Smoking is not only an important cause of cardiac diseases; cardiac patients who continue smoking after hospital discharge also have a higher risk for another cardiac incident.1,2 Quitting smoking after the development of coronary heart disease improves prognosis more than any other treatment and is associated with a risk reduction in all-cause mortality among patients with coronary heart disease.1,3 However, up to 60% of cardiac patients continue to smoke after hospital discharge without being offered smoking cessation interventions.4,5 Knowledge about the factors associated with smoking abstinence after hospitalization is critical for improving the success of smoking cessation interventions in this patient group.6
Earlier studies revealed that psychosocial cognitive factors, such as attitude toward smoking cessation, self-efficacy, and social influences, contribute to the success of smoking cessation attempts during and after hospitalization for coronary heart disease.5,7–12 Factors associated with smoking resumption after hospital discharge are a low level of self-confidence in quitting, few prior attempts to quit, a low household income, having other smokers in the household, a history of depression, high nicotine dependence, and a cardiac disease history.13–16
Although much research has been done on determinants of smoking cessation after hospitalization for a cardiac incident and these determinants have been addressed by various interventions, many cardiac rehabilitation patients persist in smoking. This suggests that other factors that have not yet been addressed may play a role in continued smoking among these patients. One of these factors may be cigarette craving (an intense urge to smoke). In previous studies, high levels of cigarette craving seemed to be related to failure of attempts to quit smoking.5,17,18 However, further research on the role of craving is necessary because, in these studies, cigarette craving was measured within the first 48 hours of hospitalization,5,18 after 3 months, or even later.17 Because smoking cessation among cardiac patients is an acute behavioral change that mostly occurs as a result of the nonsmoking policies of hospitals and the acute high-risk health status, the first few weeks after hospitalization may be crucial for successful smoking cessation attempts. Indeed, many smokers relapse within the first few weeks after a smoking cessation attempt.19,20 As far as we know, cigarette craving has not been studied in cardiac rehabilitation patients in the first few weeks after hospitalization for a cardiac incident. The current study focuses on the role of craving and psychosocial cognitive factors (ie, attitudes and self-efficacy toward nonsmoking) 2 to 4 weeks after discharge from hospital.
A second factor that needs to be studied further is anxiety. Among patients hospitalized for a cardiac event, feelings of anxiety are very common.21 Because smoking is suggested to be a means to cope with anxiety, feelings of anxiety may also impair smoking cessation attempts in cardiac rehabilitation patients. In the general population, smokers with higher levels of anxiety are less likely to quit smoking succesfully.22 Furthermore, anxiety is related to worse adherence to a smoking cessation recommendation after myocardial infarction.23 Moreover, anxiety seems to play a moderating role in the relation between craving, self-efficacy, and smoking abstinence.5 According to a previous study, self-efficacy mediated the relation between craving and smoking abstinence, and this effect was more pronounced among patients with relatively low-to-moderate anxiety at the time of hospitalization.5
Because most studies involve assessments of smoking cessation determinants at hospital admission and several months to 2 years after discharge, factors associated with (intention to) abstain from smoking in the first few weeks after hospital discharge are less well documented. These factors, however, may be crucial for smoking resumption. The current study investigates factors associated with intention toward nonsmoking among (previously) smoking cardiac rehabilitation patients 2 to 4 weeks after discharge from hospital. First, differences in psychosocial cognitions, anxiety, and craving between cardiac rehabilitation patients who quit smoking and those who continued to smoke after discharge were investigated. Second, we examined the relationship between cognitive factors (attitude, social influence, and self-efficacy), craving, and anxiety on the one hand and intention to (permanently) abstain from smoking on the other hand, with actual smoking behavior at the start of the cardiac rehabilitation program as a potential moderator. Finally, the moderating effect of anxiety on the relationship between cognitive factors, craving, and intention to abstain from smoking was assessed.
Design and Study Population
A cross-sectional survey was conducted among cardiac rehabilitation patients 2 to 4 weeks after hospital discharge. Cardiac patients were recruited between May and October 2009 at outpatient cardiac rehabilitation clinics in 2 locations: Capri Cardiac Rehabilitation Centre Rotterdam (n = 113) and Kennemer Hospital Haarlem (n = 37), The Netherlands. Indications for referral to cardiac rehabilitation were myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, angina pectoris, and other forms of chronic and acute heart disease. Patients who applied for physical rehabilitation because of coronary heart disease 2 to 4 weeks after hospital discharge received oral and written information about the study from the hospital social worker. The social worker identified eligible patients on the basis of information about their smoking habits during the past years. Cardiac rehabilitation patients were included when they had smoked in the past 2 years or still smoked during or after hospitalization. All eligible patients were given a questionnaire by the social worker after they were informed about the anonymous processing of data and they were explicitly asked to participate in the study; 150 consented to participate and returned the questionnaires. The sample size required was calculated before the study, according to Tabachnick and Fidell,24 for testing multiple correlations: n > 50 + 8 m (where m is the number of independent variables). To gain a power of 0.80 in the regression model testing, the sample size needed to be N = 114.
The Ethics Committee judged that the study complied with the Dutch law on Medical Research in Humans (Wet Medisch-wetenschappelijk onderzoek met mensen [WMO]). The study was carried out in accordance with American Psychological Association’s Ethics Code and the Declaration of Helsinki, 2013.25,26
A single paper-and-pencil questionnaire, consisting of 28 items, was administered to the patients, measuring both demographic and smoking characteristics as well as cognitive variables, intention to (permanently) abstain from smoking, anxiety, and craving.
Demographic characteristics included gender, age, and educational level. The level of education was categorized as low education level, which included primary school and basic vocational school; secondary education, which included secondary vocational school and high school degree; and high education level, which included higher vocational school degree, college degree, or university degree.
Smoking characteristics included actual smoking behavior (categorized as “smokes daily,” “smokes occasionally,” or “not smoking anymore”), smoking since hospital admission (categorized as “quit prior to admission,” “quit since admission,” or “still smoking since admission”), number of cigarettes (or cigarette-equivalents) a day, and earlier smoking cessation intervention (no = 0/yes = 1).
The psychosocial cognitive variables were measured with a standardized and validated Dutch questionnaire, based on the Attitude–Social Influence–Self-efficacy model.27 This questionnaire has been developed by Mudde et al,28 commissioned by the Dutch Expert Centre on Tobacco Control (Stichting Volksgezondheid en Roken), to standardize methodology in Dutch smoking and smoking cessation research, and has been used in multiple studies.7,8,29 In this questionnaire, attitude toward nonsmoking was assessed by measuring the level of agreement with 4 pros (Cronbach’s α = 0.75) and 4 cons (Cronbach’s α = 0.66) of nonsmoking.8,28 An example of the pros of nonsmoking was “If I continue to refrain from smoking, my health status will improve.” An example of the cons was “If I continue to refrain from smoking, I will get withdrawal symptoms.” The pros were scored positively on a 4-point scale from 0 to 3; higher scores implied that participants perceived more advantages of nonsmoking. The cons were scored negatively on a 4-point scale from −3 to 0; more negative scores implied that participants perceived more disadvantages of nonsmoking.
Two components of perceived social influence toward nonsmoking were assessed: social support and social modeling by patients’ social network and partner.8,28 Social support was assessed by a single item and asked “Do people in your environment stimulate you to quit smoking?” This item was scored on a 4-point scale, varying from 3 (“very much”) to 0 (“not at all”). Higher scores indicate a more nonsmoking-stimulating environment.
Social modeling was measured by asking whether the people in one’s environment smoked. This single item was scored on a 5-point scale varying from 0 (“[almost] no smokers”) to 4 (“[almost] all smokers”). Higher scores on this scale correspond with a less nonsmoking-stimulating environment.
Self-efficacy toward nonsmoking was assessed by a single item, asking “How capable are you to refrain from smoking in any situation that may arise?” This item was scored on a 5-point scale varying from −2 (“certainly not”), via 0 (“do not know”), to 2 (“certainly”).
Both state anxiety and trait anxiety were measured using the shortened version of the State-Trait Anxiety Inventory.30 State anxiety, which refers to the anxiety felt when thinking of the cardiac incident, was measured with 6 items, which were scored on a 4-point Likert scale, with values varying from 1 (“never”) to 4 (“very often”). Examples of items are “I feel scared” and “I’m worried.” The Cronbach’s α of this scale was 0.89. Trait anxiety concerns individual differences in the disposition to respond to stressful situations with varying amounts of anxiety. The trait anxiety scale (Cronbach’s α = 0.81) consisted of 6 items, which were scored on a 5-point scale, varying from 1 (“never”) to 5 (“always”). Examples of items are “I worry too much about things that are not so important” and “I’m getting all tense and restless when I think of my concerns.”
Craving for cigarettes was assessed with 6 items measuring the urge to smoke in the past 24 hours.31 The items addressed the frequency of desiring, missing, thinking of, looking forward to, and longing for a cigarette (eg, “I miss a cigarette” and “I often think about deeply inhaling the smoke of a cigarette”). The items were scored on a 5-point Likert scale with values varying from 1 (“never”) to 5 (“very often”). The Cronbach’s α of this scale was 0.96.
Intention to (permanently) abstain from smoking was assessed with the combination of 2 visual analog scales (range, 0–10, with 0 being “not at all” and 10 being “very strong”) indicating strength and probability of the intention to permanently refrain from smoking after finishing the cardiac rehabilitation program.28 Strength was measured with the question “How strongly do you intend not to smoke (permanently)?” and probability was measured with the question “How likely do you think it is that you will (permanently) abstain from smoking?”
Data analyses (N = 149) were performed using the Statistical Package for the Social Sciences 20. One respondent was excluded from the data analyses because of a high amount of missing values (>20%).32 After recoding the inverted items, means of scales were calculated if applicable. Descriptive data are presented as mean and SD or percentages. Differences in psychosocial cognitions, anxiety, and craving between the smokers and the nonsmokers were tested with t tests for independent samples. Scores on the outcome variable intention to (permanently) abstain from smoking were negatively skewed on both measurements and could not be transformed to normality. Therefore, we used logistic regression on the dichotomized scores: median or higher versus lower than median scores. Multiple logistic regression analyses were performed to study the associations between cognitive factors (attitude, social influence, and self-efficacy), craving, and anxiety on the one hand and the dichotomous outcome variable intention to (permanently) abstain from smoking on the other hand, followed by backward stepwise logistic regression analyses, including all mentioned variables in the first step. The role of actual smoking behavior (yes = 1/no = 0) as a potential moderator in the relation between cognitive factors, craving, anxiety, and intention was also investigated with logistic regression analysis, with the abovementioned factors, smoking behavior, and the interaction terms as independent variables and intention to (permanently) abstain from smoking as dependent variable. Finally, the moderating effect of anxiety on the relationship between cognitive factors, craving, and intention to abstain from smoking was analyzed. In all statistical analyses, a P value of less than 0.01 was considered significant, unless mentioned otherwise.
The characteristics of the total study population are shown in Table 1. The mean age of the patients was 56 years (SD, 9.4), and 69% were men. Of all patients, 103 (69%) quit smoking, of which 28 (19% of all patients) quit before hospital admission and 75 (50%) quit since hospital admission; 46 patients (31%) still smoked, of whom 40 smoked daily and 6 smoked occasionally. The mean number of cigarettes (or cigarette-equivalents) each day was 20 (SD, 14.3). Only 17 patients used smoking cessation aids in the past (eg, nicotine patches, chewing gum, medicine [Zyban], acupuncture, or self-help books).
Although the intention to (permanently) abstain from smoking was generally high in the total group of cardiac patients, this intention was significantly lower in the smokers as compared with the quitters (see Table 2). Furthermore, the smokers had a more negative attitude toward smoking cessation and a lower self-efficacy, whereas their scores on trait anxiety and craving were higher compared with the quitters. The differences in attitude toward smoking cessation and trait anxiety were only marginally significant (see Table 2). Perceived social influence did not differ between the smokers and the quitters.
Table 3 shows the results of the logistic regression analyses, with the dichotomous outcome variable intention to (permanently) abstain from smoking as dependent variable and the mentioned cognitive factors, craving, and anxiety as independent variables. Attitude pro nonsmoking and self-efficacy were both positively related to intention. Neither social influence nor state and trait anxiety was related to the intention to abstain from smoking. Craving turned out to be a strong negative correlate of intention (see Table 3). Including the background variables age, gender, and level of education as covariates in the models did not change the results; the (non)significant results from Table 3 remained (non)significant after adjustment for the mentioned covariables. Besides, none of the mentioned covariates was significantly related to intention toward nonsmoking.
Backward stepwise logistic regression analyses, including all independent variables in the model at step 1, resulted in a model with attitude pro smoking cessation and self-efficacy as positive predictors (B = 1.167, P = 0.001, and B = 0,758, P = 0.001, respectively) and craving as a negative predictor (B = −0.681, P = 0.008) of the intention toward nonsmoking.
Of the relations between these correlates and intention, only the relation between self-efficacy and intention tended to be moderated by actual smoking behavior; the interaction between smoking behavior and self-efficacy was negative and marginally significant (B = −1.061, P = 0.037). Only the quitters showed a significant positive relation between self-efficacy and intention (B = 1.245, P < 0.001, in the quitters vs B = 0.886, P = 0.233, in the smokers). Anxiety did not moderate the relation between any of the independent variables and intention to (permanently) abstain from smoking.
Of all cardiac rehabilitation patients in this study, almost one-third still smoked 2 to 4 weeks after hospital discharge. These smokers had a lower self-efficacy and intention to (permanently) abstain from smoking, whereas their craving levels were higher as compared with the quitters.
Among the total study population, attitude pro nonsmoking and self-efficacy were positively associated with the intention to (permanently) abstain from smoking. These results correspond with earlier studies in which attitude and self-efficacy were found to predict smoking abstinence 1, 2, and 6 months after hospital discharge.5,7,12 In their meta-analyses, Gwaltney et al33 suggested that the role of self-efficacy depends on the actual smoking status. The interaction we found between smoking behavior and self-efficacy indicates that only quitters show a positive relation between self-efficacy and intention to (permanently) abstain from smoking. In the smokers, self-efficacy was not related to their intention to quit. Comparable with the study of Gwaltney et al,33 self-efficacy toward nonsmoking was significantly lower in smokers as compared with quitters, which suggests that self-efficacy may be a marker of lapsing or failure to quit. Patients who already quit smoking probably base their intention to permanently abstain from smoking on their experiences in the previous weeks. Positive experiences are likely to empower patients, leading to higher scores on both self-efficacy and intention, whereas negative experiences decrease both their self-efficacy and intention to quit. Patients who still smoke generally report lower self-efficacy scores, which may rather be the result of their failure to quit than a predictor of future smoking behavior or intention.33
Craving was negatively associated with the intention to (permanently) abstain from smoking, corresponding with results of other studies, in which cigarette craving was measured either within the first 48 hours of hospitalization or after 3 months or more.5,18 To our knowledge, this is the first time craving has been studied in the first few weeks after hospitalization for a cardiac incident. Because this period is crucial for cardiac rehabilitation patients, and many attempts to quit smoking fail within the first few weeks, craving toward cigarettes should be addressed as early as possible in the further treatment of these patients. No significant interaction was found between actual smoking behavior and cigarette craving, indicating that craving is related to intention independent of actual smoking behavior.
Perceived social influence was not associated with the intention to (permanently) abstain from smoking after finishing the cardiac rehabilitation program. This contradicts former studies, in which patients who received more social support were more likely to abstain from smoking.7,10,12 This discrepancy may partially be explained by differences in outcome measurements: the present study focused on the intention to (permanently) abstain from smoking after finishing the cardiac rehabilitation program instead of actual smoking behavior. Of the mentioned studies, only Berndt et al7 looked at the intention to abstain from smoking. Their study aimed to identify risk groups among smoking cardiac patients, resulting in 3 clusters, which differed significantly in their perceived social influences, suggesting that a supportive nonsmoking social environment is a prerequisite for (the intention toward) smoking abstinence after discharge. They measured perceived social influence at hospital admission, whereas in the current study, social influence was measured 2 to 4 weeks after hospital discharge, at the start of the cardiac rehabilitation period. This timing distinction may be a possible explanation for the differences in results regarding social influence.
The moderating effect of anxiety, found in an earlier study,5 could not be confirmed in this study, neither could the direct role of anxiety.7,23 Although trait anxiety was slightly higher in the smokers as compared with the quitters, anxiety was not related to the intention to (permanently) abstain from smoking. The smokers and the quitters reported similar scores for state anxiety, the anxiety felt when thinking of the cardiac incident. Apparently, anxiety, as measured with the State-Trait Anxiety Inventory, did not decrease the likelihood to quit smoking during or directly after hospitalization. Other studies did find a significant role of anxiety, as measured with the Hospital Anxiety and Depression Scale, which may be a more specific instrument to measure anxiety in cardiac patients.5,7
The current study is subject to certain limitations. First, the cross-sectional design of the study does not allow conclusions about the causality of the relationships found. Second, the patients were not followed in time; therefore, prediction of future behavior is not possible, which impedes comparison with some other studies, which did follow the patients in time.5,7,12 Third, the scores on the outcome variable intention to (permanently) abstain from smoking were negatively skewed on both measurements and could not be transformed to normality. This means that, although intention to abstain from smoking is lower in patients who still smoke as compared with quitters, the patients overall had high scores for intention. This can be explained by their situation: it was only a few weeks ago that they experienced their cardiac incident, which may be life changing for most patients, resulting in a strong intention to change their lifestyle. Another explanation can be found in the recruitment of the participants: the patients were recruited at the start of the rehabilitation period, so selection bias and social desirability in completing the questionnaires cannot be excluded. However, the fact that significant relations could be found for the determinants attitude, self-efficacy, and craving, but not for social influence and anxiety, indicates that, despite these limitations, the contribution of the different determinants can be demonstrated in this study. Another limitation is the relatively small sample size. Generalization of the results is therefore limited. The included patients all smoked in the past 2 years or still smoked during or after hospitalization. For the patients who quit smoking within the 2 years before hospitalization (19%), their motivation to quit is not known. This motivation does not necessarily have anything to do with their heart disease. Thus, their motivation and intention to (permanently) abstain from smoking may result from other sources than that of patients still smoking at their hospital admission. Because it is known that cardiac patients with unfavorable psychosocial cognitions are at high risk for resuming or continuing smoking, it is important to develop strategies for optimizing these unfavorable factors. Therefore, future studies should aim at the development of evidence-based interventions to enhance smoking cessation among cardiac rehabilitation patients and to improve current smoking cessation interventions for cardiac patients. On the basis of the results of the current study, these interventions should focus on attitude, self-efficacy, and craving. For instance, health professionals offering smoking cessation programs in the cardiac rehabilitation period could enhance patients’ intentions toward smoking cessation by discussing the personal pros and cons of quitting with the patient. Motivational interviewing offers opportunities to promote intrinsic motivation to change behavior, including the motivation to quit smoking.34 To enhance self-efficacy to quit, health professionals could help patients to assess their triggers to relapse to smoking and discuss strategies that help deal with difficult situations. Special attention should be given to strategies against cigarette craving. Craving can be addressed through cognitive-behavioral interventions, including self-efficacy–enhancing strategies and relapse prevention strategies, such as formulating coping strategies to deal with tempting situations.35,36
In addition, cigarette craving can be addressed by nicotine replacement therapy or pharmacotherapy to counteract withdrawal symptoms, preferably starting at patients’ hospital admission.37–39 Adding nicotine replacement therapy to a cognitive-behavioral intervention enhances smoking cessation more than a cognitive-behavioral intervention alone.37
The discussed measures may help cardiac patients to quit smoking permanently. However, the weeks between hospital discharge and the start of the cardiac rehabilitation are a vulnerable period for many patients to relapse to their old smoking behavior. To prevent cardiac patients to resume smoking in this vulnerable period before the start of the cardiac rehabilitation program, it is recommended that these patients are offered structured smoking cessation counseling outside the ward shortly after their hospital discharge.
What’s New and Important
- Although smoking cessation after developing coronary heart disease improves disease prognosis more than any other treatment, approximately one-third of the cardiac rehabilitation patients in this study still smoked 2 to 4 weeks after hospital discharge.
- Cardiac rehabilitation patients who still smoked had a lower self-efficacy and intention to abstain from smoking and reported higher craving as compared with patients who quit smoking.
- The intention to (permanently) abstain from smoking, measured 2 to 4 weeks after hospitalization for a cardiac event, predominantly depends on attitude, self-efficacy, and craving; interventions aimed at smoking cessation among cardiac rehabilitation patients should focus on these factors.
The authors thank Capri Hartrevalidatie Rotterdam and Kennemer Gasthuis Haarlem for their support to recruit the patients for this study as well as all the cardiac rehabilitation patients who completed the questionnaires.
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