Abstracts

Introduction

Smoking is an important public health problem. Tobacco dependence is a complex process that involves the pharmacological action of nicotine (physical dependence); conditionings and acquired behavioral processes (behavioral dependence); and factors related to personality, emotional expressions, and social conditions (psychological dependence).^aa Rosemberg J, Rosemberg AMA, Moraes MA. Nicotina: droga universal. São Paulo: Secretaria de Saúde do Estado de São Paulo, Centro de Vigilância Epidemiológica; 2003.

Smoking cessation is an efficient and cost-effective intervention because it promotes a significant reduction in morbidity and mortality rates.^bb World Health Organization. Report on the Global Tobacco Epidemic, 2008: the MPOWER package. Geneva; 2008 [cited 2012 Dec]. Available from: http://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf Therapeutic strategies that can be used for smoking cessation include pharmacological treatments (particularly nicotine replacement and bupropion), combined with behavioral and individualized approaches, also known as cognitive-behavioral therapy.²2 Berretini WH, Lerman CE. Pharmacotherapy and pharmacogenetics of nicotine dependence. Am J Psychiatry. 2005;162(8):1441-51. DOI:10.1176/appi.ajp.162.8.1441^,1717 Reichert J, Araújo AJ, Gonçalves CMC, Godoy I, Chatkin JM, Sales MPU, et al. Diretrizes para cessação do tabagismo - 2008. J Bras Pneumol. 2008;34(10):845-80. DOI:10.1590/S1806-37132008001000014

Considering that most studies on tobacco control in Brazil contain specific population profiles,⁴4 Bortoluzzi MC, Kehrig RT, Loquercio AD, Traebert JL. Prevalência e perfil dos usuários de tabaco de população adulta em cidade do Sul do Brasil (Joaçaba, SC). Cienc Saude Coletiva. 2011;16(3):1953-9. DOI:10.1590/S1413-81232011000300029^,2020 Sales MPU, Figueiredo MRF, Oliveira MI, Castro HN. Ambulatório de apoio ao tabagista no Ceará: perfil dos pacientes e fatores associados ao sucesso terapêutico. J Bras Pneumol. 2006;32(5):410-7. DOI:10.1590/S1806-37132006000500007 knowing the profile of smokers in the context of the main difficulties associated with smoking cessation allows for more effective treatments.

The present study aimed to analyze the prevalence of the factors associated with smoking abstinence among patients who were treated at a reference unit for smoking cessation.

METHODS

The study was conducted at the Centro de Referência Especializado em Abordagem e Tratamento do Fumante (CREATF – Reference Centre Specialized in the Approach and Treatment of Smokers), in Belém, PA, Northern Brazil, which is linked to the Pará State Health Secretariat. The CREATF serves patients by spontaneous demand or referral by the municipal health units. The CREATF treated approximately 3,500 patients during its 10 years of operation.

This cross-sectional study examined the medical records of patients enrolled in the smoker attention program at the CREATF between January 2010 and June 2012. During this period, 593 individuals sought the help of the CREATF for smoking cessation. Smoking histories with incomplete or incoherent data were excluded from the analysis, as well as those not retrieved after three attempts. A total of 61 records were excluded. Therefore, the study sample comprised 532 records of patients who attended at least two sessions of cognitive-behavioral therapy.

Sociodemographic data, smoking history, treatments performed, and outcome obtained within the aforementioned program were collected. The aspects related to smoking history included number of cigarettes/day, levels of chemical dependence levels, attempts of smoking cessation, and presence of triggers (any physical, chemical, psychological, or behavioral factors that can induce the consumption of cigarettes, leading to a lapse or relapse). The variables related to treatment and its outcome were reported withdrawal symptoms, treatments performed (behavioral and/or medical approach), physical activity practice, and treatment outcome (the time when the patient ceased to be monitored at the CREATF).²⁰20 Sales MPU, Figueiredo MRF, Oliveira MI, Castro HN. Ambulatório de apoio ao tabagista no Ceará: perfil dos pacientes e fatores associados ao sucesso terapêutico. J Bras Pneumol. 2006;32(5):410-7. DOI:10.1590/S1806-37132006000500007

The following sociodemographic variables were included in the statistical analysis: sex, age, educational level, and occupational status. To simplify the statistical analysis, some variables were stratified. Education was stratified as “up to eight years of education” (this group included illiterate and semi-literate individuals) and “more than eight years of education”; occupational status was stratified as “individuals without a source of income” (unemployed), “individuals with a source of income” (formal or informal employment), and “retirees”.

The number of cigarettes/day was stratified as “up to 20 cigarettes/day” and “more than 20 cigarettes/day”. Chemical dependence was characterized according to the Fagerstrom Scale and stratified into “very low to medium” and “high to very high”. The variable “cessation attempts” was divided into patients who attempted smoking cessation and those who never attempted. The triggers associated with smoking habit were classified as behavioral, psychological, chemical, or their associations thereof; triggers leading to relapse were stratified according to the absence of triggers, the presence of a single trigger, and association of triggers. Regarding the abstinence syndrome, the patients were divided into those with up to two reported symptoms and those with more than two complaints. Regarding the treatments conducted, the patients were divided into those who underwent cognitive-behavioral therapy only (and did not require drug support) and those who, in addition to cognitive-behavioral therapy, required other therapeutic strategies (nicotine replacement or laser therapy). Treatment outcome was defined as the time of the last contact with the CREATF (as registered in the medical history) for cognitive-behavioral therapy or maintenance therapy.

Each post-treatment patient was classified as teetotaler or smoker, according to the most recent record in their medical history; the last analysis variable was “smoking status at the end of the treatment”, which indicated the rate of success and failure of treatment.

Data were tabulated and organized in spreadsheets. Statistical analysis was performed using EpiInfo software, version 3.5.2. The frequencies of the variables and their respective confidence intervals were included, and raw and adjusted analyses were included for determination of the variables associated with the final status of the patients who underwent the treatment. The statistical significance level was set at p < 0.05.

This study was approved by the Research Ethics Committee of the Fundação Pública Estadual Hospital de Clínicas Gaspar Vianna (Protocol 001795), in accordance with the guidelines for human research established by Resolution 196/96 of the National Health Council. The patients were identified by their respective medical history numbers in order to preserve their identity.

RESULTS

The mean age of individuals were treated at the CREATF was 49.73 years. Most individuals in the study group were women (56.6%). The total study group and the prevalence of teetotalers and smokers, according to sociodemographic variables, smoking history, and treatments performed are listed in Table 1.

The tobacco load was, on average, 30 packs/year; the mean smoking duration was 32.4 years. The success rate of the intervention was 75.0% in the period evaluated. On average, teetotalers were monitored for up to four months after smoking cessation, and the control and maintenance periods reached up to 33 months when their contact with the CREATF ended.

No sociodemographic variable was significantly associated with the status at the end of treatment (p > 0.05; Table 2). The analysis of smoking history and the treatments performed indicated that all variables were statistically significant, except number of cessation attempts and triggers (Table 3). The variables stratified by status at the end of treatment (teetotaler and smoker) with p < 0.2 were selected for raw analysis (Table 4). Physical activity, treatment outcome, nicotine addiction, relapse triggers, number of cigarettes/day, and the treatments performed were statistically significant (p < 0.05) variables and therefore, were subjected to adjusted analysis. The duration of participation in the program, presence of relapse triggers, and high or very high status of addiction appeared to influence the cessation process (Table 5).

DISCUSSION

The abstinence rate at the CREATF in Belém was 75.0%, which is considered high when compared with the rate from other national studies¹⁴14 Peixoto SV, Firmo JOA, Lima-Costa MF. Fatores associados ao índice de cessação do hábito de fumar em duas diferentes populações adultas (Projetos Bambuí e Belo Horizonte). Cad Saude Publica. 2007;23(6):1319-28. DOI:10.1590/S0102-311X2007000600007^,2020 Sales MPU, Figueiredo MRF, Oliveira MI, Castro HN. Ambulatório de apoio ao tabagista no Ceará: perfil dos pacientes e fatores associados ao sucesso terapêutico. J Bras Pneumol. 2006;32(5):410-7. DOI:10.1590/S1806-37132006000500007 and with the profile of patients who were treated in other health care units. The main factor associated with the success or failure of treatment was the participation in maintenance therapies, which appeared to favor abstinence, whereas the presence of relapse triggers and high or very high chemical dependence were complicating factors in this process.

Mazoni et al¹¹11 Mazoni CG, Fernandes S, Pierozan PS, Moreira T, Freese L, Ferigolo M, et al. A eficácia das intervenções farmacológicas e psicossociais para o tratamento do tabagismo: revisão da literatura. Estud Psicol (Natal). 2008;13(2):133-40. DOI:10.1590/S1413-294X2008000200005 (2008) observed that pharmacotherapy doubles the probability of abstinence.³3 Black JH 3rd. Evidence base and strategies for successful smoking cessation. J Vasc Surg. 2010;51(6):1529-37. DOI:10.1016/j.jvs.2009.10.124^,88 Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update: clinical practice guideline. Rockville (MD): US Department of Health and Human Services; 2008. However, these authors found that the association between drug therapy and cognitive-behavioral therapy is not statistically significant for the maintenance of abstinence.

Patients who underwent maintenance behavioral therapy presented a 27-fold higher probability of maintaining abstinence when compared with those who underwent only cognitive-behavioral therapy. Iliceto et al⁹9 Iliceto P, Fino E, Pasquariello S, D’Angelo Di Paola ME, Enea D. Predictors of success in smoking cessation among Italian adults motivated to quit. J Subst Abuse Treat. 2013;44(5):534-40. DOI:10.1016/j.jsat.2012.12.004 (2013) reinforced the importance of patient follow-up even after smoking cessation, considering that the risk of relapse is the highest in the initial phase.

Maintenance therapy aims to keep patients motivated to maintain abstinence because the chances of relapse are strongly associated with the lack of motivation and low attendance in therapy sessions.¹⁸18 Reis RCM, Fortes RC. Fatores associados a não cessação do tabagismo em participantes do grupo de terapia de um centro de saúde do Distrito Federal. Revisa. 2012;1(1):3-8.

In the present study, the average follow-up period after smoking cessation was four months. However, the Guidelines for Tobacco Cessation of the Brazilian Society of Pneumology and Tisiology¹⁷17 Reichert J, Araújo AJ, Gonçalves CMC, Godoy I, Chatkin JM, Sales MPU, et al. Diretrizes para cessação do tabagismo - 2008. J Bras Pneumol. 2008;34(10):845-80. DOI:10.1590/S1806-37132008001000014 (2008) suggest that the patient’s smoking cessation process should be monitored for at least six months.¹⁷17 Reichert J, Araújo AJ, Gonçalves CMC, Godoy I, Chatkin JM, Sales MPU, et al. Diretrizes para cessação do tabagismo - 2008. J Bras Pneumol. 2008;34(10):845-80. DOI:10.1590/S1806-37132008001000014 Therefore, it is important to resort to strategies that support maintenance therapy for a period longer than that reported herein.

Yong et al²²22 Yong HH, Borland R, Cooper J, Cummings KM. Postquitting experiences and expectations of adult smokers and their association with subsequent relapse: findings from the International Tobacoo Control (ITC) Four Country Survey.Nicotine Tob Res. 2010;12(Suppl 1):S12-9. DOI:10.1093/ntr/ntq127 (2010) emphasized the importance of monitoring patients for more than six months after smoking cessation through outpatient consultation and telephone contacts in order to monitor the difficulties faced by the patients and to praise their progress.

The results demonstrated that the presence of a trigger, understood as a factor that motivates smoking, acts as a deterrent to smoking cessation because it predisposes to relapse. According to Cardoso et al⁶6 Cardoso DB, Coelho APCP, Rodrigues M, Petroianu A.Fatores relacionados ao tabagismo e ao seu abandono. Rev Med (Sao Paulo). 2010;89(2):76-82. DOI:10.11606/issn.1679-9836.v89i2p76-82 (2010), the occurrence of relapse is correlated with sociodemographic variables and the level of addiction; the present study evaluated whether the presence or absence of triggers in the face of relapse was associated with patient status at the end of treatment.

Ferguson & Shiffman⁷7 Ferguson SG, Shiffman S. Effect of high-dose nicotine patch on the characteristics of lapse episodes. Health Psychol.2010;29(4):358-66. DOI:10.1037/a0019367 (2010) reinforced the idea that the presence of triggers hinders the success rates of anti-smoking treatment. These authors highlighted that behavioral strategies toward triggers should be encouraged in all patients, regardless of their drug therapy status.

Furthermore, the high degree of addiction hinders the success rates of treatment, and moderate and severe dependence enhances withdrawal symptoms during smoking cessation, favoring long-term relapse.⁵5 Calheiros PRV, Oliveira MS, Calheiros LB, Matos KS, Rosa Júnior S. Fatores associados à recaída em tagistas sob tratamento psicoterápico.Rev Cien FACIMED [Internet]. 2011[citado 2012 dez];3(3). Disponível em: http://www.facimed.edu.br/site/revista/pdfs/5dca9460a1914cd634969e7c7291b5f3.pdf
http://www.facimed.edu.br/site/revista/p... ^,2222 Yong HH, Borland R, Cooper J, Cummings KM. Postquitting experiences and expectations of adult smokers and their association with subsequent relapse: findings from the International Tobacoo Control (ITC) Four Country Survey.Nicotine Tob Res. 2010;12(Suppl 1):S12-9. DOI:10.1093/ntr/ntq127

Father & Prasad¹³13 Pai A, Prasad S. Attempting tobacco cessation: an oral physician’s perspective. Asian Pac J Cancer Prev.2012;13(10):4973-7. (2012) evaluated two groups of smokers with similar sociodemographic characteristics and found that patients with low addiction benefited from cognitive-behavioral therapy, whereas those with a high degree of nicotine dependence required nicotine replacement therapy to achieve abstinence.

The success rate of the treatment offered by the CREATF was 75.0%, which can be considered high when compared with similar services in Brazil, with average rates of smoking cessation between 40.0% and 50.0%.¹⁴14 Peixoto SV, Firmo JOA, Lima-Costa MF. Fatores associados ao índice de cessação do hábito de fumar em duas diferentes populações adultas (Projetos Bambuí e Belo Horizonte). Cad Saude Publica. 2007;23(6):1319-28. DOI:10.1590/S0102-311X2007000600007^,2020 Sales MPU, Figueiredo MRF, Oliveira MI, Castro HN. Ambulatório de apoio ao tabagista no Ceará: perfil dos pacientes e fatores associados ao sucesso terapêutico. J Bras Pneumol. 2006;32(5):410-7. DOI:10.1590/S1806-37132006000500007^,2121 Silva RLF, Carmes LR, Schwartz AF, Blaszkowski DS, Cirino RHD, Ducci RD. Cessação de tabagismo em pacientes de um hospital universitário em Curitiba.J Bras Pneumol. 2011;37(4):480-7. DOI:10.1590/S1806-37132011000400010 This information is relevant, considering the significant long-term smoking habit presented by the patients in this study. The history of smoking and duration of heavy smoking may have contributed to the patients’ awareness of their high degree of dependence, leading them to effectively engage in treatment.

According to Bortoluzzi et al⁴4 Bortoluzzi MC, Kehrig RT, Loquercio AD, Traebert JL. Prevalência e perfil dos usuários de tabaco de população adulta em cidade do Sul do Brasil (Joaçaba, SC). Cienc Saude Coletiva. 2011;16(3):1953-9. DOI:10.1590/S1413-81232011000300029(2011), being under 40 years and having low income and lower education status are factors closely associated with maintenance of smoking and higher rates of failure.¹⁰10 Kim YN, Cho YG, Kim CH, Kang JH, Park HA, Kim KW, et al. Socioeconomic indicators associated with initiation and cessation of smoking among women in Seoul. Korean J Fam Med. 2012;33(1):1-8. DOI:10.4082/kjfm.2012.33.1.1^,1919 Rodríguez-Esquivel D, Cooper TV, Blow J, Resor MR. Characteristics associated with smoking in a Hispanic sample. Addict Behav. 2009;34(6-7):593-8. DOI:10.1016/j.addbeh.2009.03.030 Nonetheless, the present study found no significant association between sociodemographic variables and status at the end of treatment.

Other studies observed the existence of heterogeneity in the sociodemographic variables associated with smoking cessation in different populations. Peixoto et al¹⁴14 Peixoto SV, Firmo JOA, Lima-Costa MF. Fatores associados ao índice de cessação do hábito de fumar em duas diferentes populações adultas (Projetos Bambuí e Belo Horizonte). Cad Saude Publica. 2007;23(6):1319-28. DOI:10.1590/S0102-311X2007000600007 (2007), in a comparative analysis between the metropolitan region of Belo Horizonte and the town of Bambuí, both in MG, Southeastern Brazil, found very similar abstinence rates (40.0% and 38.8%, respectively). However, the factors associated with smoking cessation differed among these population groups.

Azevedo et al¹1 Azevedo RCS, Higa CMH, Assumpção ISMA, Frazatto CRG, Fernandes RF, Goulart W, et al. Grupo terapêutico para tabagistas: resultados após seguimento de dois anos. Rev Assoc Med Bras. 2009;55(5):593-6. DOI:10.1590/S0104-42302009000500025 (2009) and Morissette et al¹²12 Morissette SB, Tull MT, Gulliver SB, Kamholz BW, Zimering RT. Anxiety, anxiety disorders, tobacco use and nicotine: a critical review of interrelationships. Psychol Bull. 2007;133(2):245-72. DOI:10.1037/0033-2909.133.2.245 (2007) found that the rate of failure and relapse is strongly associated with the presence of psychiatric symptoms, such as depression and anxiety. The present results showed no statistically significant association between the presence of these symptoms and failure of treatment. However, patients with psychiatric disorders were not analyzed individually.

With regard to the investigation of physical activity in similar programs, Prochaska et al¹⁶16 Prochaska JJ, Hall SM, Humfleet G, Munoz RF, Reus V, Gorecki J, et al. Physical activity as a strategy for maintaining tobacco abstinence: a randomized trial. Prev Med. 2008;47(2):215-20. DOI:10.1016/j.ypmed.2008.05.006 (2008) argued that physical exercise reduces withdrawal symptoms, promoting smoking cessation. However, the results demonstrated that the records for this variable were incomplete. Therefore, it is suggested that this variable should be included in the standard evaluation form in order to optimize therapy.

The limitations of the present study are related to the collection of secondary data, underreporting of bias, and the self-reporting of abstinence, which may have over- or under-estimated the results. Furthermore, the cross-sectional nature of the study limited the establishment of causal relationships.¹⁵15 Pereira MG. Epidemiologia: teoria e prática. Rio de Janeiro: Guanabara Koogan; 1995. However, such limitations are inherent to this type of study and therefore cannot be avoided. To minimize information bias, only records with complete data were included in the analysis.

The identification of the main factors associated with successful treatment will allow a reassessment of the health strategies aimed at smokers. Patients with a higher degree of dependence and those who relapse during treatment require increased therapeutic support. In addition, maintenance therapies should be more dynamic to ensure full adherence to treatment.

Additional studies comparing and addressing population changes that influence the success of treatment and further research to support smoking prevention and cessation initiatives are needed.

REFERENCES

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