Coronary heart disease (CHD) is the largest cause of death for women in the United States and accounts for 1 in 6 deaths.1 A diagnosis of CHD is generally 10 years later for women than for men, which creates poorer outcomes due to the greater number of comorbidities at a later age.2 Disparities between men and women with CHD include a higher death rate for women within 5 years of their first myocardial infarction (MI), experiencing heart failure and stroke after a diagnosis of CHD more often than men do, and additional risk for CHD related to menopause2 and hormone therapy.3
Tobacco use is one modifiable risk factor for CHD.2 Smoking-related disease is the number 1 preventable cause of death for women in the United States.4 Among Americans, approximately 18% of women smoke despite decades of progress to reduce smoking rates.5 Smoking increases a woman’s risk for negative health effects and death when combined with a history of CHD.4 The risk of dying from CHD is 2 to 4 times greater for smokers than for nonsmokers.4 Many risks associated with smoking and CHD have been established, which may increase the possibility of invasive CV interventions, such as percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). According to the 2001 Surgeon General’s Report on Women and Smoking,5 the negative health effects from smoking can be reduced after 1 to 2 years of smoking cessation (SC), and for CHD, these benefits are almost immediate. Because of the potential benefits to women’s health, efforts to increase the rate of SC in women are greatly needed. One focus of secondary prevention guideline recommendations is complete SC.6–10 The time of an invasive CV procedure is an opportunity for women to refocus on secondary prevention behaviors such as SC in efforts to prevent future cardiac events. Therefore, the purpose of this study, guided by the Health Belief Model (HBM), was to determine which factors predict SC in women after an invasive CV procedure.
Because the HBM attempts to better understand health behaviors11 and has been used to explain smoking behaviors, the HBM was used in this study to explain SC behavior in women with CHD who have experienced an invasive CV treatment. To engage in recommended health actions such as SC, the individual must believe that she is susceptible to a certain health condition such as CHD or a future invasive CV intervention, and the presence of illness must have at least a moderate threat to some aspect of her life.12
The HBM concepts (Figure 1) were grouped into 3 main categories and conceptualized as (1) the individual’s perceived susceptibility and perceived seriousness of CHD and of future CV interventions (perceived threat); (2) modifiable factors of depressive symptoms and an individual’s general motivation to stop smoking, cues to action (CTAs; receiving SC assistance from a healthcare provider (HCP); and (3) the outcome, likelihood (commitment) of SC at the time of the invasive procedure and factors associated with this likelihood (SC self-efficacy and perceived barriers to and benefits of SC) and the health action outcome of SC.12
Identifying factors associated with SC after an invasive CV intervention can lead to SC interventions specific to women. This study sought to determine among female smokers receiving an invasive CV intervention (PCI or CABG) which HBM variables (perceived barriers to SC, perceived threat of CHD and future CV interventions, CTAs, depressive symptoms, and SC self-efficacy) were associated with higher commitment to stop smoking at baseline and which of these variables predicted SC at 3 months follow-up.
Design and Participants
A prospective, correlational design was used. Baseline data were collected during hospitalization after the invasive CV procedure when the patient was stable and willing or at least within 1 week after discharge. Three months after their baseline interview, the women were interviewed via telephone to establish their current smoking status. Additional data collected at 3 months included commitment to stop smoking13 and depressive symptoms.14
A nonrandom sample of female smokers undergoing either CABG surgery or PCI with a diagnosis of CHD were recruited from an acute care hospital located in the Southeastern United States. The sample included women 40 to 80 years of age because older age is a risk factor for CHD.2 Additional inclusion criteria were women who (1) were identified from the medical record as a current smoker15 and had a diagnosis of CHD; (2) had an invasive CV intervention, defined as a CABG surgery or PCI (with or without stent placement) within the past week; (3) were willing to provide contact information for the 3 month follow-up; (4) had a stable medical condition; and (5) were able to read and speak in English without assistance. Women with a current diagnosis of severe mental illness such as schizophrenia were excluded because these diagnoses may have affected their ability to provide informed consent, complete questionnaires, or perceive the risks of smoking to their health.
Between April and July 2010, 76 female smokers undergoing a heart catheterization agreed to participate in the study and completed surveys at baseline (Figure 2). Ten questionnaires were administered at baseline with an average of a total of 45 minutes to complete. At 3 months, women (n = 54) were reached via telephone and completed 2 structured questionnaires and semistructured interview questions related to smoking, and the interview took, on average, 20 minutes to complete.
Smoking cessation was measured using self-report during a telephone interview 3 months after baseline. Smoking cessation was a dichotomous outcome (yes/no) in response to the question “Have you smoked at least 100 cigarettes in your lifetime and do you now smoke cigarettes every day or some days since your heart procedure?”15
Smoking status via self-report has been questioned for fear of underreporting. However, one meta-analysis of 51 comparisons between self-reported behavior and biochemical measures found that using self-report smoking status is appropriate under certain conditions,16 including self-report for smoking in women.17
Commitment to Stop Smoking
Commitment has been linked with successful SC.13,18,19 Commitment to stop smoking was operationalized as “a cognitive state of being personally bound or obligated to avoid smoking despite any potentially difficulty, discomfort, or craving associated with quitting, even when the magnitude and duration of that discomfort are unknown and variable” and was measured with the Commitment to Quitting Smoking Scale (CQSS).13 This is an 8-item Likert-type scale where higher scores indicate a greater commitment to stop smoking (total score, 8–40).13 The CQSS has established reliability and validity.13 Cronbach α for this study was .92 at baseline and .95 at the 3-month follow-up.
Self-efficacy for Smoking Cessation
Smoking cessation self-efficacy has predicted SC.20–22 Self-efficacy for SC was measured by the Smoking Self-efficacy Questionnaire (SEQ-12).20 This is a 12-item, 5-point Likert-type scale that measures individuals’ confidence in their ability to stop smoking in high-risk situations. The SEQ-12 consists of 2 subscales that measure confidence to refrain from smoking when facing internal and external stimuli. Each item was rated on a 5-point Likert-type scale. The SEQ-12 has a total score of 12 to 60, with higher scores indicating higher smoking self-efficacy.20 The reliability and validity for the SEQ-12 have been established,20,23,24 and Cronbach α at baseline was .89.
Perceived Benefits and Barriers
The smoker’s perception of benefits of and barriers to SC are supported factors related to SC.22,23,25–28 Perceived benefits to SC were measured with the Perceived Benefits Scale (PBS) of the Perceived Risk and Benefits Questionnaire (PRBQ).29 The PBS is a 21-item Likert-type scale (1–7 response option) with 6 subscales (health benefits, general well-being, finances, self-esteem, social approval, and physical attractiveness associated with stopping smoking). The total PBS score was the average of the 6 subscale scores. Higher scores indicate higher perceived benefits of SC.29 The PRBQ total scale has evidence of reliability and validity,19 and baseline Cronbach α was .91.
Perceived barriers to SC were measured using 2 scales. The Barriers to Cessation Scale (BCS) addressed barriers to SC,30 and the Weight Control Smoking Scale (WCSS) addressed a specific barrier for women.31 The BCS is a 19-item, 4-point (0–3) Likert-type scale,30 with total scores ranging from 0 to 57 and higher scores indicating greater perceived barriers to quitting smoking.30 The BCS has established reliability and validity,30 and baseline Cronbach α was .84.
The WCSS is a 3-item Likert-type scale of smoking-related concerns of weight gain and appetite.31 Each item was rated on a 4-point Likert-type scale (total score, 0–9). Higher scores indicate higher smoking-related concerns of weight and appetite.31 The reliability and validity for the WCSS have been established,26 and Cronbach α at baseline was .88.
Cues to Action
Empirical evidence was found related to the support of cues to action as a factor affecting SC.27,32–34 Cues to action are triggers that initiate an individual’s taking recommended action such as SC.12 Cues to action in this study included whether the patient received SC assistance from an HCP. This was measured by a researcher-developed 5-item questionnaire based on the 5 A’s of the 2008 Clinical Practice Guidelines for the Treatment of Tobacco Use and Dependence.10 Scores ranged from 0 (no CTA received) to 5 (all CTAs received). Cronbach α for this study was .55; thus, only descriptive data are reported.
Threat of Heart Disease and Future Cardiovascular Procedures
Smokers’ perceptions of risk for CHD are similar to the concept of perceived susceptibility in the HBM, which is proposed to influence one’s intention to perform a behavior such as SC. Measures for the threat of CHD and threat of future invasive CV interventions were included in this study, and both were adapted from the Champion Health Belief Model Scale.35 Threat of CHD was measured with the Heart Disease Threat Scale (HDTS).35,36 The HDTS is a 10-item Likert-type scale.36 Each item response was scored from 1 (strongly disagree) to 5 (strongly agree), with a possible total score of 1 to 5. Higher scores indicate greater perceived threat of heart disease. The HDTS has shown adequate reliability and validity,36,37 and Cronbach α at baseline was .81.
Perceived threat of a future invasive CV procedure was measured with the Threat to Future Cardiovascular Interventions Scale (TFCIS).36 The TFCIS is an 18-item questionnaire with a response scale of 1 (strongly disagree) to 5 (strongly agree). Possible scores range from 18 to 90, and higher scores indicate higher perceived threat of future invasive CV procedures. The reliability and validity of the Champion Health Belief Model Scale and subscales have been established,36–40 and Cronbach α for the TFCIS at baseline was .83.
An association between smoking and depression has been reported.41–43 Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D).14 This is a 20-item scale with total scores of 0 to 60 and higher scores indicating higher depressive symptoms, with cutoff scores of 16 or higher indicating possible clinical depression. The CES-D is well established with evidence of adequate reliability,44–47 and Cronbach α for this study was .92 at baseline and .88 at 3 month follow-up.
Motivation to Quit Smoking
Motivation to quit smoking was measured using the autonomous subscale of the Treatment Self-regulation Questionnaire (TSRQ).48 The TSRQ is a 12-item, 7-point Likert-type scale, and items represent reasons people engage in healthy behaviors such as SC and assesses the degree to which one’s motivation to stop smoking is autonomous. Each item response ranged from 1 (not true at all) to 7 (very true). Higher autonomous subscores indicate greater autonomous motivation to stop smoking.48 The reliability and validity of the TSRQ have been established with various health behaviors, including SC, diet, exercise adherence, and alcohol treatment,48–50 and Cronbach α for the autonomous subscale in this study was .78.
Demographic and Medical History
An investigator-developed structured questionnaire and medical chart review were used to obtain information about each participant’s demographic information, medical history and specifically cardiac history, and smoking history.
Approvals for the study were obtained from the institutional review boards at the university and hospital. Once potential participants met eligibility criteria and were stable after the procedure, the study was explained to them. Written informed consent was obtained from each woman and then questionnaires were administered to participants. Participants could complete the questionnaires themselves, or the first author or a trained research assistant read the questionnaires and recorded their responses. A reminder card was mailed to participants 8 to 10 weeks after baseline to remind participants that they would be contacted via telephone to discuss their smoking status at 3 months.
Descriptive statistics were used to describe participant characteristics and major study variables. Correlations were used to examine relationships among variables, and t tests were used to make baseline to 3-month comparisons. Hierarchal multiple linear regression and logistic regression were used to test the hypotheses. An α of P < .05 was set for statistical significance.
Sample Characteristics at Baseline
Sample characteristics are shown in Table 1. Most women were middle aged (41–74 years old), and most were white and married and lived with a spouse or other family member. About half of the women had high school or less educational levels. Most participants’ total household income was less than $40 000, with almost one-third living on an income of less than $10 000 annually. A large majority (72%) were retired, disabled, or unemployed. Many participants had an extensive cardiac history. For example, 37% had a previous MI, 62% had a previous heart catheterization, and 13% had a previous CABG surgery. No statistical differences were noted between those who completed the study at 3 months and those who did not, and there was no relationship between those with a previous MI, CABG surgery, or heart catheterization and their smoking status at 3 months (data not reported).
The smoking characteristics of participants were also examined. On average, participants had a smoking history of 33.6 years (SD, 10.2) at baseline and smoked an average of 15.3 cigarettes per day (SD, 9.8). At 3 months, the number of daily cigarettes was significantly reduced to about half a pack, on average, per day (mean [SD], 10.6 [8.5]; paired t51 = 3.43, P < .01). Women reported being somewhat likely to quit smoking after their invasive procedure (mean [SD], 3.53 [1.13]) and had some intention of stopping smoking after their procedure (mean [SD], 3.79 [1.14]) on a 5-point Likert-type scale. Most women had not tried to stop smoking within the 3 months before their heart catheterization. Of those who had attempted to quit before the procedure (n = 30), most reported trying to quit 1 to 3 times, with no success. No participants reported trying to quit smoking specifically in preparation for their heart catheterization. The 2 most common strategies used to try and quit smoking were “cold turkey” and pharmacological varenicline (eg, Chantix [Pfizer, New York, New York]). Women reported that the reason for wanting to quit smoking was their health and rated their physical health as very important to them (mean [SD], 4.64 [0.48]) on a 5-point Likert-type scale. Half of participants (51%) indicated living with another smoker in the home, most often being the spouse/significant other (30%) or children (17%).
Female smokers, on average, had a high level of commitment to stop smoking (CQSS) (Table 2). At 3 months, women’s CQSS scores were not significantly different from baseline (paired t53 = 0.37, P = .76). On average, women reported high self-efficacy to stop smoking (SEQ-12). Women, on average, recognized the benefits of SC (PRBQ) and reported few barriers (BCS) to SC. Because of a lack of normal distribution this variable with the WCSS measure, it was dichotomized. Most women (82%) did not have concerns about weight gain related to SC.
Most women reported high perceived threat of heart disease (HDTS) and high threat of future CV interventions (TFCIS) (Table 2). Participants reported the current invasive CV procedure as being somewhat stressful (mean [SD], 3.64 [1.33]) but not more stressful than other life stressors (mean [SD], 2.74 [1.14]) on a 5-point Likert-type scale.
At baseline, more than half (55%) of the sample scored above the cutoff score of 16 or higher on the CES-D, indicating high levels of depressive symptoms (Table 2). However, depressive symptoms at 3 months, on average, were lower than the cutoff score (35.2% ≥16 on the CES-D) and were significantly lower than at baseline (paired t52 = 4.84, P < .001). Based on the TSRQ, on average, the autonomous scores indicated that women had high autonomous motivation to stop smoking.
Predictors for Baseline Commitment to Stop Smoking
Hierarchical multiple regression was used to determine which HBM variables were associated with higher commitment to stop smoking at baseline. The number of daily cigarettes at baseline was significantly correlated to the outcome variable and was therefore entered as a covariate, and autonomous motivation to stop smoking was entered along with the HBM variables in step 2 because it was significantly related to commitment to stop smoking. Depression was not included because of its lack of relationship with the CQSS. The full model was significant (F6,67 = 19.37, P < .001) and contributed 66.9% of variance to commitment to stop smoking. Fewer perceived barriers to SC, high SC self-efficacy, and being more autonomously motivated to quit smoking were significant predictors of higher commitment to stop smoking at baseline (Table 3).
Logistic regression was used to examine factors associated with quitting smoking at 3 months (Table 4) in female smokers (n = 46) and nonsmokers ( n = 8) since their procedure. Depression, fear of weight gain, commitment, and CTAs were not included because of their lack of relationship with stopping smoking at 3 months. The overall model was significant (χ24 = 18.67, n = 54; P = .001). However, the only variables that were significantly different between the 2 groups were SC self-efficacy and threat of CHD. Those women who had quit smoking at the 3-month follow-up had higher SC self-efficacy at baseline and lower perceived threat of heart disease. Threats of future CV interventions and barriers to SC were not associated with whether women quit smoking.
Smoking Characteristics at 3 Months
If the women in this study who were lost to follow-up at 3 months were considered smokers, only 10.5% of the women stopped smoking (Table 5). Of the participants continuing to smoke (n = 46), the majority were smoking daily. Slightly less than half of the women did not attempt to stop smoking and 42% made at least 1 attempt, with 13% making multiple attempts. Of those women attempting to quit smoking, the majority described their quit attempt as “cold turkey,” with few using medications, cutting back the number of daily cigarettes, or trying electronic cigarettes. Of the few who tried SC medications, varenicline was the one most commonly prescribed.
Because smoking is the most preventable risk factor for CHD and has been deemed as a “winnable” health problem by the Centers for Disease Control and Prevention,51 it is imperative for clinicians to understand what factors influence patients’ SC after an invasive CV procedure. In general, women had high commitment and were autonomously motivated to stop smoking, were confident in their ability to stop smoking, and perceived benefits of and few barriers to stopping smoking. They also viewed CHD and their invasive CV procedures as a threat. Despite these positive psychological attributes, these perceptions did not translate into the behavior of stopping smoking, and few women had stopped smoking at 3 months after an invasive procedure for their heart disease. One explanation may be that although they want to stop smoking, women may not realize that they need more than “willpower” to make this behavior change. Most women indicated they were going to quit “cold turkey,” and most did not receive assistance from their HCP or others. From the 3 month follow-up, women indicated that the most common barrier to stopping smoking was anxiety and depression and suggested that smoking was a coping strategy. On average, these women had been smoking for most of their adult life and smoking may be a well-established coping mechanism. Finding healthy ways to cope, particularly after experiencing an invasive CV procedure, may be more challenging than healthcare professionals and the women themselves recognize. The HCP should continue providing follow-up about smoking long after an invasive cardiac procedure and offer referral resources. In addition, the issue of smoking as an addiction may not be well understood by patients or HCPs, and theories of addiction behavior may be more useful than the HBM in addressing SC.
Having confidence in one’s ability to stop smoking was one significant independent predictor of SC at 3 months, which is similar to previous findings in men and women with and without CHD, but not after an invasive CV procedure.20–22 This association between cessation self-efficacy and quitting smoking presents an opportunity for clinical focus, particularly with how to increase a woman’s confidence in resisting cigarettes after a meal and when around other smokers, which were identified in this study as situations with the lowest self-efficacy.
Women in this study also reported high commitment to stop smoking and multiple quit attempts at the time of their procedure and at follow-up, which indicates a willingness to continue trying to quit smoking. A thorough screening surrounding the time of an invasive cardiac procedure could identify patients who are willing to stop smoking and, perhaps, an individualized plan for SC could be established.
There were limitations of the study. This study was conducted in the Southeastern United States and therefore limits generalizability to all female smokers with CHD. Another limitation of the study was the fairly high attrition from the time of the procedure to the 3-month follow-up. Physiological and psychological variables (eg, anxiety) were not measured and may add more explanatory power to the models. Given the long history of smoking and difficulty quitting, including a measure of physiological addiction may be important to include in future studies. This study also did not examine the role of genetics in smoking and cessation and therefore could be a focus for future studies.
Because smoking and SC are multifaceted and involve many emotional and physiological aspects, other theories such as motivation theories (eg, Self-determination Theory) or theories used in addiction may provide better explanatory power. This study found anxiety to be a major reason for continuing to smoke, which could be included in future research as a modifiable sociopsychological variable. Addiction to nicotine must also be considered, and the HBM does not address physiological components related to modifying behaviors. Further studies with a larger sample size may help identify variables specific to smoking that should be included when testing this model with smokers.
Given the complexities of the women and their health as well as the addiction of smoking and using it as a coping mechanism, the HBM components may not be the best ones for explaining SC behaviors in women after an invasive CV intervention. However, findings from this study add insight into opportunities to improve clinical practice.
What’s New and Important
- After an invasive cardiovascular procedure, women were highly committed to stop smoking, highly threatened by disease and procedure, and had high self-efficacy to stop smoking but still did not stop smoking.
- Higher smoking cessation (SC) self-efficacy, lower perceived barriers to cessation, and higher autonomous motivation to stop smoking were the only individual predictors of commitment to stop smoking.
- Increased SC self-efficacy and decreased threat of chronic heart disease predicted SC.
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