Psychosocial Smoking Cessation Interventions for Coronary Heart

¶ … psychosocial smoking cessation interventions for coronary heart disease patients effective?

The association with smoking and coronary heart disease (CHD) has been well documented. To prevent further heart attacks, as well as to preserve their life, smokers have been consistently and strongly advised to quit smoking, and associations such as the American Heart Association and American College of Cardiology Task Force have drafted recommendations and reams of advice to assist patients in doing so. Nevertheless, many patients diagnosed with CHD continue to smoke despite the possibility of interventions and programs (many of them free) helping them to stop. Mortality can be reduced by as much as 36% if smokers with CHD determine to stop smoking 3-5 years after diagnosed (Critchley, 2003) aside from which dramatic reductions in cardiac attacks have been discovered when smokers have stopped smoking for as short a time as a year (Quist-Paulsen, & Gallefoss, 2003). The Coronary Artery Surgery Study also found, at a 10-year follow-up, that nonsmokers were more likely to be free of angina (54% of nonsmokers vs. 42% of smokers) and less likely to experience moderate to severe physical limitations (13% of nonsmokers vs. 24% of smokers). Non-smokers were also far less likely to have renewed CHD attacks (2.6% vs. 3.8%). According to the U.S. Department of Health and Human Services, in short, quitting not only prevents morbidity but also:

Reduces development of arteriosclerosis and lowers the incidence of initial and recurrent myocardial infarction, thrombosis, cardiac arrhythmia, and death from cardiovascular causes (Quist-Paulsen & Gallefoss, 2003, p. 676)

This is because many of these mechanisms are secondary effects of smoking and are reversible by as little as a few weeks if not days (Twardalle, et al., 2004).

Most smokers with CHD have used, or at least have been advised to use, one or more types of psychosocial interventions in their endeavors to kick the smoking habit. Psychosocial interventions seem to have a glorious press in the arsenal of clinical practitioners particularly when applied to cessation of addictive behavior. Nonetheless, researchers have found a mixed review of the efficacy of psychosocial interventions when applied to smoking-cessation making it uncertain whether or not they can be helpful in this regards. A thorough metanalysis by Barthe et al. (2008) found that smoking cessation interventions in CHD patients were almost always effective compared to the usual care. "In all trials, patients receiving the special psychosocial intervention had more than 60% higher odds of quitting" (p. 15), although considerable heterogeneity between groups did make the groups more difficult to interpret. Whilst they did not find evidence that any specific intervention was more effective than another, they did conclude that the benefits of psychosocial interventions when applied to smoking cessation were indubious (Barth, Critchley, & Benget, 2008) and these results were confirmed in a later metanalysis of 19 randomized controlled trials consisting of a total of 2677 people with 1354 receiving a psychosocial intervention. (Barth J., Critchley J. & Bengel J. (2008) Psychosocial interventions for smoking cessation in patients with coronary heart disease. Cochrane Database of Systematic Reviews, Issue 1,). Meanwhile, in a metanalysis of 14 studies rigorously and thoroughly conducted, Huttunen-Lenz, Song, and Poland (2010) found psychoeducational interventions to be effective: "Psychoeducational interventions significantly increased rates of smoking cessation, and statistically non-significantly reduced total mortality" (p 773). The authors, however, limited themselves to psychoeducational, rather than to psychosocial interventions, and although similar, there is a difference between the two. Nonetheless, the authors also pointed out a valid fact that questions remain about what exactly constitutes effectiveness. This question generalizes to interventions as a whole and, as it will be seen later, it is recommended that researchers perform conceptualization on this clause before they proceed in investigating and concluding efficacy of interventions.

Another observation is that all interventions seem to be equally effective (Huttunen-Lenz, Song, and Poland, 2010). Even though, application of psychosocial interventions seems to be helpful in encouraging smokers with CHD to stop smoking and even though, consequently, several more years of life may be added to those who stop smoking, Quist-Paulsen and colleagues (2006). wondered whether quality of health is improved as a result and whether reformed smoker has achieved a greater QoL than he or she possessed prior to his smoking habit. 240 smokers aged fewer than 76 with 28 individuals suffering different conditions of CHD were allocated to an intervention program led by cardiac nurses. Those who received training were then contacted regularly several months after discharge. The control groups meanwhile received the usual care but no further advice or support on how to stop smoking. Sociodemographic features, smoking habits and medical history were recorded. A questionnaire surveying 24 components of QoL (such as Social function, Physical function, Symptoms, Mental health, Life satisfaction and Life expectancy) was used and the whole assessed with t-test and multivariate logistic regression. Authors discovered that those who ceased smoking did not report a greater QoL increase that those who did not cease smoking. Age and already existent medical symptoms may intervene, and it may also be possible that a longer-term follow-up study is needed to more thoroughly and intensively evaluate results. On the other hand, it could also be that nicotine and the actual act and pleasure associated with smoking provides smokers with greater QoL that non-smokers lack (Quist-Paulsen, Per & Gallefoss, 2006). In short, however, whilst it is uncertain whether or not cessation of smoking enhances QoL and may actually reduce it, cessation of smoking does seem to almost certainly expend life. And psychosocial interventions seem to have a great effect in helping smokers with CHD reform there smoking habit.

Conditions of efficacy

Barth, Critchley, & Benget (2008) found that brief psychosocial interventions consisting of approximately only 4 months had none or minimal success (Huey-Ling et al., 2009) and all researchers uniformly agreed and added that they had to be intensive (at least longer than a month (Huey-Ling et al., 2009) with follow-up contact (Barth, Critchley, & Benget, 2008; Huey-Ling et al., 2009). In fact, the more follow-up contact the better. Interventions that started during hospitalization were also more effective than those entered into following hospitalization. This may be due to the fact that fear arousal messages (as Quist-Paulsen and Gallefoss (2003) discovered) are essential in persuading the smoker to curtail his habit.

The reason that less intensive sessions are less effective is due to the fact that smokers may not receive the sufficient support necessary for them to stop smoking (Huttunen-Lenz, Song, and Poland, 2010)). At best, less intensive sessions have an effect on abstinence for up to one year. Their impact is undetermined beyond that, but likely varies on the smoker as well as on circumstances and context of the smoker. It seems as though the most effective programs, in short, are those that start during hospitalizations (ibid.), are intensive, and offer at least a month's follow up after discharge. Those led by hospital-employed nurses (and possibly by even professionally certified nurses) seem to be more effective, although Quist-Paulsen and Gallefoss's (2003) study in this regard, it seems to be, is insufficiently convincing in that it was conducted only in one hospital (and therefore the character and environment of the nurses and hospital may have confounded the results) and was also conducted on a relatively small sample of 240 smokers. The study, conducted in Norway, only considered patients less than 76 years of age and daily smokers but excluded those with serious diseases. All had at least one previous cardiac heart disease. Patients were offered twice a week sessions with nurses who advised them on how to sop smoking. The control group attended the sessions that discouraged smoking but received no advice on how to quit. Nurses also provided patients in experimental study with a booklet that (and the message was emphasized by nurses) strongly affirmed that continuance of smoking would consequent in death. This was the fear arousal message. Patients of experimental study were also contacted several times and during several periods after there discharge with, during each time, the nurse encouraging them and offering them advice. After 12 months, patients were then surveyed to determine where the program had helped them stop smoking. Quist-Paulsen and Gallefoss (2003) found that the initial nurse-led conference was sufficient above and beyond further programs and follow ups to induce desire to stop smoking. Fear arousal and relapse prevention (by the frequency of the calls following discharge) also helped. The programs as a whole evidenced a low dropout rate. The study in short recommends triangulation of professionally led programs that integrate fear-arousal messages and intensity as well as frequency of support during and following discharge. Incidentally, the fear-arousal component may pose ethical concerns that, it is recommended, should be looked into before similar programs are adopted.

Researchers also consistently found that for psychosocial interventions to help in regards to smoking cessations, former smokers also need constant supportive contact after discharge (Huttunen-Lenz, Song, & Poland, 2010)).

Differences in Interventions

Both Huey-Ling and colleagues (2009) and Barth, Critchley and Benget (2008) found no indication that any single intervention was more effective than another. Behavior therapy seemed to show consistent significant positive effect as did telephone support, but then telephone support and behavior therapy are closely linked. In fact, as will be shown later and as all researchers comment, each of the psychosocial interventions share commonalties, and it is, therefore, difficult to separate them. Their underlying characteristics may be reducible to social support and to granting the smoker a feeling of optimism and self-efficacy. In this way, there may ultimately be no differences between the various interventions but rather existence of, or lack of, efficacy may be reducible to existence of one or more of these psychological characteristics: the quality and amount of social support that the smoker receives and the level of his or her self-efficacy. In fact, when Barth, Critchley, & Benget (2008) compared the success of behavioral and telephone therapy with self-help attempts they found only a slight reduction in efficacy between the latter and the former. It may be that the social support component was lacking or slightly less in the latter, but this is only my speculation. Behavior therapy or telephone therapy is little different than self-help (Huey-Ling et al., 2009).

Whilst most studies seemed to focus on psychosocial interventions alone in exclusion to including nicotine or bupropion replacement models. Huttunen-Lenz, Song, and Poland (2010) did however include pharmacotherapy to psychoeducational intervention in their meta analysis and discovered that the addition did not cause statistically significant improvement in rates of smoking cessation compared to psychoeducational intervention alone. Another insightful feature that they introduced in their study that others generally ignored was investigation of whether the therapist's introduction of his or her behavioral theory influenced the therapy. They found that such was not the case and that there was no difference between groups that did or did not rely on inclusion of particular behavioral models in their therapy. Seemingly, therefore, the particular intervention alone was the model that counted (although theory may not be wasted effort). Huttunen-Lenz, Song, and Poland (2010) also discovered, to their astonishment, that some commonly used behavioral techniques such as personalized messages and relapse prevention may not be effective.

Recommendations

Several definitions and attempts on conceptualization are in order before research proceeds. Firstly, as Barth, Critchley, and Benget (2008) point out smoking itself should be more tightly defined with the number and brand of cigarettes conceptualized and possibly assessment of whether one or more psychosocial interventions may be more effective in connection with different types of smoking. Secondly, the authors point out that questions remain about what exactly constitutes the effectiveness of interventions. This question generalizes to interventions as a whole. Another observation is that all interventions seem to be equally effective, so therefore the therapeutic elements may not necessarily be confined to the interventions bur rather may be reducible to variables such as self-efficacy and social-support. This needs to be investigated (Huttunen-Lenz, Song, & Poland, 2010). Various researchers recommend comparison psychosocial strategies of combination of psychosocial intervention with nicotine replacement theory or bupropion and comparing these with the efficacy of interventions that consist of nicotine replacement or bupropion alone. Huey-Ling and colleagues ( 2009) also recommends that the role of nicotine replacement be evaluated in psychosocial interventions) and simply comparison of the efficacy of psychosocial interventions between themselves (Barth, Critchley, & Benget, 2008). As regards the debate on whether or not to include nicotine replacement therapy in further investigations, Barth et al. (2008) is concerned about the problems of nicotine therapy on smoker's health saying that aside from earlier review by Fiore et al. (67) that showed that only 22% of heavy smokers with NRT were abstinent after 6 months compared with only 9% of controls. More seriously, there has been concern about possible adverse effects of NRT in patients with CHD. Two case studies reported adverse cardiac events while using NRT (Frothingham, et al., 2006). Several authors have investigated the influence of NRT on heart rate, blood pressure, and other cardiac parameters (e.g., arrhythmias), but no studies have shown any side effects so concern may be unwarranted, particularly since no evidence has been found for cardiac casualty even though large populations have been sampled. However, since NRT seems to be effective with only a small amount of people, Frothingham, et al., (2006) seems to think that psychosocial interventions may be a good way of integrating and recommending NRT as part of their system as well as monitoring their use so that no adverse effects will consequent.

As regards Bupropion, which is an anti-depressant, the same conditions apply. There is concern regarding its safety aside from which it is unclear as to whether or not large amounts of people can maintain their attempts to stop smoking on a Bupropion schedule. Again, Bupropion may be introduced as a part of a psychological intervention offering. This, at least, is 8's conclusion. It is possible that both NRT and Bupropion will be useful as supplement to psychosocial interventions such as behavioral therapy, telephone therapy and so forth.

General recommendations include those of Barth, Critchley, and Benget's (2008) call for greater clarity and detail description in trial procedures and related studies. Details should include the duration and intensity of the session including number of sessions, duration and so forth. It is possible that with greater description of studies, more directions may be found in formulating interventions that can assist in cessation of smoking.

I also observed that the majority of the studies conducted or observed employed a majority of males to females sometimes strikingly so. A personal recommendation, therefore, is that future researchers try to more closely match the demographics of their sampled populations particularly so since many variables can impact and influence the conditions of intervention (contaminating the effect and results and making it difficult to study), aside from which differences in age and gender may cause individuals to react to the interventions in differing ways. It would be interesting, therefore, to also assess whether there are any gender differences in response to the employed interventions, and whether more males than females (or the reverse) are prompted to stop smoking and are successful as a result despise their already having CHD.

Longitudinal and cross-sectional studies are naturally better in observing and assessing long-term 'stickiness' of efficacy of intervention particularly when assessed amongst a diverse cross-section of people. However, there are problems in conducting longitudinal and cross-sectional reviews and these include the fact that it is difficult to take into consideration and evaluate all the many other factors that may have influenced the results of smokers ceasing to smoke or not ceasing to smoke as well as their success in breaking free from smoking. Confounding factors may be advice received from others, intruding stress, certain high-impact life situations that caused them to cease or impelled them to rebound. All of these make it difficult to conduct any long-term research.