Wee35300RESEARCHSTUDY.pdf - Howard Assignments

The effectiveness of individual interventions on smoking cessation of chronic obstructive pulmonary disease patients

Ali Sharifpour1, Fatemeh Taghizadeh2, Mehran Zarghami3, Abbas Alipour4,5 1Pumonary and Critical Care Division,Iranian National Registry Center for Lophomoniasis, Mazandaran University of Medical Sciences, Sari,

2Student Research Committee, Psychiatry and Behavioral Research Centre, Addiction Institute, Mazandaran University Of Medical Sciences, Mazandaran, Sari, 3Department of Psychiatry, School of Medicine, Psychiatry and Behavioral Sciences Research Center, Addiction Institute,

Mazandaran University of Medical Sciences, Sari, 4Department of Community Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Mazandaran, Sari, 5Department of Community Medicine, Faculty of Medicine, University of Medical Sciences, Sari, Iran

ORCID: Mehran Zarghami: https://orcid.org/0000-0002-7027-0992; Fatemeh Taghizadeh: https://orcid.org/0000-0002-6544-0096

Original Article

Context: Guided self-change (GSC) is theory-driven based on cognitive-behavioral change models such as transtheoreticlal model (TTM) and can be applied with nicotine replacement therapy (NRT) for behavioral change of smoking in chronic obstructive pulmonary disease (COPD) smokers.Aims: This study aimed to investigate the individual GSC, NRT, and GSC-NRT on smoking cessation of COPD patients.Settings and Design: This randomized clinical control trial study was carried out in Imam Khomeini Hospitals in Mazandaran province in 2016–2017.Materials and Methods: Three- group block randomized controlled trial, comparing GSC (n = 20), NRT (n = 20), and GSC-NRT (n = 20) in smoking cessation and other related variables COPD smokers with follow‑up to 29‑week.Statistical Analysis Used: Descriptive statistics, Chi-square, and repeated measures ANOVA test were used to analyze the data.Results: The GEE model revealed that GSC reduced the odds of quitting smoking rate compared to the NRT group (odds ratio = 0.31, 95% confidence interval: 0.022–0.545, ES = 0.20). Furthermore, the TTM questionnaire, the Fagerstrom test for nicotine dependence, and spirometry variables were evaluated in the three groups. The recovery in nicotine dependency, the exhaled carbon monoxide and spirometry variables was more pronounced in the GSC and GSC‑NRT groups than in the NRT over 29 weeks after the treatments. Cons (PV = 0.009, ES = 0.52), pros (PV = 0.04, ES = 0.12), experiential process (PV = 0.005, ES = 0.18), counterconditioning (PV = 0.04, ES = 0.12), stimulus control (PV = 0.004, ES = 0.19), environmental‑reevaluation (PV = 0.0001, ES = 0.30), and habitual craving (PV = 0.004, ES = 0.19) were significant across the three groups.Conclusion: The interventions in the GSC and combined GSC-NRT groups were significantly more effective than in the NRT group in TTM variables, and GSC and combined GSC-NRT were equally effective in smoking cessation rate.

Keywords: Chronic obstructive pulmonary disease, Nicotine replacement therapy, Smoking cessation, Transtheoretical model

Abstract

Address for correspondence: Fatemeh Taghizadeh, Ph.D by Research Student, Student Research Committee, Psychiatry and Behavioral Research Centre, Addiction Institute, Mazandaran University of Medical Sciences, Zare Hospital, Neka Road, Sari, IR Iran. E-mail: [email protected]: 22 July 2019; Accepted: 14 September 2019; Published: 27 December 2019.

Access this article onlineQuick Response Code:

Website:www.jnmsjournal.org

DOI:10.4103/JNMS.JNMS_38_19

How to cite this article: Sharifpour A, Taghizadeh F, Zarghami M, Alipour A. The effectiveness of individual interventions on smoking cessation of chronic obstructive pulmonary disease patients. J Nurs Midwifery Sci 2020;7:13-21.

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

For reprints contact: [email protected]

[Downloaded free from http://www.jnmsjournal.org on Saturday, December 28, 2019, IP: 140.234.253.9]

Sharifpour, et al.: Smoking cessation in COPD patients

14 Journal of Nursing and Midwifery Sciences | Volume 7 | Issue 1 | January-March 2020

INTRODUCTION

Effective approaches to improvement of pulmonary function in chronic obstructive pulmonary disease (COPD) are involved in studies on tobacco control programs.[1] Such approaches are theory driven and generally based on the behavioral change models.[2] One of these models in quitting smoking is the transtheoretical model (TTM).[3,4] TTM is a most framework used for quitting smoking.[5,6] Numerous questionnaires were provided based on the TTM to assess what interventions could change people’s behaviors.[7] TTM improved using higher than 300 psychotherapy theories, and was validated and popularized behavior change over the last 20 years.[8] The TTM comprises four structures, including stage of change, processes of change, decisional balance, and temptation.[9] In fact, this model suggests a structure in which it is assumed that health behavior change contains five stages of change, ten processes of change, two decisional balance, and three temptation domains.[2,10] The process of change is one of the main structures of the TTM and assess the improvements of behavior changes from the preparation stage to the action phase.[10,11] Temptation refers to a psychological state that might encourage an individual to cigarette smoking if threatened with a challenging condition[12] As expected, the nine items of the temptation structure comprise three subscales of social situation, habitual craving, and negative affect situation.[13] This model suggests that the three subscales should be considered for quitting smoking interventions.[14,15] Meanwhile, decisional balance showed two subscales: pros and cons,[16] that shows benefits and harms of decision‑making for quitting smoking.[14] The decisional balance of the TTM suggests that pros and cons are the main parts of the model.[17] Based on the stages of change model, people are in various stages of smoking cessation behavior,[17] including precontemplation, contemplation,[18] preparation,[19] action,[20] and maintenance.[21] Guided self‑change (GSC) is a shortened cognitive‑behavioral motivational treatment.[22,23] Since individually GSC has not been applied in Iran yet, a randomized controlled clinical trial was carried out by the researchers to study the effectiveness of GSC for decreasing smoking in COPD patients in Imam Khomeini Hospital in Sari in northern Iran.

MATERIALS AND METHODS

Based on the previous study and considering the mean and standard deviation (SD) of the difference between the reduction in the number of cigarettes equal to 1 and 0.8 cigarettes after GSC intervention, moreover, considering the power of study equal to 80% and the probability of the first type error equal to 0.01, A sample size of 60

participants was calculated (conferring 80% power to detect an absolute difference of 10% in cessation rates across the three groups) and 20 patients considered for each group.[24] Furthermore, according to the study of Sharifirad et al., and considering the ratio of smoking stopped people in the intervention and nonintervention groups equal to 46% and 4%, and considering the power of study equal to 80% and the probability of the first type error equal to 0.05, respectively, the sample size is calculated as 15 in each group.[25] Increasing the power of the study, we assigned 20 participants in each group that one patient in each group, discontinued the study, after allocation.

Block randomization with a block size of 6 and 9 was used for the assignments [Figure 1]. The randomization was conducted through SPSS software(version 16, SPSS Inc., Chicago, IL, USA), by an independent investigator with no contact with the patients or researchers. The number of the participants and the type of intervention were packed in a closed packet, and then they were disclosed by visiting the patient and after a primary assessment for inclusion criteria.

The nicotine cartridges included 2 mg nicotine/ml. First, the participants were randomly allocated to nicotine replacement therapy (NRT), GSC, and combined groups. Following randomization, baseline information, including education, smoking and abstinence history, medical disease, and other correlated data were collected. Constant smoking abstinence (self‑reported abstinence during the whole period of follow‑up), every 3 weeks’ following the quitting day, was evaluated, and TTM evaluations were carried out 12 and 29 weeks’ following treatments.

First, the patients were explained on the purpose and method of the study, and NRT’s potential side‑effects. The patients were asked to complete a consent form. All the patients completed personal information and Fagerstrom test for nicotine dependence (FTND) questionnaire before the commencement of the intervention. Then, the interventions were performed by an expert psychotherapist in five individual sessions for the GSC and combined groups. Furthermore, nicotine was used to NRT and combined groups for 6 weeks.

The inclusion criteria included the age over 45 years, COPD, and cigarette smoking. The participants had persistent airway obstruction and referral by a pulmonologist.

Exclusion criteria included the presence of other systemic medical diseases such as diabetes, normal spirometry, respiratory failure, and contraindications for nicotine gum use (allergy, active heart disease, dangerous arrhythmias,

[Downloaded free from http://www.jnmsjournal.org on Saturday, December 28, 2019, IP: 140.234.253.9]

Sharifpour, et al.: Smoking cessation in COPD patients

Journal of Nursing and Midwifery Sciences | Volume 7 | Issue 1 | January-March 2020 15

severe angina, hyperthyroidism, insulin‑dependent diabetes, active peptic ulcers, pregnancy, and lactation), severe psychiatric disorders history such as psychosis and severe depression, and anxiety with the patient report history, and the GSC psychotherapist and psychiatrist diagnosis.

Ethics Committee of Mazandaran University of Medical Sciences (IR. MAZUMS. REC.95.2137) accepted the trial procedure. The trial procedure was registered at the Iranian Registry of Clinical Trials (IRCT201609271457N11; www.irct.ir) and carried out based on the Declaration of Helsinki and its following revisions. The research was conducted between December 2016 and November 2017. The statistical population contained all COPD subjects referring from pulmonologist to Imam Khomeini Hospital of Sari in Mazandaran Province of Iran.

Transtheoreticlal model questionnairesTTM questionnaire was validated for quitting cigarette smoking, and suggested it in two versions: the original questionnaire including 83 items, and the short one containing 38 items. In this study, we used the short form comprising of 4 constructs [26] as follows:

The stage of changeIt assesses the current smoking behaviors of individuals and whether they wish to leave cigarette smoking or not.

This theory has five stages, including precontemplation, contemplation, preparation, action, and maintenance. In the current research, if a smoker decided to quit smoking over the next month, he was identified as being in the preparation stage.[27]

The processes of change scaleIt assesses 10 processes of change in two key groups: experiential process and behavioral actions to change their cigarette smoking behaviors. It comprises 10 experiential statements and 10 behavioral procedures statements.[28]

Temptation scaleIt evaluates situational temptation. We used three subparameters of temptation in our research. This structure contains nine items on social conditions, craving situations, and negative affect situations.[29]

Decisional balance scaleIt determines the attitude of smoker toward quitting. This structure contains six items, including items on pros and cons. The statements use a five‑point Likert‑type scale.[30]

In Western countries, TTM questionnaire has been evaluated in several researches.[31] In Iran, the Cronbach’s alpha is in the range of 0.60–0.84, representing an acceptable outcome. Moreover, internal correlation

Assessed for eligibility (n=900)

Randomized (n=60)Excluded (n=720)♦ Not meeting inclusion criteria (n=720)♦ Declined to participate (n=120)♦ Other reasons (n=0)Allocation

Enrollment

Follow- up

Analysis

Allocated to intervention (n=20)♦ Received allocated intervention (n=19)♦ Did not receive allocated intervention (give reasons) (n=1)

Lost to follow-up (give reasons)(n= 0) Discontinued intervention(give reasons) (n=0)

Lost to follow-up (give reasons) (n= 0) Discontinued intervention (give reasons) (n=0)

Analysed (n=19) ♦ Excluded from analysis (give reasons) (n=0)

Analysed (n= 19) ♦ Excluded from analysis (give reasons) (n= 0)

Figure 1: CONSORT diagram of patients’ randomization, intervention, and analysis

[Downloaded free from http://www.jnmsjournal.org on Saturday, December 28, 2019, IP: 140.234.253.9]

Sharifpour, et al.: Smoking cessation in COPD patients

16 Journal of Nursing and Midwifery Sciences | Volume 7 | Issue 1 | January-March 2020

corresponding to coefficient in the range of 0.61–0.83 is a suitable outcome.[32]

Guided self‑change treatmentThe GSC model for the treatment of alcohol‑related problems was developed by Sobell and Sobell.[33] This model is based on cognitive‑behavioral therapy (CBT) and motivational interview, and it consists of one initial assessment session and four treatment sessions, plus two follow‑up telephone calls. Participants were guided by the motivation enhancement principles and a self‑help manual. The self‑help manual was discussed during the treatment sessions. All treatments in three groups were delivered by the same therapist, a trained CBT counselor with more than 15 years of experience in psychotherapy. This counselor was trained to give GSC treatment by a psychiatrist and a psychologist at a 3‑day workshop and subsequently treated five participants before the study. The treatment sessions in the GSC arm of the study were tape‑recorded to ensure treatment fidelity.

Guided self‑change intervention protocolThe GSC intervention protocol was applied in 5 1‑h sessions for 5 weeks[34] (see attached protocol).

Statistical analysisThe sample size of 60 participants (20 in all groups) conferred 80% power, with two‑sided P = 0.05, for detecting a total difference of 10% among the three groups in terms of rates of quitting. The Shapiro–Wilk test was utilized to test the normality of the data distribution. Descriptive baseline characteristics corresponding to comparisons of the groups were arranged as mean (SD), median (interquartile range), or percentages. The initial efficacy information on smoking quitting was examined with intention‑to‑treat analysis. The comparison of the results between the three groups was performed with repeated measures ANOVA test using the General Linear Model. The time of assessment and intervention state (start of treatment, follow‑up of 12 and 29 weeks of treatment) was considered the within‑subject factor and the between‑subject factor, respectively. The time groups (interaction term) were regarded as group differences (between groups). Mauchly’s sphericity test was applied for the compound symmetry assumption. The data were analyzed using SPSS 16 and Stata for FTND and smoking cessation rate evaluations comparing three groups.

RESULTS

As shown in Table 1, the observed differences between the study groups were not statistically significant with respect to marital status (PV = 0.36), occupation (PV = 0.51), motivation

for smoking cessation (PV = 0.62), importance of smoking cessation (PV = 0.61), the number of smoker friends (PV = 0.5), FTND (PV = 0.93), the number of daily cigarettes (PV = 0.71), and other related variables. In this study, 60 men 45–75 years of age with a mean age of 53.6 (±8.43) were randomly assigned to three groups, 20 to the GSC, 20 to the NRT, and 20 to the combined GSC and NRT groups [Figure 1] and TTM variables changes in three groups was shown [Figures 2‑5].

Smoking variablesThe mean age of their initiation of smoking was 19.6, with a range of 8–34, and with a mean duration of smoking of 32.9 years, and a range of 9–59 years. The mean number of daily cigarettes smoked was 23, with a range of 5–60.The level of nicotine dependence with the FTND was more than 5 in 42.1% of participants and decreased over the baseline, 12 and 29 weeks [Figure 2]. The mean number of past quitting attempts was two times, with a range of 0–10, and the mean of the longest period of abstinence was 2.9 years, with a range of 0–10 years. The reason for the decision to quit in 28 (49%) of the participants was their current illness (COPD). Moreover, 53 (93%) participants smoked after a main meal and 13 (22.8%) participants regularly smoked after sex. A total of 39 (68.4%) of them smoked deeply into the lungs. The type of cigarettes smoked was high‑nicotine in 8 (14.9%) of the participants. All of the participants were in the preparation stage of TTM. Self‑reported daily cigarettes smoking declined steadily over the baseline, 12 and 29 weeks, from 23.2 (±1.7) to 7.6 (±1.0) and 6 (±1.0) (P = 0.001), respectively. A total of 9 (47.4%) participants in the GSC and combined groups and 4 (21.1%) participants in the NRT group reported total abstinence from smoking by the end of 29 weeks. Moreover, The GEE model revealed that GSC reduced the odds of quitting smoking rate compared to the NRT group (odds ratio = 0.31, 95% confidence interval: 0.022–0.545, ES = 0.20).

Transtheoretical model variablesAs shown in Tables 2‑4 and the Figures 3‑6, in cons (PV = 0.05) and temptation (PV = 0.05), reinforcement‑management (PV = 0.4), self‑liberation (PV = 0.13), environmental‑reevaluation (PV = 0.05), self‑reevaluation (PV = 0.05), social‑liberation (PV = 0.05), consciousness‑raising (PV = 0.05), socio‑positive situation (PV = 0.05), negative‑affect situation (PV = 0.05), and habitual craving (PV = 0.13), no significant changes were seen in the NRT group, while these variables were statistically different in the GSC and combined GSC‑NRT groups. Moreover, cons (PV = 0.009, ES = 0.19), pros (PV = 0.04, ES = 0.12), experiential process (PV = 0.005, ES = 0.18), counterconditioning (PV = 0.04, ES = 0.12), stimulus control (PV = 0.004, ES = 0.19), environmental

[Downloaded free from http://www.jnmsjournal.org on Saturday, December 28, 2019, IP: 140.234.253.9]

Sharifpour, et al.: Smoking cessation in COPD patients

Journal of Nursing and Midwifery Sciences | Volume 7 | Issue 1 | January-March 2020 17

reevaluation (PV = 0.0001, ES = 0.30), and habitual craving (PV = 0.004, ES = 0.19) were statistically significant across the three groups and these variables improved in the GSC and combined GSC‑NRT groups more than in the NRT group in the 29‑week follow‑up. Furthermore, interaction effects in temptation (PV = 0.02), socio‑positive situation (PV = 0.02), and negative affect‑situation (PV = 0.01) were statically significant among three groups.

DISCUSSION

We examined GSC with NRT in behavioral change of smoking in COPD smokers. Several studies were conducted on TTM applying in smoking cessation as follows:

In a randomized clinical trial in Iran, the experimental group received the individual counseling and NRT and telephone follow‑ups. Total abstinence without relapse was 46% in the experimental group and 3.3% in the control group. All of the variables at change stages, including quitting smoking, experimental and behavioral process, and temptation revealed a significant difference between the two groups. There was a significant difference in FTND test at the beginning and end of the intervention in the experimental group, with no significant difference in the control group.[25] Meanwhile, in our study, significant differences in the experimental and behavioral process were found in GSC and combined group compared. Moreover,

Figure 2: Fagerstrom test of nicotine dependency trends over the timeFigure 3: Behavioral process trends over the time

Table 1: Basic demographic and clinical characteristics of patients in three groups (n=19)Variable Group PV

GSC NRT Combined

Age, mean±SD 50±6 56±10 54±8 0.08Marital status, n (%)

Married 15 (31) 16 (32) 18 (37) 0.36Single/divorced/widowed 4 (50) 3 (38) 1 (13)

Job, n (%)Self‑employee 14 (39) 11 (31) 11 (31) 0.51Employed 5 (24) 8 (38) 8 (38)

Motivation of quitting, n (%)Desperate and unwilling 1 (50) 0 1 (50) 0.62Hopeful and very hopeful to giving up 18 (33) 19 (35) 18 (33)

Importance of smoking cessation, n (%)Trivial and somewhat 1 (50) 0 1 (50) 0.61Very much and too much 18 (33) 19 (35) 18 (33)

Smoker friends, n (%)None of them and a bit 13 (36) 13 (36) 10 (28) 0.50Half and the most 6 (29) 6 (29) 9 (43)

Craving (mean±SD) 22±8 23±6 26±8 0.21HSI (mean±SD) 1.8±1 2±1 1.7±1 0.74FTND score (mean±SD)

FTND was >5 in 42.1% of patients 4.7±2 4.9±3 4.9±2 0.93Daily cigarette (mean±SD)

5–60 (mean=23) cigarettes in a day 24±13 26±18 20±7 0.71FEV1 act 2.39±0.57 1.94±0.74 1.91±0.7 0.62FVC act 3.68±0.71 3.18±1.02 3.41±0.83 0.82

Data are expressed as the mean or as n (%). GSC: Guided self‑change, NRT: Nicotine replacement therapy, SD: Standard deviation, HSI: Heaviness of smoking index, FTND: Fagerstrom test for nicotine dependence, FEV1: Forced expiratory volume in the first second, FVC: Forced vital capacity

[Downloaded free from http://www.jnmsjournal.org on Saturday, December 28, 2019, IP: 140.234.253.9]

Sharifpour, et al.: Smoking cessation in COPD patients

18 Journal of Nursing and Midwifery Sciences | Volume 7 | Issue 1 | January-March 2020

FTND decreased significantly in the three groups. In addition, this variable had a significant difference in the three groups, and the decreased rate in the combined and GSC groups was higher than the NRT group. In another study,[35] the results clearly showed the effectiveness of both methods, TTM and CBT, on the self‑efficacy in drug use abstinence in adolescents. Otherwise, in one study, 2471 smokers were randomized to either control or TTM‑based self‑help program and followed up 12 months after the intervention. Smokers in the TTM group were

had a positive move in stage, but that was not significant. The TTM‑based intervention was not more effective for the smokers in precontemplation or contemplation than for participants in the preparation stage.[36] TTM may be useful in understanding the stages in smokers for quitting smoking.

Moreover, another descriptive study was conducted using the convenient sampling method (n = 578). Approximately 75% of the smokers were in the precontemplation and

Table 2: Repeated measure analyses of variance (group effect and interaction effect) for transtheoretical model variable transtheoreticlal model constructs groups baseline, 12 weeks and 29 weeksVariables Time Between

effectGroup effect

Interaction effect

Effect size

F statisticBaseline Follow‑up after 12 weeks Follow‑up after 29 weeks

ConsGSC 7 (5–11) 5 (3–10) 5 (3–10) 0.001 0.009 0.65 0.19 0.52Nicotine 11 (9‑14) 11 (7‑14) 11 (7‑14) 0.05Combine 7 (6‑11) 3 (3‑7) 4 (3‑6) 0.001

ProsGSC 11 (7‑11) 15 (11‑15) 15 (11‑15) 0.001 0.04 0.07 0.12 4.74Nicotine 11 (9‑11) 11 (10‑15) 11 (10‑15) 0.02Combine 11 (9‑11) 11 (10‑15) 11 (10‑15) 0.001

TemptationGSC 21 (16‑28) 8 (0‑20) 7 (0‑19) 0.0001 0.08 0.02 0.09 2.63Nicotine 24 (19‑26) 24 (17‑26) 24 (17‑26) 0.05Combine 28 (21‑32) 8 (0‑23) 8 (0‑23) 0.0001

Behavioral‑processGSC 14 (11‑20) 30 (12‑32) 32 (12‑32) 0.0001 0.18 0.2 0.06 1.75Nicotine 15 (10‑19) 16 (10‑25) 16 (10‑25) 0.02Combine 14 (10‑18) 28 (14‑32) 28 (16‑32) 0.0001

Experiential‑processGSC 31 (22‑36) 40 (31‑48) 48 (36‑48) 0.0001 0.005 0.06 0.18 5.91Nicotine 26 (20‑34) 28 (20‑39) 28 (20‑39) 0.02Combine 31 (23‑35) 46 (34‑48) 47 (34‑48) 0.0001

Data are expressed as the median (IQR). IQR: Inter‑quartile range, GSC: Guided self‑change

Table 3: Repeated measure analyses of variance (group effect and interaction effect) for transtheoretical model the processes of change (behavioral processes) groups baseline, 12 weeks and 29 weeksVariables Time Between

effectGroup effect

Interaction effect

Effect size

F statisticBaseline Follow‑up after

12 weeksFollow‑up after

29 weeks

The processes of change (behavioral processes)Counterconditioning

GSC 3 (0‑4) 8 (3‑8) 8 (3‑8) 0.001 0.04 0.07 0.12 3.50Nicotine 2 (0‑3) 2 (0‑4) 2 (0‑4) 0.02Combine 2 (0‑3) 7 (2‑8) 7 (3‑8) 0.001

Self‑liberationGSC 7 (4‑8) 8 (8‑8) 8 (8‑8) 0.001 0.09 0.085 0.08 2.47Nicotine 6 (4‑8) 6 (4‑8) 6 (4‑8) 0.13Combine 7 (4‑8) 8 (7‑8) 8 (7‑8) 0.002

Reinforcement‑managementGSC 7 (4‑8) 8 (6‑8) 8 (6‑8) 0.02 0.6 0.6 0.02 0.57Nicotine 8 (6‑8) 8 (8‑8) 8 (8‑8) 0.4Combine 8 (4‑8) 8 (8‑8) 8 (8‑8) 0.007

Stimulus‑controlGSC 3 (0‑5) 8 (2‑8) 8 (3‑8) 0.0001 0.004 0.17 0.19 6.15Nicotine 0 (0‑2) 0 (0‑5) 0 (0‑5) 0.02Combine 0 (0‑4) 7 (2‑8) 7 (3‑8) 0.0001

Helping‑relationshipGSC 4 (0‑8) 8 (2‑8) 8 (2‑8) 0.018 0.9 0.5 0.01 0.15Nicotine 4 (1‑8) 8 (2‑8) 8 (2‑8) 0.018Combine 4 (0‑8) 8 (4‑8) 8 (4‑8) 0.0001

Data are expressed as the median (IQR). IQR: Inter‑quartile range, GSC: Guided self‑change

[Downloaded free from http://www.jnmsjournal.org on Saturday, December 28, 2019, IP: 140.234.253.9]

Sharifpour, et al.: Smoking cessation in COPD patients

Journal of Nursing and Midwifery Sciences | Volume 7 | Issue 1 | January-March 2020 19

17.8% in the preparation stage.[21] In our study, all of the participants were in the preparation stage. Furthermore, in a population‑based descriptive study consisting of 357 smokers in Tennessee, US, 56% of the participants

were in the precontemplation stage, as compared to the previous finding of 40% in the national samples. The participants’ scores for the pros of smoking were similar to the stages of change in our sample, and although the scores for the cons differed significantly across the stages in the sample, post hoc analysis indicated that the only significant change occurred between the precontemplation and contemplation stages. The scores for temptation to smoke

Figure 4: Temptation trends over the time

Figure 5: Experiential process trends over the time

Table 4: Repeated measure analyses of variance (group effect and interaction effect) for transtheoretical model the processes of change (experiential processes) and temptation groups baseline, 12 weeks and 29 weeksVariables Time Between

effectGroup effect

Interaction effect

Effect size

F statisticBaseline Follow‑up after

12 weeksFollow‑up after

29 weeks

The processes of change (experiential process)Environmental‑reevaluation

GSC 4 (4‑8) 8 (4‑8) 8 (8‑8) 0.0001 0.0001 0.2 0.30 11.55Nicotine 4 (0‑4) 4 (0‑8) 4 (0‑8) 0.05Combine 4 (4‑8) 8 (4‑8) 8 (4‑8) 0.001

Dramatic‑reliefGSC 4 (3‑6) 6 (4‑8) 8 (4‑8) 0.001 0.08 0.2 0.09 2.61Nicotine 4 (2‑4) 4 (2‑6) 4 (2‑6) 0.02Combine 4 (2‑4) 7 (4‑8) 7 (4‑8) 0.001

Self‑reevaluationGSC 5 (4‑8) 8 (4‑8) 8 (5‑8) 0.001 0.07 0.07 0.09 2.8Nicotine 5 (2‑6) 5 (2‑8) 5 (2‑8) 0.05Combine 4 (3‑8) 8 (6‑8) 8 (6‑8) 0.0001

Social‑liberationGSC 4 (4‑0) 4 (1‑4) 4 (1‑4) 0.002 0.4 0.1 0.03 0.94Nicotine 2 (2‑4) 4 (1‑4) 4 (1‑4) 0.05Combine 4 (1‑4) 4 (4‑4) 4 (4‑4) 0.001

Consciousness‑raisingGSC 7 (4‑8) 8 (7‑8) 8 (7‑8) 0.007 0.18 0.4 0.06 1.8Nicotine 5 (4‑8) 7 (4‑8) 7 (4‑8) 0.05Combine 6 (3‑8) 8 (7‑8) 8 (7‑8) 0.001

Temptation

Socio‑positive situationGSC 7 (5‑12) 1 (0‑5) 1 (0‑5) 0.0001 0.06 0.02 0.1 3Nicotine 8 (7‑8) 8 (4‑8) 8 (4‑8) 0.05Combine 8 (5‑10) 1 (0‑8) 1 (0‑6) 0.0001

Negative affect‑situationGSC 10 (8‑15) 2 (0‑12) 2 (0‑12) 0.0001 0.9 0.01 0.04 0.01Nicotine 6 (6‑6) 6 (6‑6) 6 (6‑6) 0.05Combine 12 (9‑12) 4 (0‑12) 4 (0‑11) 0.0001

Habitual‑cravingGSC 4 (3‑6) 0 (0‑5) 0 (0‑5) 0.0001 0.004 0.058 0.19 6.24Nicotine 11 (5‑12) 10 (3‑12) 10 (3‑12) 0.13Combine 10 (5‑12) 3 (0‑10) 1 (0‑10) 0.0001

Data are expressed as the median (IQR). IQR: Interquartile range, GSC: Guided self‑change

[Downloaded free from http://www.jnmsjournal.org on Saturday, December 28, 2019, IP: 140.234.253.9]

Sharifpour, et al.: Smoking cessation in COPD patients

20 Journal of Nursing and Midwifery Sciences | Volume 7 | Issue 1 | January-March 2020

did not differ significantly across the stages of change in this sample.[17] The cons and pros in our study, after follow‑up, had significant differences across the three groups.

In another study,[9] it was stated that their intervention resulted in greater pros of quitting over time, but, in contrast to our study, their participants reported fewer cons of quitting at the follow‑up. Our study indicated significant associations in the three intervention groups in temptation, pros and cons, and behavioral and experiential processes of TTM. These results also demonstrate that participants who quit are more likely to benefit from the behavioral process than smokers.[37] Moreover, in contrast to TTM, former smokers reported more consciousness risings and social liberation than smokers.[38] Glanz et al.[39] reported that social liberation was unclearly associated with the stages. In line with consciousness raising, it could be explained that smokers who quit may have increased awareness of the costs of smoking.[40‑42] In this regard, a randomized controlled trial was conducted in Konya, Turkey, on a group of females that divided by precontemplation, contemplation, and preparation stages and age. The study was completed with an intervention group consisting of 38 participants and a control group of 39 participants. The intervention group was interviewed five times and was given counseling and training in the first three interviews. The TTM scales were evaluated for both groups at the beginning and at 2‑ and 6‑month follow‑up. In the 6‑month follow‑up, smoking cessation rate and progress rate were found to be higher in the intervention group than in the control group. All the variables had differences except for the cognitive processes, and the pros of change in the intervention group over time,[29] being consistent with the results of our study in the cognitive process. In another study,[43] using a convenience sample of 123 smokers, the results of the study demonstrated the role of temptation, increase in the cons, decrease in the pros, and nicotine dependence. In our study, the motivation for cessation was high in COPD participants, and all of the groups showed

decrease in temptation, increase in the cons, decrease in the pros, and nicotine dependence.

CONCLUSION

The GSC and combined GSC‑NRT groups were significantly more effective than the NRT group in TTM variables, and GSC and combined GSC‑NRT were equally effective in smoking cessation rate. The interventions showed decrease in temptation, increase in the cons, decrease in the pros, and nicotine dependence. TTM may be useful in understanding the stages of changes in COPD smokers in deciding on the appropriate intervention for smoking cessation.

Conflicts of interestThere are no conflicts of interest.

Authors’ contributionsMZ developed the original idea for the trial and attracted funding. FT, SS and MZ and ASH were responsible for the design of the study protocol. FT conducted the GSC and performed the required follow‑ups. AA performed the statistical analyses. Clinical interpretations were conducted by MZ, SS and SA. The first draft of the paper was developed by FT and revised for important intellectual content by MZ, AA, SA, SS and ASH. All authors read and approved the final version.

Financial support and sponsorshipThis study was supported by Mazandaran University of Medical Science.

AcknowledgmentsThe authors are grateful to Mazandaran University of Medical Sciences, all the patients who participated in this study, and the research assistants and colleagues who kindly cooperated in the conduct of the study.

REFERENCES

1. Brick LA, Redding CA, Paiva AL, Velicer WF. Intervention effects on stage transitions for adolescent smoking and alcohol use acquisition. Psychol Addict Behav 2017;31:614‑24.

2. Schumann A, Meyer C, Rumpf HJ, Hannöver W, Hapke U, John U. Stage of change transitions and processes of change, decisional balance, and self‑efficacy in smokers: A transtheoretical model validation using longitudinal data. Psychol Addict Behav 2005;19:3‑9.

3. Rios LE, Herval ÁM, Ferreira RC, Freire MD. Prevalences of stages of change for smoking cessation in adolescents and associated factors: Systematic review and meta‑analysis. J Adolesc Health 2019;64:149‑57.

4. Zarghami M, Taghizadeh F, Sharifpour A, Alipour A. Efficacy of smoking cessation on stress, anxiety, and depression in smokers with chronic obstructive pulmonary disease: A randomized controlled clinical trial. Addict Health 2018;10:137‑47.

5. Huang CM, Wu HL, Huang SH, Chien LY, Guo JL. Transtheoretical

Figure 6: Pros trends over the time

[Downloaded free from http://www.jnmsjournal.org on Saturday, December 28, 2019, IP: 140.234.253.9]

Sharifpour, et al.: Smoking cessation in COPD patients

Journal of Nursing and Midwifery Sciences | Volume 7 | Issue 1 | January-March 2020 21

model‑based passive smoking prevention programme among pregnant women and mothers of young children. Eur J Public Health 2013;23:777‑82.

6. Atak N. A transtheoretical review on smoking cessation. Int Q Community Health Educ 2007;28:165‑74.

7. Sarbandi F, Niknami S, Hidarnia A, Hajizadeh E, Montazeri A. The transtheoretical model (TTM) questionnaire for smoking cessation: Psychometric properties of the Iranian version. BMC Public Health 2013;13:1186.

8. Carlson LE, Taenzer P, Koopmans J, Casebeer A. Predictive value of aspects of the transtheoretical model on smoking cessation in a community‑based, large‑group cognitive behavioral program. Addict Behav 2003;28:725‑40.

9. Gillen EM, Hassmiller Lich K, Yeatts KB, Hernandez ML, Smith TW, Lewis MA. Social ecology of asthma: Engaging stakeholders in integrating health behavior theories and practice‑based evidence through systems mapping. Health Educ Behav 2014;41:63‑77.

10. Son HM. Differences in processes of change, decisional balance, and temptation across the stages of change for smoking cessation. Taehan Kanho Hakhoe Chi 2005;35:904‑13.

11. Tsoh JY, Hall SM. Depression and smoking: From the transtheoretical model of change perspective. Addict Behav 2004;29:801‑5.

12. Anatchkova MD, Velicer WF, Prochaska JO. Replication of subtypes for smoking cessation within the preparation stage of change. Addict Behav 2006;31:359‑66.

13. Yasin SM, Taib KM, Zaki RA. Reliability and construct validity of the Bahasa Malaysia version of transtheoretical model (TTM) questionnaire for smoking cessation and relapse among Malaysian adult. Asian Pac J Cancer Prev 2011;12:1439‑43.

14. Chouinard MC, Robichaud‑Ekstrand S. Predictive value of the transtheoretical model to smoking cessation in hospitalized patients with cardiovascular disease. Eur J Cardiovasc Prev Rehabil 2007;14:51‑8.

15. Melzer AC, Golden SE, Wiener RS, Iaccarino JM, Slatore CG. A brief report of smoking behaviors in patients with incidental pulmonary nodules: Associations with communication and risk perception. Tob Use Insights 2019;12:1‑5.

16. Hoeppner BB, Velicer WF, Redding CA, Rossi JS, Prochaska JO, Pallonen UE, et al. Psychometric evaluation of the smoking cessation processes of change scale in an adolescent sample. Addict Behav 2006;31:1363‑72.

17. Macnee CL, McCabe S. The transtheoretical model of behavior change and smokers in Southern Appalachia. Nurs Res 2004;53:243‑50.

18. Lee JY, Ahn H, Lee H. Factors affecting secondhand smoke avoidance behavior of vietnamese adolescents. Int J Environ Res Public Health 2018;15. pii: E1632.

19. Bilgiç N, Günay T. Evaluation of effectiveness of peer education on smoking behavior among high school students. Saudi Med J 2018;39:74‑80.

20. Talley B, Masyn K, Chandora R, Vivolo‑Kantor A. Multilevel analysis of school anti‑smoking education and current cigarette use among South African students. Pan Afr Med J 2017;26:37.

21. Sharifirad G, Charkazi A, Berdi‑Ghourchaei A, Shahnazi H, Moudi M. Smoking behavior based on stages of change model among Iranian male students in 2009‑2010 academic year. Zahedan J Res Med Sci 2012;14:13‑7.

22. Tubman JG, Wagner EF, Gil AG, Pate KN. Brief motivational intervention for substance‑abusing delinquent adolescents: Guided self‑change as a social work practice innovation. Health Soc Work 2002;27:208‑12.

23. Saladin ME, Santa Ana EJ. Controlled drinking: More than just a controversy. Curr Opinion Psychiatry 2004;17:175‑87.

24. Sotoodeh Asl N, Taher Neshatdost H, Kalantari M, Talebi H, Mehrabi HA, Khosravi AR. The effectiveness of cognitive behavioral therapy on the reduction of tobacco dependency in patients with essential hypertension. J Res Behav Sci 2011;9:94‑103.

25. Sharifirad GR, Eslami AA, Charkazi A, Mostafavi F, Shahnazi H. The effect of individual counseling, line follow‑up, and free nicotine replacement therapy on smoking cessation in the samples of Iranian smokers: Examination of transtheoretical model. J Res Med Sci 2012;17:1128‑36.

26. Sarbandi F, Niknami S, Hidarnia A, Hajizadeh E, Masooleh HA, Nobari SE. Psychometric properties of the Iranian version of the fagerstrom test for nicotine dependence and of heaviness of smoking index. J Res Health 2015;5:96‑103.

27. Velicer WF, Cumming G, Fava JL, Rossi JS, Prochaska JO, Johnson J. Theory testing using quantitative predictions of effect size. Appl Psychol 2008;57:589‑608.

28. Plummer BA, Velicer WF, Redding CA, Prochaska JO, Rossi JS, Pallonen UE, et al. Stage of change, decisional balance, and temptations for smoking: Measurement and validation in a large, school‑based population of adolescents. Addict Behav 2001;26:551‑71.

29. Koyun A, Eroğlu K. The effect of transtheoretical model‑based individual counseling, training, and a 6‑month follow‑up on smoking cessation in adult women: A randomized controlled trial. Turk J Med Sci 2016;46:105‑11.

30. Rossi SR, Greene GW, Rossi JS, Plummer BA, Benisovich SV, Keller S, et al. Validation of decisional balance and situational temptations measures for dietary fat reduction in a large school‑based population of adolescents. Eat Behav 2001;2:1‑18.

31. Di Noia J, Thompson D. Processes of change for increasing fruit and vegetable consumption among economically disadvantaged African American adolescents. Eat Behav 2012;13:58‑61.

32. Dishman RK, Jackson AS, Bray MS. Validity of processes of change in physical activity among college students in the TIGER study. Ann Behav Med 2010;40:164‑75.

33. Sobell MB, Sobell LC. Individualized behavior therapy for alcoholics – Republished article. Behav Ther 2016;47:937‑49.

34. Camarelles F, Asensio A, Jiménez‑Ruiz C, Becerril B, Rodero D, Vidaller O. Effectiveness of a group therapy intervention to quit smoking. Randomized clinical trial. Med Clin (Barc) 2002;119:53‑7.

35. Jafari M, Shahidi S, Abedin A. Comparing the effectiveness of cognitive behavioral therapy and stages of change model on improving abstinence self‑efficacy in Iranian substance dependent adolescents. Iran J Psychiatry Behav Sci 2012;6:7‑15.

36. Aveyard P, Massey L, Parsons A, Manaseki S, Griffin C. The effect of transtheoretical model based interventions on smoking cessation. Soc Sci Med 2009;68:397‑403.

37. Hoeppner BB, Redding CA, Rossi JS, Pallonen UE, Prochaska JO, Velicer WF. Factor structure of decisional balance and temptations scales for smoking: Cross‑validation in urban female African‑American adolescents. Int J Behav Med 2012;19:217‑27.

38. Velicer WF, Prochaska JO, Redding CA. Tailored communications for smoking cessation: Past successes and future directions. Drug Alcohol Rev 2006;25:49‑57.

39. Glanz K, Rimer BK, Viswanath K. Health behavior and health education: theory, research, and practice; John Wiley & Sons,San Francisco, Jossey‑Bass, 2008.

40. Sutton S. Back to the drawing board? A review of applications of the transtheoretical model to substance use. Addiction 2001;96:175‑86.

41. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997;12:38‑48.

42. Yusufov M, Prochaska JO, Paiva AL, Rossi JS, Blissmer B, Redding CA, et al. Baseline predictors of singular action among participants with multiple health behavior risks. Am J Health Promot 2016;30:365‑73.

43. Eslami AA, Charkazi A, Mostafavi F, Shahnazi H, Badeleh MT, Sharifirad GR. Smoking behavior, nicotine dependency, and motivation to cessation among smokers in the preparation stage of change. J Educ Health Promot 2012;1:47.

[Downloaded free from http://www.jnmsjournal.org on Saturday, December 28, 2019, IP: 140.234.253.9]

Copyright of Journal of Nursing & Midwifery Sciences is the property of MazandaranUniversity of Medical Sciences and its content may not be copied or emailed to multiple sitesor posted to a listserv without the copyright holder's express written permission. However,users may print, download, or email articles for individual use.