of sleep. At the start of therapy almost half of all participants (44.2% of ex-smokers, 60.0% of smokers, P ¼ 0.119) stated to be dissatisfied with their sleep pattern fearing negative consequences in terms of health outcomes. Throughout both f/u visits a significant reduction of such unhappiness was found in ex-smokers but remained the same in smokers. At f/u 2, 55.6% of smokers still believed that the amount and poor quality of sleep negatively influenced their health and well-being; in ex-smokers this was the case in only 21.7% (P ¼ 0.015). Prior to starting the smoking cessation program, smokers were much more displeased with their level of physical activity (PA) compared to ex-smokers (80.8% vs 51.9%; P ¼ 0.003). Throughout the 12 month observation period, this dissatisfaction decreased to 60% in smokers, although not at a significant level. Significant were the findings for ex-smokers however. Within this group only 25% (P ¼ 0.012) reported to still feel unhappy about their level of PA. At recruitment when asked to estimate the effects of PA on health, almost three quarter of participants strongly believed that an increase in the level of PA would have a positive effect on health. Initially, roughly 50% of ex-smokers believed for this to be the case (P ¼ 0.010). In both groups a reduction in such attitude was observed at f/u 2; a significant one in ex-smokers and small, non-significant one in smokers (19.6% compared to 47.6%; P ¼ 0.004). Stress management and relaxation techniques are a big component of the inpatient smoking cessation program. Prior to the start of the program almost one-third of participants (27.3% of ex-smokers and 34.5% of smokers, P ¼ 0.438) reported being able to manage stress without (frequently) suffering poor health outcomes. The f/u visits revealed that over time, more and more former smokers seemed able to develop healthier stress management techniques; this group no longer relied on nicotine to cope with stress or other
Please cite this article in press as: Schoberberger R, et al., Heavy dependent nicotine smokers e Newfound lifestyle appreciation after quitting successfully. Experiences from inpatient smoking cessation therapy, Public Health (2015), http://dx.doi.org/ 10.1016/j.puhe.2015.02.011
4
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e6
Fig. 1 e Subjective changes of dissatisfaction in terms of various lifestyle factors experienced by inpatient smoking cessation therapy participants. Successful (post program) ex-smokers are compared with less successful (post program) smokers at recruitment, six month and 12 month post-therapy follow-up (F/U).
unpleasant emotions (f/u 1 32.3%, f/u 2 36.5%) (P ¼ 0.047). In spite of being a therapy component, such success wasn't observed in still smokers. No significant group differences concerning dissatisfactions or estimates of negative effects on health were found with respect to eating habits and alcoholism. No gender differences were detected.
Discussion Regardless of what success rate participants complete during an inpatient smoking cessation program, the initial dread seems to be the same in almost every smoker. Many fear significant disadvantages or drawbacks such as increased anxiety, irritability, fear of failure,5 difficulty concentrating, and increased appetite19 prior to even starting such a program which is often grounded in confusion, misinformation, and
angst. These findings show however that 12 months post program completion, less than 10% of ex-smokers believe that an in-patient smoking cessation therapy has a negative effect on one's health, the opposite seems the case - such encouraging, supportive environment seems to assist in the cessation process.5 Smokers often smoke to cope with stress, calm nerves or aid relaxation.4,20 Due to the stress management component in the program it was shown that ex-smokers increase their ability to handle stress without having to reach for a tobacco product. In terms of program successes 40% of participants manage to successfully quit (identified as non-smokers at f/u 1 and 2) their tobacco consumption. Similar to findings from other research, e.g. Piper et al.21 post program ex-smokers who successfully manage to quit their tobacco consumption report an increased feeling of well-being, vitality, and health compared to individuals who continue to smoke. 84.3% of initially heavy nicotine
Fig. 2 e Subjectively assumed negative influence of various lifestyle factors on health as reported by inpatient smoking cessation therapy participants. Successful (post program) ex-smokers are compared with less successful (post program) smokers at recruitment, six month and 12 month post-therapy follow-up (F/U). Please cite this article in press as: Schoberberger R, et al., Heavy dependent nicotine smokers e Newfound lifestyle appreciation after quitting successfully. Experiences from inpatient smoking cessation therapy, Public Health (2015), http://dx.doi.org/ 10.1016/j.puhe.2015.02.011
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e6
dependent smokers who became successful non-smokers after completing the inpatient smoking cessation program, and who remained smoke free throughout the f/u visits, report of such significantly improved sense of well-being. This also includes declined restlessness and better stress management techniques, supporting findings from Schlam et al.22 Similar to preprogram, the majority of still smokers report a continued impairment of their well-being. Post program smokers are not able to experience changes to their sense of well-being agreeing with findings from Taylor et al.’s4 systematic review that quitting smoking is associated with significant improvements in psychological quality of life. Such possibility should give reason and encouragement to quit smoking. The real power of the findings lies perhaps in: educating current heavy smokers about the health gains to be expected as non-smokers; correcting commonly held misunderstanding about unfounded fear and worry; using this knowledge to highlight and empower smokers in their undertaking which is not an impossible task; and re-emphasizing health benefits in terms of their diseases. In this study the authors forego the use of a ‘proper’ control group; they understand the limitations of this decision. The positive effects and health benefits experienced by post program non-smokers are compared to those of post program smokers who did not manage to remain smoke-free after completing the three week inpatient smoking cessation program, thus they focus on evaluating the program. Based on ethical reasons they can't justify a time and resource intensive recruitment process to identify smokers who have developed severe illnesses and diseases related to their tobacco consumption to then randomly place a portion of these individuals into a control group. Furthermore, comparing the group to average smokers from the population doesn't really make much sense. Using the average smoker as comparator wouldn't underline the findings as these are, after all, specific to the group of smokers - the inpatient smoking cessation program participants. The three week inpatient smoking cessation program available in Austria offers even for the most heavy nicotine dependent smoker possibility of reaching tobacco abstinence. Successful quitters experience a significant increase in satisfaction of life and well-being compared to program participants unable to quit smoking.
Author statements Acknowledgements The authors wish to acknowledge and thank the team of the Sick Fund of Upper Austria who, with great commitment, carry out the inpatient smoking cessation program at the Kurheim Linzerheim, Bad Schallerbach, Austria.
5
Ethical approval The Ethics Commission of the Medical University of Vienna approved this study without any objections (EKNr: 1691/2013).
Funding None.
Competing interests None declared.
references
€ ngigkeit, Nikotin und 1. Lesch O, Lichtenschopf A. Tabakabha Sucht. In: Lichtenschopf A, editor. Standards der Tabakentw€ ohnung. Wien, New York: Springer; 2012. p. 14e9. 2. Aigner K, Neuberger M. Epidemiologie. In: Lichtenschopf A, editor. Standards der Tabakentw€ ohnung. Wien, New York: Springer; 2012. p. 5e9. € m KO, Kunze M, Schoberberger R, Breslau N, 3. Fagerstro € m L, Zatonski W. Hughes JR, Hurt RD, Puska P, Ramstro Nicotine dependence versus smoking prevalence: comparison among countries and categories of smokers. Tob Control 1996;5:52e6. 4. Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P. Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ 2014;348. 5. Thompson B, Thompson LA, Thompson J, Fredickson C, Bishop S. Heavy smokers: a qualitative analysis of attitudes and beliefs concerning cessation and continued smoking. Nicotine Tob Res 2003;5:923e33. 6. Cosci F, Pistelli F, Lazzarini N, Carrozzi L. Nicotine dependence and psychological distress: outcomes and clinical implications in smoking cessation. Psychol Res Behav Manag 2011;4:119e28. 7. Hurt RD, Dale LC, Offord KP, Bruce BK, McClain FL, Eberman KM. Inpatient treatment of severe nicotine dependence. Mayo Clin Proc 1992;67(9):823e8. 8. Schumann A, Hapke U, Rumpf HJ, Meyer C, John U. The association between degree of nicotine dependence and other health behaviors. Eur J Public Health 2001;11:450e2. € re 9. Schoberberger R, Bayer P, Groman E, Kunze M. Stationa Rauchertherapie e Projekt Josefhof. Erste Resultate des Modellprojektes. Sucht 2000;46:424e7. 10. Neumann T, Rasmussen M, Heitmann BL, Tønnesen H. Gold standard program for heavy smokers in a real-life setting. Int J Environ Res Public Health 2013;10(9):4186e99. € hm G, Groman E, Kunze M. Klinische 11. Schoberberger R, Bo € re Psychologie im Bereich Sozialmedizin e Stationa € hnung als Beispiel nationaler Raucherentwo Forschungskooperation. In: Lehrner J, Stolba K, Traun-Vogt G, € lkl-Kernstock S, editors. Klinische Psychologie im Vo Krankenhaus. Wien, New York: Springer; 2011. p. 283e90. €ngiger 12. Starzer-Eidenberger B. Psychosoziale Bereuung nikotinabha €rer Behandlung [Masterthesis]. DonauPatienten in stationa € t Krems; 2005. Universita 13. Hays JT, Croghan IT, Schroeder DR, Burke MV, Ebbert JO, McFadden DD, Hurt RD. Residential treatment compared to
Please cite this article in press as: Schoberberger R, et al., Heavy dependent nicotine smokers e Newfound lifestyle appreciation after quitting successfully. Experiences from inpatient smoking cessation therapy, Public Health (2015), http://dx.doi.org/ 10.1016/j.puhe.2015.02.011
6
14.
15. 16. 17.
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outpatient treatment for tobacco use and dependence. Mayo Clin Proc 2011;86:203e9. Willemsen MC, de Vries H, van Breukelen G, Genders R. Longterm effectiveness of two Dutch work site smoking cessation programs. Health Educ Beahv 1998;25(4):418e35. Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Collab 2009;(2). Special Eurobarometer 385. Attitudes of Europeans towards tobacco. Brussels: TNS Opinion & Social; 2012. Schoberberger R, Kunze U, Schmeiser-Rieder A, Groman E, Kunze M. Wiener Standard zur Diagnostik der € ngigkeit: Wiener Standard Raucher-Inventar Nikotinabha (WSR). Wien Med Wschr 1998;148:52e64. Dlugosch G, Krieger W. Der Fragebogen zur Erfassung des Gesundheitsverhaltens (FEG). Frankfurt: Harcourt Test Gesellschaft; 1995.
19. Picone G, Sloan F. Smoking cessation and lifestyle changes. In: Cutler D, Garber A, editors. NBER book Frontiers in health Policy research. Cambridge, MA: MIT Press; 2003. p. 115e42. 20. Scales MB, Monahan JL, Rhodes N, Roskos-Ewoldsen D, Johnson-Turbes A. Adolescents' perceptions of smoking and stress reduction. Health Educ Behav 2009;36:746e58. 21. Piper ME, Kenford S, Fiore MC, Baker TB. Smoking cessation and quality of life: changes in life satisfaction over 3 years following a quit attempt. Ann Behav Med 2012;43(2):262e70. 22. Schlam TR, Piper ME, Cook JW, Fiore MC, Baker TB. Life 1 year after a quit attempt: real-time reports of quitters and continuing smokers. Ann Behav Med 2012;44(3):309e19.
Please cite this article in press as: Schoberberger R, et al., Heavy dependent nicotine smokers e Newfound lifestyle appreciation after quitting successfully. Experiences from inpatient smoking cessation therapy, Public Health (2015), http://dx.doi.org/ 10.1016/j.puhe.2015.02.011
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Heavy dependent nicotine smokers e Newfound lifestyle appreciation after quitting successfully. Experiences from inpatient smoking cessation therapy €hm a,c, Y. Schroeder b,d R. Schoberberger a,*, G. Bo a b
Institute of Social Medicine, Center of Public Health, Medical University of Vienna, Vienna, Austria Department of Finance, Faculty of Business, Economics and Statistics, University of Vienna, Vienna, Austria
article info
abstract
Article history:
Objectives: This is an evaluation of an ongoing inpatient smoking cessation program
Received 1 April 2014
available in Austria and aims to show to what extent even heavy nicotine dependent
Received in revised form
smokers can benefit from a three-week inpatient therapy.
12 January 2015
Study design: A particular focus lies on analyzing the benefits and changes in lifestyle and
Accepted 1 February 2015
sense of well-being.
Available online xxx
Methods: 270 initially heavy nicotine dependent smokers are observed for a one year period consisting of recruitment, therapy and two post-therapy follow-up visits; post program
Keywords:
smokers are compared to post program ex-smokers.
Nicotine dependence
Results: 12 month post-therapy, 42.6% of participants are identified by carbon monoxide-
Inpatient smoking cessation
verifications as ex-smokers, 34% as smokers and the remaining did not attend follow-up
Lifestyle
visits. Significant changes in lifestyle satisfaction are reported by ex-smokers compared
Quality of life
to still smokers. Conclusions: Convincing heavy dependent nicotine smokers that significant changes in lifestyle satisfaction can be expected as part of a successful cessation process should lead to enough motivation for these individuals to seek such inpatient smoking cessation program. © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Smoking leads in 70e80% of cases to nicotine dependence1 and is a risky behavior jeopardizing one's health. It is
estimated that annually in Austria 11,000 people die prematurely due to smoking related illnesses.2 The degree of nicotine dependence and level of addiction,3 experience of withdrawal symptoms as well as personal
* Corresponding author. Tel.: þ43 1 40160 34887; fax: þ43 1 40160 934886. € hm), E-mail addresses: [email protected] (R. Schoberberger), [email protected] (G. Bo [email protected] (Y. Schroeder). c Tel.: þ43 1 40160 34888; fax: þ43 1 40160 934889. d Tel.: þ43 1 4277 38267; fax: þ43 1 4277 838267. http://dx.doi.org/10.1016/j.puhe.2015.02.011 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Schoberberger R, et al., Heavy dependent nicotine smokers e Newfound lifestyle appreciation after quitting successfully. Experiences from inpatient smoking cessation therapy, Public Health (2015), http://dx.doi.org/ 10.1016/j.puhe.2015.02.011
2
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e6
characteristics differs from individual to individual. Many smokers want to quit, but the irritability, anxiety and depression they feel when not having smoked for a while pose a major barrier.4 For some, this psychological distress experienced as part of the quitting process might be a challenge.5 Often the more determining factor in the continuation of smoking is the strong dependence to nicotine itself.6 In spite of experiencing tobacco associated diseases or their own committed, genuine effort to quit, some nicotine consumers are unable to stop smoking on their own.7 In addition smokers with heavy nicotine dependence show additional unhealthy behaviors: they tend to consume unhealthy food and alcohol more frequently, are less physically active and experience more challenges when trying to quit.1,8 As a result and to accommodate particularly heavy dependent nicotine smokers, an inpatient smoking cessation program was started over 10 years ago in Austria.9 Although such therapies are not available on a nationwide basis, they are seen as an important option in becoming smoke free particularly for this group of smokers.10
based on patients having completed the program at Kuranstalt Linzerheim, the additional therapeutic and in-patient services offered at this location are listed in Table 1.13 Then, after completing the three week program, patients have to attend two follow-up (f/u) meetings at six months intervals; voluntary monthly (jour fixe) meetings are also available. The same standardized questionnaire as in the recruitment step is used at both f/u's which allows capturing possible changes. Thus, analysis of these questionnaires is the basis for assessing program successes. The program is only available to a special group of tobacco consumers, to those who require focused, specialized attention due to their pronounced nicotine dependence and resulting poor health. Although inpatient smoking cessation programs are rather rare they tend to treat heavy nicotine dependent smokers more frequently.14 In fact, such programs cater to the specific needs of this group of smokers. Moreover the effect of treatment on smoking cessation depends on nicotine dependency levels meaning that heavy smokers are most successful with comprehensive interventions than minimal ones.15,16
Sample
Methods Inpatient smoking cessation therapy The inpatient smoking cessation therapy starts with a specific selection process in which participants are identified based on their personal situation, health and level of nicotine dependence. Essential inclusion factors for the three week inpatient € m Test for smoking cessation program are a FTND (Fagerstro Nicotine Dependence)-Score 5, a CO-value 20 ppm and the earnest desire to quit smoking completely. Exclusion criteria are an ongoing treatment for a psychiatric disorder or an existing dependence on alcohol or other drug. In addition, parts of the FEG questionnaire by Dlugosch and Krieger11 are utilized to capture participants' satisfaction with their own lifestyle as well as lifestyle choices, attitude and behavior concerning health and diseases.12 In particular, questions concerning satisfaction and consequences for health with respect to nutrition, physical activity, alcohol consumption, smoking, medication, sleep and well-being are included. Additionally, the questions to ‘Dealing with health and disease’ and ‘Physical complaints’ are utilized. Week one focuses on behavior based elements; smoking is still permitted. Nicotine replacement therapy is available upon request. The smoke free period starts with week two. At this point patients have to undergo carbon monoxide (CO) testing to confirm nicotine abstinence. Teaching and exposing participants to existing alternatives to smoking and analyzing triggers most likely to occur in daily life are a focus of this week. Strengthening the positive image of oneself as a nonsmoker is the goal of week three. Two institutions in Austria offer such a program, the Grazer Gesundheitseinrichtung ‘Josefhof’ belonging to the insurance company for Austrian Railways and Mining Industry and the Kurheim Linzerheim in Bad Schallerbach, an institution of the Sick Fund of Upper Austria. As this program evaluation is
Between October 2003 and December 2011, 270 participants completed the inpatient smoking cessation program at Kurheim Linzerheim. Description of the sample is shown in Table 2. In most aspects gender differences were not found because this was not the main interest of the study there is only a short descriptive comparison between men and women in Table 2. Based on recruitment process and aim of program, participants attending the inpatient smoking cessation program differ significantly from the average Austria population (AP) in terms of nicotine dependence, resulting smoking behavior and smoking related illnesses. Inpatient program participants smoke on average 31.9 cigarettes per day (AP ¼ 18.3 cigarettes per day).17 23.7% started to smoke at very young age - prior to the age of 15 years (AP ¼ 10%). Moreover, in terms of heavy nicotine dependence inpatient smoking cessation program participants reach high CO-values (average of 24.9 ppm) and FTND values (average 7.25). In contrast, an Austrian representative study reports a FTND value of 3.59 in smokers.3 63% of participants have been diagnosed with diseases to the respiratory system, 47.4% to the cardiovascular system, 28.9% show metabolic diseases, and 28.9% show other illnesses (multimorbidity occurring).
Table 1 e In-patient services. Additional care available Medical care Psycho-social care Psycho-social one-on-one counseling Cardiovascular training (such as Nordic walking, ergometer training, gymnastics) Breathing exercises Relaxation training & stress management Nutritional advise & cooking classes Physical therapy & massages Biofeedback
Hours Based on need 21 h >1 h 21 h 7.5 h 10 h 3h 1h Based on need
Please cite this article in press as: Schoberberger R, et al., Heavy dependent nicotine smokers e Newfound lifestyle appreciation after quitting successfully. Experiences from inpatient smoking cessation therapy, Public Health (2015), http://dx.doi.org/ 10.1016/j.puhe.2015.02.011
3
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e6
Table 2 e Description of the sample. Average age in years Average body mass index in % Occupation in % Employed (active workforce) AMS (Public Employment Services Austria) Household/housewife Pension/retired No information available
Men
Women
50.67 27.31
53.16 25.68
52.0 8.0 0 27.3 12.7
33.3 7.5 5.0 45.8 8.4
Table 3 e Inpatient smoking cessation program: Comparing carbon monoxide (CO)-values of successes and failures at three different time periods.
Recruitment CO-value 6 month follow-up CO-value 12 month follow-up CO-value
Post program ex-smoker
Post program smoker
No data available
N
24.3 ppm
25.9 ppm
44.8%
28.9%
26.3%
199
2.7 ppm 42.6%
21.4 ppm 34.0%
23.4%
207
1.4 ppm
18.5 ppm
270
Analysis/evaluation Data collection occurred at three different time periods (recruitment and f/u visit six months and 12 months post program completion) utilizing the same standardized questionnaire which were analyzed using SPSS (version 20.0). Averages and frequencies were measured via descriptive analysis. Comparison between ex-smokers (successful participants) and smokers (less successful participants) of factors such as lifestyle, as well as physical ailment was done via a non-parametric Wilcoxon signed-rank test. BMI, FTND and number of smoked cigarettes were analyzed via t-test and Chi-square test. Additionally, to evaluate program success results from the Vienna Standardized Smokers Inventory,18 the FTND as well as the CO-measurements were utilized.
Results Data availability for analysis: of the 270 participants who had completed the program, 199 attended the first f/u visit six months post program completion and 207 the second f/u 12 months post program completion. Important results are shown in Table 3. Based on the standardized FEG questionnaire11 utilized, participants' satisfaction with their own lifestyle and the anticipated impact or effect of certain lifestyle choice on health are presented in Figs. 1 and 2. Prior to the start of the inpatient smoking cessation program, almost all participants (86.4% of post program exsmokers and 88.7% of post program smokers, P ¼ 0.781) reported to be unhappy or dissatisfied with their tobacco consumption. This reduced significantly in ex-smokers to 5.1% at f/u 1 and 2.4% at f/u 2 (P ¼ 0.000). Throughout observation no significant change in such attitude was observed in smokers. Moreover, at recruitment participants also reported to be aware of the negative consequences smoking had on their health and well-being (96.6% of ex-smokers and 98% of smokers, P ¼ 1.000). This changed to 14.6% at f/u 1 (P ¼ 0.000) and 12.5% at f/u 2 (P ¼ 0.000) in ex-smokers who still felt negative consequences of their former smoking behavior. In smokers - the perceived effect of tobacco consumption on health remained rather high (82.3% at f/u1 and 87% at f/u 2). Moreover, many of the participants, although less exsmokers than smokers, reported at recruitment to be dissatisfied with their sense of well-being (50.9% vs 70.2%, P ¼ 0.068) and that such posed further challenges to their health (62.5%
of ex-smokers, 60.8% of smokers, P ¼ 0.193). 12 months post program completion, ex-smokers expressed a higher sense of well-being; significantly fewer patients reported to feel dissatisfied (16.7% at f/u 1 and 15.7% at f/u 2; P ¼ 0.000). These results are in line with the findings that 12 months after therapy only 10.4% (f/u 1) and 8.7% (f/u 2) of ex-smokers believed in the negative effects an inpatient smoking cessation therapy can have on their health (P ¼ 0.000). No statistically significant changes were observed in the group of post program smokers. Similar results are available in terms of sleep. At the start of therapy almost half of all participants (44.2% of ex-smokers, 60.0% of smokers, P ¼ 0.119) stated to be dissatisfied with their sleep pattern fearing negative consequences in terms of health outcomes. Throughout both f/u visits a significant reduction of such unhappiness was found in ex-smokers but remained the same in smokers. At f/u 2, 55.6% of smokers still believed that the amount and poor quality of sleep negatively influenced their health and well-being; in ex-smokers this was the case in only 21.7% (P ¼ 0.015). Prior to starting the smoking cessation program, smokers were much more displeased with their level of physical activity (PA) compared to ex-smokers (80.8% vs 51.9%; P ¼ 0.003). Throughout the 12 month observation period, this dissatisfaction decreased to 60% in smokers, although not at a significant level. Significant were the findings for ex-smokers however. Within this group only 25% (P ¼ 0.012) reported to still feel unhappy about their level of PA. At recruitment when asked to estimate the effects of PA on health, almost three quarter of participants strongly believed that an increase in the level of PA would have a positive effect on health. Initially, roughly 50% of ex-smokers believed for this to be the case (P ¼ 0.010). In both groups a reduction in such attitude was observed at f/u 2; a significant one in ex-smokers and small, non-significant one in smokers (19.6% compared to 47.6%; P ¼ 0.004). Stress management and relaxation techniques are a big component of the inpatient smoking cessation program. Prior to the start of the program almost one-third of participants (27.3% of ex-smokers and 34.5% of smokers, P ¼ 0.438) reported being able to manage stress without (frequently) suffering poor health outcomes. The f/u visits revealed that over time, more and more former smokers seemed able to develop healthier stress management techniques; this group no longer relied on nicotine to cope with stress or other
Please cite this article in press as: Schoberberger R, et al., Heavy dependent nicotine smokers e Newfound lifestyle appreciation after quitting successfully. Experiences from inpatient smoking cessation therapy, Public Health (2015), http://dx.doi.org/ 10.1016/j.puhe.2015.02.011
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p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e6
Fig. 1 e Subjective changes of dissatisfaction in terms of various lifestyle factors experienced by inpatient smoking cessation therapy participants. Successful (post program) ex-smokers are compared with less successful (post program) smokers at recruitment, six month and 12 month post-therapy follow-up (F/U).
unpleasant emotions (f/u 1 32.3%, f/u 2 36.5%) (P ¼ 0.047). In spite of being a therapy component, such success wasn't observed in still smokers. No significant group differences concerning dissatisfactions or estimates of negative effects on health were found with respect to eating habits and alcoholism. No gender differences were detected.
Discussion Regardless of what success rate participants complete during an inpatient smoking cessation program, the initial dread seems to be the same in almost every smoker. Many fear significant disadvantages or drawbacks such as increased anxiety, irritability, fear of failure,5 difficulty concentrating, and increased appetite19 prior to even starting such a program which is often grounded in confusion, misinformation, and
angst. These findings show however that 12 months post program completion, less than 10% of ex-smokers believe that an in-patient smoking cessation therapy has a negative effect on one's health, the opposite seems the case - such encouraging, supportive environment seems to assist in the cessation process.5 Smokers often smoke to cope with stress, calm nerves or aid relaxation.4,20 Due to the stress management component in the program it was shown that ex-smokers increase their ability to handle stress without having to reach for a tobacco product. In terms of program successes 40% of participants manage to successfully quit (identified as non-smokers at f/u 1 and 2) their tobacco consumption. Similar to findings from other research, e.g. Piper et al.21 post program ex-smokers who successfully manage to quit their tobacco consumption report an increased feeling of well-being, vitality, and health compared to individuals who continue to smoke. 84.3% of initially heavy nicotine
Fig. 2 e Subjectively assumed negative influence of various lifestyle factors on health as reported by inpatient smoking cessation therapy participants. Successful (post program) ex-smokers are compared with less successful (post program) smokers at recruitment, six month and 12 month post-therapy follow-up (F/U). Please cite this article in press as: Schoberberger R, et al., Heavy dependent nicotine smokers e Newfound lifestyle appreciation after quitting successfully. Experiences from inpatient smoking cessation therapy, Public Health (2015), http://dx.doi.org/ 10.1016/j.puhe.2015.02.011
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e6
dependent smokers who became successful non-smokers after completing the inpatient smoking cessation program, and who remained smoke free throughout the f/u visits, report of such significantly improved sense of well-being. This also includes declined restlessness and better stress management techniques, supporting findings from Schlam et al.22 Similar to preprogram, the majority of still smokers report a continued impairment of their well-being. Post program smokers are not able to experience changes to their sense of well-being agreeing with findings from Taylor et al.’s4 systematic review that quitting smoking is associated with significant improvements in psychological quality of life. Such possibility should give reason and encouragement to quit smoking. The real power of the findings lies perhaps in: educating current heavy smokers about the health gains to be expected as non-smokers; correcting commonly held misunderstanding about unfounded fear and worry; using this knowledge to highlight and empower smokers in their undertaking which is not an impossible task; and re-emphasizing health benefits in terms of their diseases. In this study the authors forego the use of a ‘proper’ control group; they understand the limitations of this decision. The positive effects and health benefits experienced by post program non-smokers are compared to those of post program smokers who did not manage to remain smoke-free after completing the three week inpatient smoking cessation program, thus they focus on evaluating the program. Based on ethical reasons they can't justify a time and resource intensive recruitment process to identify smokers who have developed severe illnesses and diseases related to their tobacco consumption to then randomly place a portion of these individuals into a control group. Furthermore, comparing the group to average smokers from the population doesn't really make much sense. Using the average smoker as comparator wouldn't underline the findings as these are, after all, specific to the group of smokers - the inpatient smoking cessation program participants. The three week inpatient smoking cessation program available in Austria offers even for the most heavy nicotine dependent smoker possibility of reaching tobacco abstinence. Successful quitters experience a significant increase in satisfaction of life and well-being compared to program participants unable to quit smoking.
Author statements Acknowledgements The authors wish to acknowledge and thank the team of the Sick Fund of Upper Austria who, with great commitment, carry out the inpatient smoking cessation program at the Kurheim Linzerheim, Bad Schallerbach, Austria.
5
Ethical approval The Ethics Commission of the Medical University of Vienna approved this study without any objections (EKNr: 1691/2013).
Funding None.
Competing interests None declared.
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