Smoking Cessation, Smoking Attitudes and Behaviors - Essay Example

Cigarette smoking is of growing concern for health care workers. Cessation interventions are numerous; however the value of CBT to the nurse in support of smoking cessation remains unclear. Using a case study approach and A-B-A-B design with semi-structured interview, this study found that the participant reported lower BAI scores on average following cognitive-behavioural intervention. It is anticipated that this study will extend understandings of smoking cessation, smoking attitudes and behaviors, and the contribution of CBT to nurses intervention of smoking cessation. Introduction Smoking is recognized as the single most preventable cause of numerous other diseases and premature death. The cessation of smoking has been related to decreased risk of diseases that have been associated with continued smoking. Generally, smoking has been indicated with increased mortality across many of the industrialized nations in the past thirty years (Ezzati, Lopez, Rodgers, Vander Hoorn, & Murray, 2002). It is acknowledged that differences in mortality for males and females globally effects people across geographical region and age (Ezzati & Lopez, 2004). Such findings indicate that smokers are at a much higher risk of diseases such as heart disease, diabetes, and early retirement due to chronic disease (Housron Person, Pletcher et al., 2006). In turn, the socio-economic burden of smoking related diseases can result in dramatic financial consequences for the individual as well as the wider community (Murray & Lopez, 1997). Smoking cessation interventions such as cognitive-behvioural therapy have been found to deliverable by nurses, and act as effective and efficient methods of supporting a person from quitting the habit (Coleman, 2004a). This aim of the research was to use a case study approach to investigate smoking cessation using a CBT intervention to inform nurses understanding of smoking behaviours and cessation experiences. Firstly, a review of the literature will be presented in relation to smoking statistics in the UK, suggested smoking cessation interventions, and the value of cognitive-behavioural therapy in supporting cessation. Secondly, the method of the study will be detailed. Next, the results and discussion will reflect on the main points of the paper and demonstrate the viability of nurses using CBT to support smoking cessation patients. A Review of the Literature The Statistics on UK Smoking Behaviours It is estimated that smoking in the UK kills almost 120, 000 people annually (Milner & Bates, 2002). As a life threatening addiction that is continuously found to kill half of its regular participants, smoking generates a reported 1.1 million GP consultations each year, costing the NHS about £1.5 billion a year. It has been estimated that 364, 000 admissions to hospital were due to smoking in the year 1997/98. And that nicotine dependence is the cause of one in every five deaths in the UK. Cessation Interventions The NHS has proposed that tobacco dependence be classified as an illness in itself, and so be treated as a preventative approach to tobacco-related diseases (Milner & Bates, 2002). There is an abundance of evidence that cost effectiveness of suitable smoking cessation interventions. As across time, reduced prevalence of smoking will reduce smoking related consultations and the costs of treatments. A study by the British Doctors indicated that for those who successfully stopped smoking that there were numerous health benefits. And the Government has leant its support for smoking cessation, as demonstrated in the White paper of public spending by the Treasury as part of the national strategy to deal with health inequalities. Recently it has been shown that successful quitting requires significant support and follow up by trained nurses (Coleman, 2004b). Cognitive Behavioral Theory It is accepted among cognitive behavioral therapists that cognitive processes and behavioral techniques can intervene and positively aid in the treatment of smoking cessation (Coleman, 2004b). However, paramount to CBT is the critical relationship between a person and their chosen therapist. Once smokers have been identified, it is important to assess their interest in stopping smoking with an open question such as "how do you feel about your smoking?" It is important to ask sensitively as some smokers feel defensive when doctors raise the issue, and this can make it difficult to ascertain patients true views. The most effective methods of helping smokers to quit smoking combine pharmacotherapy (such as nicotine or bupropion) with advice and behavioural support. These two components contribute about equally to the success of the intervention. Doctors and other health professionals should therefore be familiar with what these strategies offer, encourage smokers to use them, and be able at least to provide simple advice and behavioural support to smokers. The principles of a cognitive approach seek to encourage a sense of therapeutic independence within the client, to enable and empower the client to be aware of their own healing abilities (Coleman, 2004b). The strategies that a CBT approach imparts to the client, and the different perspectives that are offered to reconstruct meaning from daily events, provides the client with greater opportunities for self-reliance, self-efficacy and self-awareness. Behavioural support usually involves a review of patients smoking histories and their motivation to quit, with smokers being helped to identify situations where they might have a high risk of relapsing during a quit attempt; counsellors also encourage smokers to develop problem based strategies for dealing with these situations (Coleman, 2004b). The Research Question Are those who cease smoking finding support through CBT intervention? The Research Hypothesis It was anticipated that the smoker in this study would experience, on average, less anxiety during cessation when aided by CBT by a trained nurse. Method Participant The participant will be over the age of 30 years to provide enough lifespan data to test the hypotheses. Inclusion criteria will necessitate that the participant speak English as a first language to reduce the likelihood of misunderstanding of items on the questionnaire and during the interview. To further lessen the likelihood of misunderstanding during the therapy sessions it is necessary that the participant have been born in the UK, and to have resided within the UK for at least 10 years. The gender of the participant can be either female or male. Informed consent needs to be seriously considered at the start of any research project (Shank, 2002). Consent is about participants making a reasonable choice to take part in the study; as such their aspirations need to “fit” with the goals of the research (Mason, 1997). Informed consent includes the awareness of the researcher that participation is dependant on the participants understanding of the aims of the project, and what is expected of them during their participation. Informed consent will ensure respect for participant dignity (Mack et al., 2005). Coercion of participation will be avoided at all costs, as the emphasis is on voluntary participation (Penslar, 1995). Hence, informed consent will maintain the well being of the participant as its priority. Additionally, the participant will be made aware that their information shall directly contribute to a sharing of knowledge for other smokers seeking to cease the habit. Also, that it will benefit them in that they will have the opportunity to express their experiences of smoking, attempting to quit and of the intervention used in this study. The participant shall be assured of their rights to confidentiality, anonymity, and voluntary withdrawal without penalty. It shall be made very clear to the participant that their answers to the interview questions shall in no way affect their future treatment that they are eligible for receiving from the hospital. They will be provided with an information sheet about the study, and when they acknowledge that they understand their requirements they will be asked to sign an informed consent form. Signing of the consent form will provide permission to have their interviews tape-recorded. The participant will be asked if they understand what is involved in the project, and unfamiliar terms will be explained. The name and contact details of the researcher will be made known, and community contacts made available in case the participant should be distressed during or after the interviews or from times when smoking is abstained from (Penslar, 1995). Materials Psychometric Test A standardized measure, the Beck Anxiety Inventory (BAI) (Beck & Steer, 1990) will be used. This will provide a comparison of the participant’s levels of anxiety across the CBT intervention periods when the treatment is administered and when it is not. The scale is comprised of 21 items on 4-point scales that range from 0 to 3. The participant responds to how much they have been affected by each particular symptom during the past week. Items are summed to provide a total score that can range from 0 to 63. The BAI has numerous supports for its strong internal reliability and validity. The independent variables will be the times of testing (i.e., ABAB) and the dependant variables will be the levels of anxiety. The Semi-Structured Interview As a semi-structured in-depth interview will be carried out, necessary materials will include notebooks and writing materials, as well as a tape-recorder, tapes and extra batteries. A semi-structured in-depth interview provides a human element to the research process (Bryman, 2004; Shank, 2002). It is a flexible method in that it uses a guide of questions as a framework, whilst allowing the participant to have a free flow of conversation. As such, it provides an opportunity for the participant to talk in-depth about a topic (Mason, 1997). Although the order of items in the question guide will not change across participants, the different responses of each participant will necessitate different promptings for additional details. This type of interview provides the researcher with insight into the experiences of participants, from the participant’s point of view (Guion, 2001; Mason, 1997). The interview is a one-to-one process, usually, and allows the researcher to gauge the participant’s interpretation of the relationships they see between events, people and social values (Bryman, 2004). The researcher asks neutral questions and listens actively, does not approve or disapprove of answers, and does not encourage the participant to provide particular answers, instead facilitating the participant to follow up on previous answers (Padgett, 2004). For this project tape recordings of interviews will be used to type transcripts that will also incorporate researcher notes taken during the interview. The data will then be thematically coded for analyses (Patton, 2002). Design A case study approach provides for a focus on understanding the complexity of an issue such as smoking and its cessation. It is able to build on knowledge developed from previous research. The case study seeks to detail the context in which the analysis occurs, and as such focuses on a select number of events or conditions and the interrelationships between these (Blampied, 1999; Kaxdin, 1998; Kendall, Grayson, & Butcher, 1999; Mack et al., 2005; Padget, 2004). The case study design has been a popular method with researchers in the health and social sciences, primarily as the qualitative approach allows assessment of day-to-day experiences (Padget, 2004). The case study is of greatest use for phenomenon wherein the boundaries are not clearly delineated and multiple sources of information are used. The case study is suited to time series data collection (Blampied, 1999), that will require the same test to be administered to the participant on alternate weeks. The A-B-A-B design takes a measure at baseline (A), and then a treatment measure (the initial B), then withdrawal of treatment (A2), and the re-introduction of treatment (B2) (Kendall, Grayson, & Butcher, 1999; Parry, 2000). Thus, the A-B-A-B design has two parts; the first gathers baseline data, provides application of the treatment and a measure of the treatment effects; and the second part is a measurement of return to baseline (i.e., what occurs when the treatment is removed) and then applying the treatment again and measuring the change. To ensure high reliability and validity of the data, collection will occur over 20 weeks (Kendall, Grayson, & Butcher, 1999; Parry, 2000). Statistical analyses of the raw data will be undertaken with NUD*ST v. 4 and SPSS v. 12. Thematic analyses, frequencies and percentages, Chi Square and Pearson’s r correlations shall be the statistical analyses used for this research study. For thematic analysis, following each interview the written notes of the interviewer shall be summarized, and assessed for their relevance to the questions asked. Comments on observations made during the interview will also be included. The taped interviews shall be transcribed verbatim onto a word document. Two raters, who will be unaware of the research hypotheses, shall independently identify key themes in the transcripts, in regards to the research question (N.B. Research assistants shall be paid “in-kind”). Inter-rater reliability will then be checked, and themes with at least a moderate agreement (r = .60) will be included for further analyses (Shank, 2002). Key themes will be organised into broad categories and specific sub-categories and labels provided respectively (Patton, 2002; Shank, 2002). Again, inter-rater reliability will be used to reach at least a moderate agreement. The primary investigator shall then make interpretative conclusions about each category and sub-category, evaluate proportions within each group, where possible assess the strength of an attitude or perception, and identify issues that differ dramatically in opinion across the sample (Padgett, 2004; Shank, 2002). Frequencies and percentages shall be obtained via basic descriptive analysis of all variables. The Chi square test shall be used for all categorical variables (e.g., gender and themes). Continuous levels of measurement shall be used for Pearson’s r correlations (e.g., age and BAI scores). Procedure When the participant first arrives at the therapy session they will be provided with an informed consent form, and, when the nurse is confident that the participant fully understands the expectations of them during the sessions they will be asked to sign the form. The participant will then complete the first BAI measure (i.e., A1). On the second day the participant will receive a CBT intervention and will not participate in any smoking behaviours (they will be provided with a nicotine patch and nicotine gum). The BAI will again be administered (i.e., B1). The third day, the participant will have the opportunity to simply talk with the therapist, they will be able to smoke during their day to day activities, and no CBT intervention will be provided. At the end of the third session the BAI will again be administered. (i.e., A2). The following day will be B2, the next A3, and so on over 3 weeks. Strengths and Limitations There are numerous strengths and weaknesses of this research study. An important consideration is that the ABAB design withholds relief from the participant. However, for this study there is justification for this removal, as the relief (i.e., smoking) is known to have detrimental health effects that far outweigh its benefits at relieving experiences of addiction. Strengths include the gaining of a personal perspective as opposed to a group interpretation of experiences with smoking cessation as would be the case with a focus group (Shank, 1995). Also, use of the interview method allowed the participant to share their feelings, opinions and experiences of smoking and smoking cessation, and the consequences of the use of CBT for cessation, for themselves, and where applicable for their family, friends and social others (Mason, 1997; Padgett, 2004). It was a strength of this study to gain the individual’s interpretation of events, and how they structured their worldview (Patton, 2002). The interview process will also allowed the researcher to observe the conversational nuances, body language, casual comments and contradictions of participant interpretations (Mason, 1997). In fact, the interview process was an extremely positive experience for both the interviewer as they were entrusted with the personal experiences of another (Mason, 1997). The interview was also be of benefit to participants in that it was cathartic, allowing them to express themselves in a way that were not normally be possible, for example, the degree of frustration they felt during the cessation periods (Penslar, 1995). The use of audiocassettes to tape record the interviews increased the accuracy of reporting, transcription and the final interpretation by the primary investigator (Penslar, 1995). However, due to the subjective nature of the interview process, it is inevitable that the information collected also contained biased opinions and feelings (Shank, 1995). Additionally, there would be the need to have a large number of participants to sufficiently compare responses (e.g., over 1,000, Penslar, 1995), and given the time and budget constraints of this project, this number was unlikely to be obtained. A strong contributing limitation was the different environments in which the interviews took place given that the hospital is a busy environment and a set room could not be used. This increased the likelihood of distractions that could have influenced responses (e.g., telephone calls, visitors, emergencies outside of the room, and their previous experiences in hospitals). Also, interpretation of the data was subjective, and so exposed to researcher bias (Patton, 2002). Another limitation was that the participants answers were modified in order to please the researcher (i.e., demand characteristics, social desirability). Alternatively, the gender, age, social status or ethnicity of the primary investigator may have influenced responses inadvertently (Mason, 1997). Hence, reliability for the semi-structured in-depth interview was low, especially as there was a large amount of subjectivity in the interpretation of the response categories by the primary investigator. Thus, the results of this study will not be able to be generalized to a wider population (Patton, 2002). Results and Discussion The hypothesis for this study was supported in that the participant, on average, had a lower BAI score (M = 2.5, SD=1.7) when smoking cessation was accompanied by CBT intervention. This result supports findings that CBT is an effective intervention to support the needs of smokers who are quitting smoking. It also highlighted the importance of nurse support staff to investigate the motivations, and underlying psycho-social causes of smoking, and to aid the participant in becoming aware of these underling factors. It is anticipated that future nursing interventions for smoking cessation can provided more target support by attending to the areas of intrapersonal perceptions (i.e., coping ability), family relationships, social networks, and job stressors. This research can directly contribute the formation of better training for nurses who are expected to aid and support those ceasing to smoke. References Beck, A. and Steer, R. A. (1990). Manual for the Beck Anxiety Inventory. San Antonio, TX, Psychological Corporation Blampied, N., M. (1999). A Legacy Neglected: Restating the case for Single Case Research in CBT. Behaviour Change, 16: 89-104. Bryman, A (2004). Social Research Methods (2nd ed.). Oxford University Press, Oxford Coleman T (2004a). Cessation interventions in routine health care. British Medical Journal 328; 631-3 Coleman T (2004b). Use of simple advice and behavioural support. British Medical Journal 328; 397-9 Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL (2002). Selected major risk factors and global and regional burden of disease. Lancet 360; 1347-60 Ezzati M, Lopez AD (2004). Regional, disease specific patterns of smoking-attributable mortality in 2000. Tobacco control 13; 388-95 Guion, I (2001). Conducting an In-Depth Interview. Family Youth and Community Sciences Housron TK, Person SD, Pletcher MJ, et al (2006). Active and passive smoking and development of glucose intolerance among young adults in a prospective cohort: CARDIA study. British Medical Journal. doi:10.1136/bmj.38779.584028.55 (published 7 April 2006) Husmoen L, et al (2004). Smoking and subsequent risk of early retirement due to permanent disability. European Journal of Public Health 14; 86-92. Kaxdin, A. (1998). Research Design in Clinical Psychology. Kendall, J. N., Grayson, H. James, C. & Butcher, N. (Eds.)(1999). Handbook of Research Methods in Clinical Psychology. Wiley, New York. Mack, N, et al. (2005). Qualitative Research Methods: A Data Collector’s Field Guide. North Carolina, Family Health International Mason, J (1997). Qualitative Researching: An Introductory Text. New York, Sage Publications Milner D, Bates C (2002). Smoking interventions in the new GP contract. Available at www.ash.org.uk/html/cessation/gpcontract.pdf Accessed February 19, 2007 Parry, G. (2000). Evidence based psychotherapy: special case or special pleading? Evidence Based Mental Health, BMJ (May): 35-36. Patton, M Q (2002). Qualitative Research and Evaluation Methods. Thousand Oaks, Sage Publications Padget, D K (2004). The Qualitative Research Experience. Thompson Learning, Southbank Penslar, R L (Ed.) (1995). Research Ethics: Cases and Materials. Indiana University Press, Bloomington Shank, G D (2002). Qualitative Research: A Personal Skills Approach. Columbus, Merrill/Prentice Hall Read More