Smoking cessation process and quality of life

httpjnepsciedupresscom Journal of Nursing Education and Practice 2017 Vol 7 No 9

ORIGINAL RESEARCH

Hatzilia Despoina1 Malliarou Maria lowast2 Korompeli Anna1 Tsoumakas Konstantinos1 Fildissis George1

1Faculty of Nursing National and Kapodistrian University of Athens Zografou Attica Greece2Technological Educational Institute of Thessaly Thessaly Greece

Received February 6 2017 Accepted March 14 2017 Online Published March 23 2017DOI 105430jnepv7n9p1 URL httpsdoiorg105430jnepv7n9p1

ABSTRACT

Background and objective Smoking habit cessation is undoubtedly a strenuous extremely demanding and stressful process forsmokers therefore treatment should focus on timely cessation and relapse prevention The aim of this study is to assess irritabilitydepression anxiety and the health-related quality of life of patients visiting a smoking cessation clinic during both all 3 phases ofthe treatment and 1 year after completionMethods The participants of the study were 97 people who attended the smoking cessation department of a public tertiaryhospital of the capital of Greece The study consists of 4 phases that took place at intervals of 1 3 and 12 months respectively Aspecially designed questionnaire was used to collect demographic characteristics of the sample and of factors related to theirsmoking behavior as well as EuroQol (EQ-5D) Fagestrom scale and Snaith-IDA irritability scaleResults Results demonstrated positive outcomes both in terms of participation and smoking cessation Calculations performedby using the Fagestrom Test of Nicotine Dependence showed that 362 highly dependent showing that it was difficult for themto quit smoking permanently EQ-5D questionnaire results imply that participants are faced with some problems walking butnot to the point of being unable to take care of themselves however they do seem to have some problems in carrying out usualactivities Forty-three percent of the sample admitted to moderate pain or indisposition in phase 1 whereas again in phase 1 (firstmonth of the smoking cessation treatment) 789 showed signs of moderate anxiety or depression Correlation of EQ-D5 VASvalues between phases 2 and 3 shows that there is statistically significant correlation with a p-value at 001 revealing that theperceived level of quality of life of individuals in phase 2 (completion of smoking cessation program) is higher (7043) than inphase 3 (one year after) (6739)Conclusions The present study shows that the smoking cessation process affects positively quality of life in all its aspectsreduction of anxiety and depression symptoms

Key Words Smoking Cessation Quality of life

1 INTRODUCTIONThe conviction that smoking is the primary extrinsic factor ofmorbidity and mortality in humans has long been establishedWorld Health Organization (WHO) cites tobacco use as thesecond leading cause of death (9) behind hypertensiveheart disease (responsible for 13 of deaths) followed byhigh blood glucose (responsible for 6 of deaths)[1] It isestimated that one third of adult world population ie 11

billion people are smokers and that tobacco causes 6 mil-lion deaths worldwide per year approximately Smokingincreases morbidity and mortality of populations from car-diovascular and respiratory diseases as well as the chancesof neoplastic diseases often leading to health and life threat-ening conditions (about 25) Smoking is a major risk factorin eight (8) out of sixteen (16) causes of death (ie 50) ofpeople aged 65 and over Both direct and indirect treatment

lowastCorrespondence Malliarou Maria Email mmalliarougmailcom Address Technological Educational Institute of Thessaly Thessaly Greece

Published by Sciedu Press 1

costs for tobacco-related diseases are borne by the healthcare system and state budget worldwide

Addiction is the state of a person getting used to a substancepresent in their blood without which that person is unable tohave a normal lifeperform everyday tasks Nicotine is highlyaddictive which explains the difficulty in quitting smokingAddiction is a two-stage process a) the body getting famil-iar with the substance the person experiences unpleasantsymptoms such as nausea and vomiting and b) dependence

A person is deemed to be nicotine-dependent when a chronicconsumption background is present as follows substanceabuse continuous self-administration despite all perceivedadverse effects high tolerance to such substance and with-drawal symptoms during a smoking cessation process Ad-diction to nicotine is a multidimensional process its mainfeature being the individualrsquos desire to experience the phar-macological effects of nicotine and avoid possible manifesta-tions of the withdrawal and dependence syndrome either ina negative (absence of nicotine leading to distress) or a posi-tive manner (psychoactive stimulation) In fact the criteriaadopted by WHO and used in the International Classificationof Diseases place tobacco dependence code F17 in ldquoMentaland Behavioral Disorders due to use of tobaccordquo[2]

Absence of nicotine in smokersrsquo body can cause withdrawalsymptoms (within the first four to twelve hours from smokingcessation) irritability tremor hyperactivity concentrationproblems anxiety distress or depression hunger sleep disor-ders increased heart rate and arterial blood pressure intensedesire (craving) for nicotine intake which is actually thebiggest obstacle for those wishing to quit smoking Othersymptoms include fatigue headache insomnia and dizzi-ness Excessive amount of nicotine may cause dizzinessrise in body temperature blisters queasiness sweat reten-tion anorexia arrhythmia tremor nausea intestine spasmsdiarrhea and drop of arterial blood pressure[3]

Smoking cessation has to do with the conditions which makea smoker maintain such behavior rather than with those thatled himher to start smoking It took time for someone tostart smoking and it undoubtedly take time for someone tolearn to live without the smoke[4 5]

In classical conditioning a specific behavior is associatedwith a neutral stimulus (external (in the environment) or inter-nal stimuli) When it comes to smoking neutral stimuli canbe a pack of cigarettes ash trays the relaxing feeling aftera meal etc Repetition of the sequence ldquostimulus-responserdquoproduces such association that a specific behavior-response(smoking) becomes a ldquoconditionedrdquo response paired with thespecific stimulus A smoker lights a cigarette under specific

conditions without being conscious of that fact such condi-tions have now become conditioned stimuli For examplea smoker may light a cigarette only because it is associatedwith the smell of coffee or the ringing of the phone Mostsmokers light a cigarette without even realizing it Smok-ing behavior is reinforced by the effect of the nicotine itselfin the body Nicotine is an agent with drug-dependenceaction and caused the body to become addicted to it Ittakes less than 10 seconds after inhalation for the nicotineto reach the targeted areas of the brain The nicotine effectitself is a reward for the smoker It acts as a trigger to thesympathetic NS by subsequently releasing neurotransmitterswhich play a determinant role in nicotine addiction and theemergence of withdrawal symptoms Such neurotransmit-ters include a) dopamine and norepinephrine which maybe associated with causing feelings of pleasure and anorexiab) acetylocholine which may improve memory and c) beta-endorphin which might be associated with reducing anxietyand nervousness Smokers are likely to repeat the actionthat produces such pleasant effect hence generate a viciouscircle of addiction This is the point where physical andpsychological addiction concur The need for nicotine isthe physical expression of addiction whereas satisfying suchneed is a pleasant effect that boosts psychological addictionto smoke We can identify four aspects of smoking by whichsmoking behavior is maintained at the same time makingcessation more difficult to achieve a) Physical habit fornicotine intake (physical dependence) b) Smoking as an in-stinctive action under specific circumstances (psychologicalDependence) c) The pleasant effects of smoking (psycho-logical dependence) d) The beliefs regarding the pleasanteffects that smokers anticipate from smoking behavior andthe negative expectations regarding the effects of withdrawal(psychological dependence)

A smoking cessation treatment is more effective when all es-sential aspects of smoking dependence are taken into accountie both physical dependence from nicotine and psycholog-ical Dependence evolving into a habit pleasant effects andsmoking-related beliefs In order for a smoker to be consid-ered a successful quitter he must overcome both addictions

Smoking habit cessation is undoubtedly a strenuous ex-tremely demanding and stressful process for smokers there-fore treatment should focus on timely cessation and relapseprevention

Smoking cessation-oriented treatments range from plain ad-vice by the physician to special smoking cessation programsThe effectiveness of interventions-smoking cessation treat-ments ranges between 1 and 19 compared to the rateof successful sustained cessation among self-quitters which

2 ISSN 1925-4040 E-ISSN 1925-4059

reaches 7[6] It also seems that the occurrence rate of suc-cessful smoking cessation raises along with the intensityof the intervention With each intervention lasting over 10minutes total duration of intervention exceeding 8 weeksand sessions ranging between 4 and 7 result in a highestsuccessful cessation rate[7]

Resuming smoking after a quit attempt is referred to as smok-ing relapse Relapse rates reach up to 60-90 within thefirst 12 months from cessation with 50 in cases of surgi-cally treated laryngeal cancer 30 following myocardialinfarction and 40 following laryngectomy[8]

11 The relationship between irritability depression andquality of life among smokers during smoking cessa-tion treatment

According to a study examining the association betweensmoking cessation and depression smokers were twice aslikely to show symptoms of depression compared to thoseindividuals who had never smoked or to ex-smokers[9]

A study conducted in 2010 on 1504 daily smokers (iesmokers of 9 cigarettes and above per day) motivated to stopsmoking has concluded that smokers with anxiety symptomsreported higher rates in occurrence of withdrawal symptomsand lower possibility for them to continue to abstain fromsmoking for a period between 8 weeks and 6 months More-over anxiety attacks were more associated to increased de-sire for smoking high relapse rates and reduced response tomedication[10] Based on results using Fagerstroumlm Test forNicotine Dependence 569 patients showed reduced levelsof anxiety during cessation treatment which were found un-changed during the three month re-assessment Increasedlevels of anxiety were found in women and patients receivingpsychiatric medication Patients who relapsed also showedlevels of anxiety compared to those prior to relapse[11]

In a 2014 study in Argentina participating adult patients-smokers were treated with the Latin American Spanish ver-sion of Anxiety Sensitivity Reduction Program for SmokingCessation Results demonstrated that the treatment that in-volved follow-up visits in 1 2 4 8 and 12 weeksrsquo timeshowed positive results both in terms of participation andsmoking cessation (5 out of 6 continued to abstain fromsmoking during the 12 follow-up weeks) Results regard-ing reduction of anxiety sensitivity among patients-smokerswere even more important[12]

A study that used Questionnaire of Life (QoL) as a toolto measure the quality of life a randomized controlled trialwhere subjects received varenicline and bupropion concludedthat both the change in health status and QoL self-assessmentscored better among smokers receiving medication compared

to those receiving placebo treatments The study has shown asignificant positive association between length of continuousabstinence and improved health self-control anxiety andoverall mental profile[3]

12 Aim of the studyThe aim of this study is to assess irritability depression anx-iety and the health-related quality of life of patients visitingthe smoking cessation clinic Recording and assessment ofthe results of the study helps to understand the pathogenesisof the specific mood swings observed in smokers-patientsand to ensure that the latter are best and most effectivelyapproached by health professionals Additionally know-ing the specific characteristic of the smoking renders themethodology of a therapeutic approach an ongoing processand allows for the adoption of a comprehensive anti-smokingcare plan by the scientific community by introducing specialpsychological interventions and support

2 METHODOLOGY OF RESEARCH21 Phases of the studyThe study consists of 4 phases that took place at intervalsof 1 3 and 12 months respectively The researcher handedout the same questionnaires at each phase The participantsof the study were 97 people who attended the smoking ces-sation department of a public tertiary hospital of the capitalof Greece During the first visit to the clinic (phase 0) thephysician assessed the patientrsquos decision to quit smoking andenroll in the program Protocol entry is carried out during thisphase The date of smoking cessation was preferably set 15days following first session and the help provided involved ei-ther counselling or medication depending on smokersrsquo wishneeds and particularities After the designing of the treatmentpattern follow-up visits were scheduled every other weekfor the first month of treatment (phase 1) Completion ofthe smoking cessation program and the medication treatment(Nicotine replacement therapy or Zyban or Champix) was setat 3 months (phase 2) Within the first 3 phases patients makean appointment with the special clinic for re-assessment ef-fort evaluation counselling intervention and resolution ofany issues or queries Follow-up evaluation and assessmentmainly focusing on the quality of life of patients was com-pleted after one year of treatment (phase 3) ndashreleased fromprotocol At the last phase results are recorded either in thecase of a face-to-face meeting or by phone where patientsdid not wish to visit the clinic

22 Measuring instrumentA specially designed questionnaire was used to collect de-mographic characteristics of the sample and of factors re-lated to their smoking behavior (smoking onset number of

cigarettes per day level of dependence to nicotine medicalhistory-concomitant diseases medication use of alcohol orpsychotropic substances previous quit attempts with or with-out treatment) Three questionnaires with 29 items in totalwere used at the study The first questionnaire is EuroQol(EQ-5D) It is a reliable and valid tool used for assessing thequality of life in Greece as well[13]

The EQ-5D consists of a self-classifier and a visual analoguescale (EQ-VAS) The self-classifier consists of a 5-item de-scriptive system and assesses health in the 5 dimensionsof mobility self-care usual activities pain discomfort andanxietydepression There are 3 responses for each dimen-sion no problems somemoderate problems and extremeproblems The EQ-VAS is a vertical graduated (0 to 100points) 20-cm ldquothermometerrdquo with 100 representing ldquobestimaginable health staterdquo and 0 representing ldquoworst imagin-able health staterdquo Respondents classify and rate their healthstatus on the day of the survey

The second questionnaire used in the study is the Fagestromtest consisting of 6 items which help to assess the level ofdependence to nicotine (low moderate high) The third ques-tionnaire is the Snaith-IDA (Irritability Depression Anxiety)scale consisting of a total of 18 items with good psycho-metric properties and is proved to be practical easy to useand reliable instrument that helps clinicians assess symptomsof irritability and anxiety The IDA has been validated in ageneral hospital setting[14]

Fagerstroumlm Test for Nicotine Dependence[15] is designedto provide both YESNO and multiple-choice items that issummed to a total score which is a valuable tool for clinicalpractice The higher the score the more intense the nicotinedependence of that individual A score up to four and higherindicates the need for prescribing medication and signalsthat a more intense manifestation of withdrawal syndrome isimminent

23 Procedure

The EQ-5D questionnaire was filled out in four different in-tervals during the initial visit (phase 0) 1 month after initialvisit (phase 1) 3 months later (phase 2) and 12 months later(phase 3) whereas Snaith-IDA irritability scale was filledout at three different intervals during initial visit (phase 0)1 month after initial visit (phase 1) 3 months after the begin-ning of the study (phase 2) The remaining questionnairesthe one consisting of socio - demographic data-related itemssmoking habit health profile and Fagestrom Nicotine De-pendence Test were filled out only at first contact with thesmoking cessation clinic (phase 0)

24 Statistical analysisThe EQ-5D questionnaire in the Greek version was filled outduring the scheduled visit at the smoking cessation clinic byway of interviews in parallel with the special questionnaireconsisting of social demographic and anthropometric dataFor comparisons against the two groups an independent t-testwas used for the two independent samples while the pairedt-test was used for dependent ones For comparisons againstthe groups with more than two independent samples one wayAnovas were used

Testing the normality of the distribution was carried out us-ing the Kolmogorov-Smirnov nonparametric test The valuesof the Snaith-IDA irritability scale were used as continu-ous variables Pearsonrsquos correlation coefficient was used tocheck possible correlations p-values referred to are basedon two-way analysis and statistical significance was set at05 Statistical analysis of the data was run with using SPSS19

3 RESULTS31 Demographic data resultsTable 1 displays the demographic data of the sample of thestudy 567 of the sample are men mainly self-employed(438) whereas average age is 5532 years

Table 1 Frequency distribution (absolute amp relative) ofdemographic data

Frequency

Gender

Men 55 567

Women 42 433

Profession

Employee - public sector 29 302

Employee - private sector 7 73

Self-employed 42 438

Retired 15 156

Housekeeping 3 31

Mean SD

Age 5532 +-11345

Table 2 outlines the smoking habits of the sample It canbe therefore inferred that the average age of participants inthe study was 20 years whereas currently they smoke 25cigarettes per day on average They were asked to use a10-Point Grading scale (1-10) where the minimum value is 1and the maximum value is 10 to write down how importantquitting smoke was for them and based on the mean valueof answers produced set significance at 834 while when asimilar scale was used to measure the level of difficulty toquit smoking the value was 858 722 of them admitted

4 ISSN 1925-4040 E-ISSN 1925-4059

to previous quit attempts using different methods

Comparing the methods used in previous quit attempts tothe one the participants selected during the study it can beinferred that there is a shift toward the use of Champix as itshows an increase from 175 to 325 among participants

in the study Also worthy of note is the fact that although216 among them had not sought any assistance in previousquit attempts this is no longer the case There also seemsto be a considerable increase in the use of nicotine substi-tutes 412 of the sample did quit smoking 292 reportedalcohol consumption

Table 2 Frequency distribution (absolute amp relative) of smoking habit among the sample

Mean SD

Smoking habit

Smoking onset age (in years) 1982 +-3587

Number of cigarettes smoked daily (cigarettes) 25 +-11983

How important is it for you to quit smoking (min 1 - max 10) 834 +-1547

How difficult do you think will be for you to quit smoking (min 1 - max 10) 858 +-1695

Frequency

Previous quit attempts

No 27 278

Yes 70 722

Previous quit attempt method

Gradual reduction of cigarettes smoked 19 196

Nicotine substitutes 20 206

Zyban 12 124

Champix 17 175

No assistance 21 216

Other 8 82

Smoking cessation method at the beginning of the study

Zyban 5 125

Champix 13 325

Other 9 225

Quit smoking (after one year from first visit to the smoking cessation clinic)

Yes 41 412

No 57 588

Alcohol consumption

No 68 708

Yes 28 292

Table 3 displays the answers in Fagestrom Nikotine Depen-dence Test where 417 report smoking between 11 and 20cigarettes per day 615 that they smoke more cigarettesin the morning than in the afternoon 385 smoke the firstcigarette of the day between 6 and 30 minutes after wakingup 167 within the first 5 minutes from wake up whereas188 smoke the first cigarette of the day one hour later Anextra note is that 667 find it hard not to smoke that first

cigarette 594 report that they smoke even when they arein bed sick and 484 said that they find it hard not to smokein areas where smoking is prohibited

32 Fagerstrom nicotine dependence testDependence of respondents was calculated based on theFagestrom Nicotine Dependence Test 213 showed lowdependence 426 moderate dependence and 362 high de-pendence (see Table 4)

Table 3 Frequency distribution (absolute amp relative) of FAGESTROM Nicotine Dependence Test

How many cigarettes do you smoke in a day

Less than 10 10 104

11-20 40 417

21-30 23 240

31 or more 23 240

Do you smoke in the morning rather than in the afternoon

No 37 385

Yes 59 615

How soon after you wake up do you smoke the 1st cigarette of the day

Within 5 minutes 16 167

6-30 minutes 37 385

31-60 minutes 25 260

After 60 minutes 18 188

Which of the cigarettes you smoke in the day do you find most hard to go without

First cigarette of the day 64 667

Any cigarette at any moment of the day 31 323

Do you smoke even when you are in bed sick

No 39 406

Yes 57 594

Do you find it hard not to smoke in areas where smoking is prohibited

No 49 516

Yes 46 484

The maximum mean value in these scales can be seen inphase 1 and 1 month after first contact with the smoking ces-sation clinic Irritability (outward-inward) anxiety and de-pression reached the highest value at phase 1 of the study iein the first month of smoking cessation treatment whereasthe lowest value was seen at the phase of completion ofthe smoking cessation program with the exception of anx-iety which has remained more or less unchanged betweenintroduction in the program and completion (see Table 5)

Table 4 Frequency distribution (absolute amp relative) ofFagestrom Nicotine Dependence Test

Fagerstrom Nicotine Dependence Test n

Low dependence 20 213

Moderate dependence 40 426

High dependence 34 362

Table 6 displays results of the correlation of IDA test (pairedt-test) between phases 1 and 2 where mean value of theinward (mean value 1 = 362 ndash mean value 2 = 253) andoutward irritability (mean value 1 = 453 - mean value 2 =394) as well as depression (mean value 1= 646 - meanvalue 2 = 434) and anxiety (mean value 1 = 751 - mean

value 2 = 557) show the highest mean value during phase1 compared to phase 2 which is found to be statisticallysignificant p-value = 000

Mean values of EQ-D5 VAS in all phases of the study aredisplayed in Table 7 Therefore in phase 0 mean value ofEQ-D5 VAS is 6536 in phase 1 mean value is 6557 inphase 2 mean value is 7052 and in phase 3 mean value ofEQ-D5 VAS is 6739

Table 8 displays results of paired t-test carried out to examinecorrelation of EQ-D5 VAS values between phases 2 and 3which is statistically significant with p-value at 001 andrevealing that the perceived level of quality of life of individ-uals in phase 2 comes to 7043 mean value whereas in phase3 the value drops 6739

Table 9 displays the five dimensions of EQ-5D with the sumof the frequencies corresponding to levels 2 and 3 ie thelsquoproblematic onesrsquo Mean values of summary indexes arealso displayed

4 DISCUSSIONSmoking is responsible for the deaths of millions of peo-ple worldwide every year[16ndash18] and in particular active and

6 ISSN 1925-4040 E-ISSN 1925-4059

passive smoking kills almost 6 million people according tothe WHO May 2014 Fact Sheet[19] In Europe 700000people die every year as a result of smoking whereas ap-

proximately 13 million suffer from smoking-related diseaseswith devastating effects on economy society and health caresystems[20]

Table 5 Measures of location and dispersion of scales inward irritability ndash outward irritabilityndash anxiety - depression in 3different phases of the study

N Min Max Mean SD

Phase 0 (first contact)

Inward irritability 96 00 900 311 1907

Outward irritability 96 100 900 420 1582

Depression 96 00 1000 503 2346

Anxiety 96 00 1300 544 2474

Phase 1 (month)

Depression 95 100 1100 646 2457

Anxiety 95 00 1300 751 2409

Phase 2 (quarterly)

Depression 95 00 1000 434 2127

Anxiety 95 00 1100 557 2214

Table 6 IDA test correlation with paired t-test between phases 1 and 2

N Mean SD p-value

Pair 1 inward irritability Phase 1 94 362 1837

000 inward irritability Phase 2 94 253 1577

Pair 2 outward irritability Phase 1 94 451 1564

000 outward irritability Phase 2 94 394 1483

Pair 3 depression phase 1 95 646 2457

000 depression phase 2 95 434 2127

Pair 4 anxiety phase 1 95 751 2409

000 anxiety phase 2 95 557 2214

Table 7 Mean value and SD of EQ-D5 VAS in all phases of the study

ΕQ-D5 VAS N Minimum Maximum Mean SD

ΕQ-D5 VAS phase 0 96 3000 10000 6536 14349

ΕQ-D5 VAS phase 1 95 3000 10000 6557 14418

ΕQ-D5 VAS phase 2 95 3000 10000 7052 13398

ΕQ-D5 VAS phase 3 92 3000 10000 6739 14815

Table 8 EQ-D5 VAS correlation among participantsbetween phases 2 and 3 of the study

ΕQ-D5 VAS N Mean SD p

Pair 1 ΕQ-D5 VAS phase 2 92 7043 13417

001 ΕQ-D5 VAS phase 3 92 6739 14815

Note Paired t-test

According to the OECD 2013 and Eurobarometer[21 22]

Greece has the highest percentage of smokers among EUcountries but also among OECD countries with the preva-lence of smoking reaching as high as 41 (45 in men and38 in women)[23]

Table 9 Sum of the frequencies corresponding to levels 2 and 3 of the five dimensions of EQ-5D and comparison againstgeneral population

ΕQ-D5 M SC UA PI ΑD

Ν () Ν () Ν () Ν () Ν ()

GENERAL POPULATION 214 50 187 334 435

PHASE 0 47 (485) 2 (21) 23 (240) 41 (427) 42 (437)

PHASE 1 43 (453) 3 (32) 28 (295) 41 (432) 79 (831)

PHASE 2 42 (443) 1 (11) 20 (211) 29 (305) 61 (642)

PHASE 3 45 (484) 3 (32) 24 (258) 36 (387) 56 (602)

GENDER

MEN (PHASE 0) 28 (596) 2 (1000) 13 (565) 21 (525) 19 (463)

WOMEN 19 (404) 0 10 (435) 22 (475) 23 (537)

MEN (PHASE 1) 25 (581) 3(1000) 17 (607) 20 (488) 42 (547)

WOMEN 18 (419) 0 11 (393) 21 (512) 37 (453)

MEN (PHASE 2) 26 (610) 1(1000) 12 (600) 16 (552) 27 (443)

WOMEN 16 (390) 0 8 (400) 13 (448) 34 (557)

MEN (PHASE 3) 25 (556) 3(1000) 14 (565) 19 (528) 27 (491)

WOMEN 20 (444) 0 10 (435) 17 (472) 29 (509)

CESSATION (PHASE 2)

YES 16 (366) 0 5 (250) 18 (621) 22 (361)

NO 26 (634) 1 (1000) 15 (750) 11 (379) 39 (639)

CESSATION (PHASE 3)

YES 17 (378) 1(333) 5 (174) 12(333) 18 (327)

NO 28 (622) 2(667) 19 (826) 24 (667) 38(673)

ΒΜΙ (PHASE 2)

lt25 13 (317) 0 7 (350) 10 (345) 20 (328)

gt25 29 (683) 1 13(650) 19 (655) 41(672)

ΒΜΙ (PHASE 3)

lt25 15 (333) 2 (667) 8 (304) 14 (389) 20 (345)

gt25 30 (667) 1 (333) 16 (696) 22 (611) 36 (655)

Task phase 0

YES 29 (683)

NO 13 (317)

Note M Mobility SC self-care UA usual activities PI Pain or indisposition ΑDAnxiety or depre

Smoking has a harmful effect on human organism makingeffective interventions for smoking cessation and smokingprevalence reduction an imperative Smokers lose at least10 years of life expectancy compared with those who havenever smoked whereas quitting before the age of 40 reducesdeath risk associated with use of tobacco by 90[24] Smok-ing is associated with a number of diseases mainly withrapid lung function decline and increased mortality

The severe effects of smoking on human organism are trans-lated to diseases of the respiratory system Smoking is thecause of 80-90 of is the major cause of chronic obstruc-tive pulmonary diseases (chronic bronchitis asthma emphy-

sema) Smoking kills up to 50 of smokers causes coronaryartery disease with mortality rate of 30-40 and 90-95of lung cancer[25] It is estimated that the majority of the 11bn tobacco product users worldwide wish to quit smoking[16]

Although countries do work on restricting smoking by imple-menting various anti-smoking measures millions of peoplesuffer from effects of smoking which not only reduces lifeexpectancy but also causes the quality of life to deteriorategiven that the benefits to be drawn from smoking cessationare invaluable as they also constitute a major contribution tothe improvement of public health[16ndash18 26] In recent yearsnicotine substitutes have been a successful smoking cessation

8 ISSN 1925-4040 E-ISSN 1925-4059

method as has also been the case with medications that acton the receptors of the brain (bupropion varenicline) First-line medications constitute the nicotine substitution treatmentas they reduce the intensity of withdrawn symptoms and thedesire for smoking whereas second-line treatments are ad-dressed to patients who do not respond to first-line ones[27]

Since the adverse effects of smoking were first seen in smok-ers and treatments of smoking cessation ensued many re-searchers conducted research with an aim to assess anxi-ety and quality of life of smokers as an additional meanthat would help them understand the pathogenesis of moodswings of smokers-patients during smoking cessation treat-ment In the present study 567 of the sample is menprimarily self-employed of an average age of 5532 smok-ing onset age 20 years on average smoking 25 cigarettesper day on average The health profile of participants in thestudy shows that 13 among them suffer from hypertensiondiabetes mellitus about 14 among suffer from thyroid dis-ease while a percentage below 20 suffer from COPD andreceive treatment In a 2014 study in Argentina participatingadult patients-smokers were treated with the Latin AmericanSpanish version of Anxiety Sensitivity Reduction Programfor Smoking Cessation Results demonstrated that the treat-ment that involved follow-up visits in 1 2 4 8 and 12 weeksrsquotime showed positive outcomes both in terms of participationand smoking cessation (5 out of 6 continued to abstain fromsmoking during the 12 follow-up weeks) Results in reduc-tion of anxiety sensitivity among patients-smokers were evenmore important[12]

Participants in the study responded that quitting smoking issignificant scoring 834 on a 10-Point Grading scale andthat they found it difficult to do so producing a 858 scoreAbout 23 admitted to previous quit attempts using differentmethods Comparing the methods used in previous quit at-tempts to the one the participants selected during the study itcan be inferred that there is a shift toward the use of champixas now twice a many participants chose this specific treat-ment Also worthy of note is the fact that although they hadnot sought any assistance in previous quit attempts this isno longer the case There also seems to be a considerableincrease in the use of nicotine substitutes Less than half ofthe sample managed to quit smoking

Calculations performed by using the Fagestrom Test of Nico-tine Dependence showed that 426 was moderately de-pendent on smoking and 362 highly dependent showingthat it was difficult for them to quit smoking permanentlyAs demonstrated in another research conducted in 2010 on1504 daily smokers (ie smokers of 9 cigarettes and aboveper day) motivated to quit smoking smokers with anxiety

symptoms reported higher rates in occurrence of withdrawalsymptoms and lower possibility for them to continue to ab-stain from smoking for a period between 8 weeks and 6months Moreover anxiety disorder attacks were more asso-ciated to increased desire for smoking high relapse rates andreduced response to medication[10] Results obtained fromthis study show that irritability (outward ndash inward) anxietyand depression reached the highest value at phase 1 of thestudy ie in the first month of smoking cessation treatmentwhereas the lowest value was seen at the phase of com-pletion of the smoking cessation program These findingsthough are in contrast to those from a recent study whichconcluded that smoking cessation is positively associatedwith improvement of irritability and anxiety symptoms morespecifically the severity of anxiety attacks among smokerswho had enrolled in a smoking cessation program reducedas early as one week after joining the program Those smok-ers who remained smoke-free for one month experiencedless and reduced severity anxiety symptoms compared tothose in relapse[28] Based on results from yet another re-search where the Fagerstroumlm Test for Nicotine Dependencewas used 569 participants who smoked 23 cigarettes perday showed reduced levels of anxiety during cessation treat-ment which were found unchanged during the three monthre-assessment[11]

In the present research no statistically significant associationwas found between the gender sub-scales this is opposedto the findings of a study published in 2015 where it wasargued that the impact of depression on smoking was moresevere among women which means that this has to be takeninto account during selection of treatment[29] In yet anotherresearch that used data from 3010 smokers there was a clearassociation between women smokers and quality of life withwomen scoring lower in QoL assessment compared to mensmokers These results reflect the need to classify womenparticipating in smoking cessation programs as a separatestudy group[30]

Comparing smokers who eventually managed to quit to thosewho did not succeed in doing so it can be seen that in phase1 ie in the first month of the smoking cessation treatmentsmokers who did not eventually quit showed higher inwardirritability than those who eventually managed to quit Asregards anxiety those who quit smoking scored a lower meanvalue in the grading scale compared to those who did notie there was more anxiety among smokers Based on resultsfrom yet another study where the Fagerstroumlm Test for Nico-tine Dependence was used 569 participants who smoked 23cigarettes per day showed reduced levels of anxiety duringcessation treatment which remained unchanged during thethree-month re-assessment Increased levels of anxiety were

found on women and patients receiving psychiatric medi-cation Patients who relapsed also showed higher levels ofanxiety compared to those prior to relapse[11]

Findings in the present study relating to depression duringcompletion of the program for both smokers and nonsmok-ers seem to be consistent with those in other studies suchas the one conducted on 1725 psychiatric patients whichdemonstrated a correlation between smoking and severity ofdepression and anxiety symptoms but also between smokingand slow progress of recovery of nicotine-dependent smok-ers[31] In the present study it was found that in phase 2which is practically the phase of completion of the programthe mean value of depression among smokers was higherthan in those who managed to quit smoking

Regarding findings of the present study on the level of qual-ity of life drawn from the EQ-5D questionnaire they implythat participants are faced with some problems walking butnot to the point of being unable to take care of them how-ever they do seem to have some problems in carrying outusual activities About 432 of the sample admitted tomoderate pain or indisposition in phase 1 whereas againin phase 1 (first month of the smoking cessation treatment)789 showed signs of moderate anxiety or depression Thisis the highest rate compared to those in all other phasesAnxietydepression has been the most frequently reporteddimension that was found to cause problems Our findingsmatch those of another which examined the correlation be-tween smoking cessation and depression and smokers werefound twice as likely to show symptoms of depression com-pared to those individuals who had never smoked or to ex-smokers[9] Another study conducted on 1725 psychiatric pa-tients showed that at the beginning of the smoking cessationprocess they had symptoms of depression and anxiety Evensymptoms of agoraphobia were more severe among addictedsmokers compared to nonsmokers or non-addicted smok-ers and symptoms of depression and anxiety were slower toimprove It can therefore be inferred that there is a correla-tion between smoking and severity of depression and anxietysymptoms but also between smoking and slow progress ofrecovery of nicotine-dependent smokers[31]

A study on smoking that involved administration of bupro-pion together with the use of a nicotine substitute showed thatself-reported quality of life was higher among ex-smokerscompared to those who had not quit The research used theAssessment of Health Status using SF-36 where after 12months from smoking cessation scoring for physical factorbut principally mental factor was higher among smokerswhich means that abstinence from smoking is associatedwith better quality of life especially in mental health-related

issues[32] A study conducted to define the quality of lifeusing 5234 participants of which 2639 were nonsmokers1419 ex-smokers and 1048 were smokers within a timeperiod of 4 years (2000-2006)ndashshowed that smokers had alower score in general health status social functioning aswell as emotional and mental health whereas those who hadquit around the time of the research demonstrated signifi-cant improvement in emotional and mental health comparedsmokers who continued smoking or those who started smok-ing The general conclusion drawn from this research is thatit appears to be a clear correlation between smoking and re-duced score in the overall quality of life but mostly in mentalhealth while it also appears that smoking-related changeshave significant effect on health[33]

A randomized controlled trial that used QoL as a tool tomeasure quality of life and subjects received vareniclineand bupropion concluded that both the change in health sta-tus and QoL self-assessment scored better among smokersreceiving medication compared to those receiving placebotreatment The study has shown a significant positive associ-ation between length of continuous abstinence and improvedhealth self-control anxiety and overall mental profile[3] An-other study conducted in 2012 that used the same QoL toolto define the quality of life among 1504 participants thosewho had been successful in stopping smoking reported animprovement in their quality of life a fact that had a posi-tive impact on those who continued to smoke[34] A 2014study showed that QoL Questionnaire seemed to be of helpto smokers in order for them to cope better with side effectsof smoking cessation thereby enhancing their motivationto quit and subsequently improving cessation rates and thepositive results of the treatment[35]

5 CONCLUSIONSSmoking is a pathological addiction Today the medicalcommunity and health care authorities see people addictedto smoke as patients This is why international guidelines onsmoking addiction strongly recommend that today a healthcare policy should embrace and thus incorporate both specialsmoking cessation programs and medications which wouldwork to the benefit of the people

Smoking cessation constitutes a major step toward reduc-tion of health risks for smokers as smoking is the biggesthealth risk the most typical example of a selected unhealthybehavior and the leading preventable cause of morbidityand mortality[19] Absence of nicotine can cause withdrawalsymptoms (within the first four to twelve hours from smokingcessation) irritability tremor hyperactivity concentrationproblems anxiety distress or depression hunger sleep disor-ders increased heart rate and arterial blood pressure intense

10 ISSN 1925-4040 E-ISSN 1925-4059

desire (craving) for nicotine intake which is actually thebiggest obstacle for those wishing to quit smoking As al-ready mentioned the main problem caused by abstinencefrom nicotine is withdrawal symptoms both physicalorganicand psychological ones This explains the high relapse rateof each smoking cessation attempt

Relapse is an especially disappointing fact but constitutesan ldquoinescapablerdquo event in the process of discontinuing theconsumption of tobacco products permanently Relapse isa common and early finding among ex-smokers as the vastmajority of smokers who join Smoking Cessation Programssay they had a history of cessation attempts There are plentyof studies exploring the relationship between anxiety depres-sion and quality of life among smokers nonsmokers andex-smokers Most of these studies demonstrate there is animprovement in quality of life in all its aspects reductionof anxiety and depression symptoms or the possibility toaddress such medical conditions offered to both nonsmokersand quitters

The present study shows that during smoking cessation pro-cess the individual undergoing treatment regardless of

whether the outcome is positive or negative experienceshigh levels of anxiety inward irritability and depressionFurthermore during completion of the program those whocontinued to smoke and did not manage to quit showed higherlevels of depression compared to those who managed to quitAge and gender did not show any statistically significantassociation with inward and outward irritability depressionand anxiety in any of the phases of the study The level ofimportance and difficulty in quitting smoking did not showany statistically significant association with inward and out-ward irritability depression and anxiety in any of the phasesof the study

Co-morbidity seems to affect the quality of life which meansthat individuals suffering from hypertension treated for dia-betes mellitus but also alcohol drinkers assess their qualityof life to be at a lower level on a per cent scale Accordingto the Fagestrom Test for Nicotine Dependence the levelof dependence does not show any statistically significantassociation with the level of quality of life

CONFLICTS OF INTEREST DISCLOSUREThe authors declare that there is no conflict of interest

REFERENCES[1] WHO Global report Mortality attributable to tobacco 2012 Avail-

able from httpwwwwhointtobaccopublicationssurveillancerep_mortality_attributableen

[2] European Network for Smoking and Tobacco Prevention (ENSP)ENSP guidelines for treating tobacco dependence Brussels Belgium2016 Available from httpelearning-enspeuassetsEnglish20versionpdf

[3] Hays T Croghan I Baker C et al Changes in health-related qual-ity of life with smoking cessation treatment European Journalof Public Health 2010 22(2) 224-229 PMid20884658 httpsdoiorg101093eurpubckq137

[4] Saito T Tobacco dependence Japanese Medical Society of Alcoholand Drug Studies 1998 33(5) 549-556

[5] Ulrich J Meyer C Rumpf HJ et al Smoking nicotine dependenceand psychiatric comorbidity A population-based study includingsmoking cessation after three years Drug and Alcohol Dependence2004 76 287-295 PMid15561479 httpsdoiorg101016jdrugalcdep200406004

[6] Toumpis M Strategy for smoking cessation M 130 Panhellenic Pul-monary Congress Patra Hellenic Pulmonary Association 2004

[7] West R Mcneill A Raw M Smoking cessation guidelines forhealth professionals an update Thorax 2005 55 987-999 httpsdoiorg101136thorax5512987

[8] Krall E Garvey A Garcia R Smoking relapse after 2 years ofabstinence findings from the VA Normative Aging Study Nico-tine and Tobacco Research 2002 4(1) 95-100 PMid11906685httpsdoiorg10108014622200110098428

[9] Luger T Suls J VanderWeg V How robust is the association be-tween smoking and depression in adults A meta-analysis using

linear mixed-effects models Addictive Behaviors 2014 39 1418-1429 PMid24935795 httpsdoiorg101016jaddbeh201405011

[10] Piper M Cook J Schlam T et al Anxiety diagnoses in smokers seek-ing cessation treatment relations with tobacco dependence with-drawal outcome and response to treatment Addiction ResearchReport 2010 106 418-427 PMid20973856 httpsdoiorg101111j1360-0443201003173x

[11] Marqueta A Jimeacutenez-Muro A Beamonte A et al Evolution ofanxiety during the smoking cessation process at a Smoking Ces-sation Clinic Adicciones 2010 22(4) 317-24 PMid21152850httpsdoiorg1020882adicciones173

[12] Zvolensky M Bogiaizian D Salazar P et al An Anxiety Sensitiv-ity Reduction Smoking-Cessation Program for Spanish-SpeakingSmokers (Argentina) Cognitive and Behavioral Practice 2014 21350-363 httpsdoiorg101016jcbpra201310005

[13] Kontodimopoulos N Pappa E Niakas D et al Validity of the Euro-QoL (EQ-5D) Instrument in a Greek General Population Value inHealth 2008 11(7) 1162-1169 httpdxdoiorg101111j1524-4733200800356x

[14] Aylard PR Gooding JH McKenna PJ et al A validation study ofthree anxiety and depression self-assessment scales Journal of Psy-chosomatic Research 1987 31 261-268 httpsdoiorg1010160022-3999(87)90083-3

[15] Fagerstrom KO Schneider NG Measuring nicotine dependence areview of the Fagerstrom Tolerance Questionnaire J Behav Med1989 12(2) 159-82 httpsdoiorg101007BF00846549

[16] Anderson JE Jorneby DE Scott WJ et al Treating tobacco useand dependence Evidence based clinical practice guideline for to-

bacco cessation Chest 2002 121(3) 932-941 PMid11888979httpsdoiorg101378chest1213932

[17] Panagiotakos DB Pitsavos C Manios Y et al Socio-economic sta-tus in relation to risk factors associated with cardiovascular dis-ease in healthy individuals from the ATTICA study Eur J Car-diovasc Prev Rehabil 2005 12(1) 68-74 PMid15703509 httpsdoiorg10109700149831-200502000-00011

[18] Yosho M Jun S Tabahiko O et al Does smoking cessation improvemental health JP and Clinical Neurosciences 2000 (54) 169-172

[19] WHO Report on the global tobacco epidemic WHO 2015 Availablefrom httpwwwwhointtobaccowntden (30 November2016 date last accessed)

[20] European Lung Foundation European Respiratory Society Lunghealth in Europe Facts amp Figures A better understanding of lungdisease and respiratory care in Europe European Lung Foundation2013

[21] OECD (2013) Health at a Glance 2013 OECD IndicatorsOECD Publishing httpsdoiorg101787health_glance-2013-en

[22] Special Eurobarometer 385 Attitudes of European to-wards Tobacco Report May 2012 Available fromhttpeceuropaeuhealthtobaccodocseurobaro_attitudes_towards_tobacco_2012_enpdf

[23] Filippidis F Vardavas C Loukopoulou A et al Prevalence and deter-minants of tobacco use among adults in Greece 4 year trends TheEuropean Journal of Public Health 2012 5 772-776

[24] Jha P Ramasundarahettige C Landsman V et al 21st-Century Haz-ards of Smoking and Benefits of Cessation in the United StatesThe New England and Journal of Medicine 2013 368 341-350httpsdoiorg101056NEJMsa1211128

[25] European Tobacco Control Status Available fromhttpwwwsocidrogalcoholorgtabacodocumentosfile34-european-tobacco-control-statusreport-who-2014htmltmpl=component (30 November 2016 date lastaccessed)

[26] WHO Tobacco or Health a global status report World Health Orga-nization Geneva 1995

[27] Roupa A Tsaras K Papathanasiou I Smoking correlation withchronic obstructive pulmonary disease and the role of health profes-sionals Epistimonika Xronika 2015 20(1) 41-53 [in greek]

[28] Farris S Allan N Morales P et al Does successful smoking cessationreduce anxious arousal among treatment-seeking smokers Journalof Anxiety Disorders 2015 36 92-98

[29] Liew HP Gardner S The interrelationship between smoking anddepression in Indonesia Health Policy and Technology 2015

[30] Wilson D Chittleborough C Kirke K et al The health-related qualityof life of male and female heavy smokers Soz Praumlventivmed 200449 406-412

[31] Jamal M Willem Van der Does A Cuijpers P et al Associationof smoking and nicotine dependence with severity and course ofsymptoms in patients with depressive or anxiety disorder Drugand Alcohol Dependence 2012 126 138-146 PMid22633368httpsdoiorg101016jdrugalcdep201205001

[32] Sales M Oliveira M Mattos I et al The impact of smoking cessationon patient quality of life J Bras Pneumol 2009 35(5) 436-441httpsdoiorg101590S1806-37132009000500008

[33] Guiteacuterrez-Bedmar M Seguiacute-Goacutemez M Goacutemez-Gracia E et al Smok-ing Status Changes in Smoking Status and Health-Related Qual-ity of Life Findings from the SUN (ldquoSeguimiento Universidad deNavarrardquo) Cohort Int J Environ Res Public Health 2009 6 310-320

[34] Piper M Kenford S Fiore M et al Smoking Cessation and Quality ofLife Changes in Life Satisfaction Over Three Years Following a QuitAttempt Ann Behav Med 2012 43(2) 262-270 PMid22160762httpsdoiorg101007s12160-011-9329-2

[35] Goldenberg M Danovitch I Ishak W Quality of Life and Smok-ing The American Journal of Addictions 2014 23 540-562PMid25255868 httpsdoiorg101111j1521-0391201412148x

12 ISSN 1925-4040 E-ISSN 1925-4059

Introduction

The relationship between irritability depression and quality of life among smokers during smoking cessation treatment

Aim of the study

Methodology of research

Phases of the study

Measuring instrument

Procedure

Statistical analysis

Results

Demographic data results

Fagerstrom nicotine dependence test

Discussion

Conclusions