'It's not worth stopping now': why do smokers with chronic obstructive pulmonary disease continue to smoke? A qualitative study

What are the Barriers of Chronic Obstructive Pulmonary Disease (COPD) Patients in Smoking Cessation?

Objectives

Smoking is the major determinant of developing chronic obstructive pulmonary disease (COPD). A substantial proportion of patients with COPD continue smoking although they have significant respiratory symptoms, exacerbation history and comorbidities. We aimed to find the associated factors and clinical features of the patients who maintain smoking.

Methods

200 current smokers and 132 former smokers with a spirometry-confirmed diagnosis of COPD were recruited from the outpatient department. Demographic characteristics, smoking backgrounds, treatment status, comorbidities, exacerbation history of the previous year, pulmonary function tests, blood biochemistry, dyspnea scales, symptom scores, and BECK anxiety scores were all recorded.

Results

No age and gender differences were found between current and former smokers. Compared to former smokers, current smokers were less qualified, had more cardiovascular diseases, more frequently exposed to tobacco smoke at home and at work place, more severe pulmonary function impairment, longer duration of COPD, longer time of smoking, earlier age of commencement in smoking, higher scores of BECK anxiety scores (BAI), higher levels of inflammatory markers in blood tests p<0.05. In multivariable analysis, lower values of FEV1%, higher scores of CAT and BAI, higher levels of platelet and CRP were found to decrease the likelihood of smoking cessation p<0.05. Additionally having diabetes, coronary artery disease and hypertension were inversely correlated with quitting smoking p<0.05.

Conclusion

COPD is a systemic inflammatory disease. We found over half of the patients with COPD were currently smoking, despite the severity of their airflow limitation, symptoms and even the comorbidities. Furthermore, 2 out of 5 of the current smokers reported having moderate to severe anxiety. Dyspnea and inflammatory markers had negative effects on smoking cessation, and anxiety might be the cause that led these patients to keep smoking.

The impact of smoking status on anticipated stigma and experience of care among smokers and ex-smokers with chronic illness in general practice

OBJECTIVES

To compare self-reported levels of 'anticipated' stigma and experience of care in general practice between current and ex-smokers living with COPD, other chronic illnesses, or those with no chronic conditions.

METHODS

Participants completed an online survey, advertised through social media, about their experience of care from general practitioners (GPs) in the past 12 months. Respondents self-reported doctor-diagnosed chronic illnesses. Experience of care and anticipated stigma was assessed using validated questions. Multi-nominal regressions were used to determine independent effect of smoking status on anticipated stigma and other indicators of patient experience in primary care.

RESULTS

Patients with COPD (n = 161) reported significantly higher anticipated stigma scores compared to those with other chronic conditions (n = 225) and this was strongly related to delayed or avoidance in seeking help from a GP when needed. This relationship remained irrespective of current smoking status. There was no difference between groups for relational components of experience of care.

DISCUSSION

Primary care patients living with COPD reported worse experience of care across several domains and were more likely to anticipate experiencing stigma in the GP setting irrespective of their current smoking status compared to those with other chronic illnesses or no chronic illnesses.

The primary care experience of adults with chronic obstructive pulmonary disease (COPD). An interpretative phenomenological inquiry

BACKGROUND

Studies of the lived experience of chronic obstructive pulmonary disease (COPD) reveal a number of challenges patients face when interacting with healthcare providers that may be exacerbated by unwillingness or inability to quit smoking. However, none have explored, in-depth, primary care experiences among patients with COPD in community healthcare settings.

AIMS/ OBJECTIVE

The study investigated healthcare experiences of patients living independently in the community with COPD who smoked or had recently quit (at most within the last 5 years), seeking care in primary care settings.

METHOD

An Interpretative Phenomenological Analysis (IPA) involving thirteen participants purposively recruited from social media posts in COPD and carer support groups, general community groups, community noticeboards and paid adverts on social media. In-depth interviews were held between February and April 2022 by phone or Zoom™ and explored patient experience of primary care, focusing on how smoking patterns, addiction and stigma impact upon and shape these experiences.

RESULTS

Participants were aged between 45 to 75 years. Nine were female and two thirds were current smokers. Problematic experiences including time-constrained consultations, having to self-advocate for care "…go digging myself and then go and see him and say, can we do this, can we do that type of thing?" and guilt about smoking were common. Positive care experiences described non-judgemental interpersonal interactions with doctors, timely referral, proactive care and trust "I have an actual great trust for my GP… they're awesome, they'll look after you". Participants described how their care experience shifted as primary care adapted care delivery during COVID-19.

CONCLUSIONS

Pro-active, empathetic care from general practitioners is desired from patients living with COPD. Stigma and fear of judgement was an important underlying driver of negative care experiences contributing to delayed help seeking from general practitioners.

Healthcare experiences of adults with COPD across community care settings: a meta-ethnography

Background

Studies investigating lived experiences of patients with COPD raise important concerns about interactions with healthcare professionals. Patients often describe feelings of guilt and shame associated with their COPD and may experience stigma and poor patient experience of care. The aims and objectives of the present study were to systematically scope and synthesise findings from peer-reviewed qualitative studies describing healthcare experiences of patients living with COPD across community care settings.

Methods

A meta-ethnography was undertaken. Database searches were performed in Ovid MEDLINE, PsychINFO, Ovid Emcare, CINAHL Plus and Sociological Abstracts. Eligible qualitative studies were included. Study screening and data extraction was performed by two independent reviewers. A "line-of-argument" synthesis and deductive and inductive analysis was used to identify key themes, where the deductive element aligned to Wong and Haggerty's six key dimensions of patient experiences.

Results

Data from 23 studies were included. Experiences and their meaning to patients were explored within the context of six domains of patient experience including access, interpersonal communication, continuity and coordination, comprehensiveness and trust. Inductive coding revealed emotion, stigma, identity and vulnerability shaped healthcare experiences of adults with COPD.

Implications

Experiences often fell short of what was expected and needed in community settings. Adopting strategies to improve experiences of care in the community can be expected to improve self-management and contribute to improved health outcomes and quality of life. These strategies should take account of vulnerability, stigma and emotions such as guilt and blame that are potent affective drivers of the experience of care for patients with COPD.

Barriers and Facilitators for Smoking Cessation in Chinese Smokers with Chronic Obstructive Pulmonary Disease: A Qualitative Study

Background

Smoking cessation is recommended as a key intervention for chronic obstructive pulmonary disease (COPD) smokers. However, in China, few COPD smokers quit successfully. The aim of this study was to explore in depth the barriers and facilitators for smoking cessation among smokers with COPD in China.

Methods

A purposive sample of 32 hospitalized smokers with COPD were included, 17 ex-smokers and 15 current smokers, participated in the semi-structured interviews. Interviews were analyzed thematically and using a deductive approach guided by Capability, Opportunity, Motivation-Behavior (COM-B) framework.

Results

Three inter-related themes were generated: smokers’ motivation was a prerequisite for quitting, maintaining capability to quit smoking, and opportunities that facilitated smokers to quit. Motivation to quit for most participants was activated by COPD-related symptoms, although they had a limited knowledge of COPD. Physical benefits from quitting and strong willpower were facilitators for maintaining quitting, while exposure to smoking environment and strong addiction to nicotine were frequent reasons for relapse. Most ex-smokers quit smoking by their own willpower rather than professionally delivered smoking cessation interventions. Smokers’ attitudes toward these interventions depended on their effectiveness and convenience. Very few participants had experienced pharmacotherapy or behavioral support from physicians. However, interviewees preferred auricular acupressure to pharmacotherapy.

Conclusion

Motivation to quit among smokers with COPD was usually initiated by COPD-related symptoms. Physical benefits observed by quitting and strong willpower facilitated smoking cessation, while exposure to smoking environment and strong addiction to nicotine led to relapse. COPD smokers in China preferred auricular acupressure to pharmacotherapy.

Substance Use and Misuse among Adults with Chronic Obstructive Pulmonary Disease in the United States, 2015-2019: Prevalence, Association, and Moderation

BACKGROUND

Despite the advancements in chronic obstructive pulmonary disease (COPD) treatment, complications related to COPD exacerbation remain challenging. One associated factor is substance use/misuse among adults with COPD. Fewer studies, however, examined the prevalence and association between COPD and substance use and misuse. In addition, limited knowledge existed about the moderation effects of serious psychological distress and gender among adults with COPD and substance use/misuse. We aimed, therefore, to measure such prevalence, association, and moderation from nationally representative samples in the United States.

METHOD

Data were drawn from the 2015-2019 National Survey on Drug Use and Health. Weighted logistic regressions were used to measure the associations of last-month tobacco (cigarettes, cigars, pipe, and smokeless tobacco products), other licit and illicit substance use (alcohol, marijuana, cocaine, crack, heroin, hallucinogens, and inhalants), and substance misuse (pain relievers, tranquilizers, stimulants, and sedatives) among adults with COPD. Serious psychological distress and gender were tested as moderators in the association between COPD and substance use/misuse.

RESULTS

The findings revealed that adults with COPD [Weighted N = 53,115,718) revealed greater odds of cigarettes [adjusted odds ratio (aOR) = 2.48 (95%CI = 1.80-3.42)) and smokeless tobacco (aOR = 3.65 (95%CI = 1.75-7.65)). However, they were less likely to use alcohol (aOR = 0.61 (95%CI = 0.45-0.84)). Adults with COPD who had serious psychological distress were more likely to use pipe tobacco and alcohol; however, they were less likely to use hallucinogens and inhalants. Finally, males compared to females with COPD were less likely to use smokeless tobacco.

CONCLUSION

Adults with COPD in the United States were more likely to use tobacco products and less likely to use alcohol. In addition, serious psychological distress and gender were moderators in associations between COPD and substance use but not in substance misuse. Future studies should longitudinally assess the factors that may contribute to the initiation and progression of substance use and misuse among adults with COPD.

A cross sectional study to assess tobacco use and its correlates among patients attending non-communicable disease clinics of a Northern Jurisdiction in India

BACKGROUND

Non-Communicable Diseases (NCDs) continue to rise unabated globally and the existing evidence has unequivocally established the relationship between tobacco use and NCDs. In 2010 the Government of India (GOI) introduced NCD clinics under the National Program for Prevention and Control of Cancer, Diabetes, Cardio Vascular Diseases and Stroke (NPCDCS) with the purpose of preventing and combating the NCD epidemic. This study was undertaken with an objective to comprehensively determine tobacco use and its correlates among patients attending these NCD clinics.

METHODS

A descriptive cross-sectional study was carried out among 1172 patients attending NCD clinics at district level, in Punjab, India between May to October 2018. Using systematic sampling every fourth patient was interviewed and equal numbers of visits were made to both the clinics.

RESULTS

Overall, the current tobacco use in any form was reported to be 10.2% among the study respondents. Majority of the tobacco users were males (23.3%), in 40-49 year age group, (18.7%), residing in urban area (15%), educated up to secondary school (18%) and non-government occupation bracket (27.4%) and hypertension disease category (41.6%). More SLT users had thought of quitting in past in comparison to smokers (46.6% vs 40%) and had higher quit attempts in past (42.5% vs 38.3%). In the binary logistic regression analysis, odds of tobacco use increased with increasing age, three times higher among participants who were employed (OR 3.75; CI 1.41-10.02),6 times higher in COPD disease category (OR 6.88; CI 2.1-20.59).

CONCLUSION

Higher tobacco use among the NCD clinic attendees with increasing age predisposes them to develop grave complications. This calls for the need to administer intensive behaviour change interventions for tobacco cessation at the existing NCD clinics. This could further strengthen existing health systems and thereby improving health outcomes followed by achieving Sustainable Development Goals.

Factors Associated with the Intention to Quit Smoking in Elderly Korean Men: The Korea National Health and Nutrition Examination Survey 2010-2015

Background

Tobacco smoking is the most preventable cause of diseases and death in older adults. This study aimed to evaluate the factors associated with the intention to quit smoking in elderly Korean men.

Methods

We investigated 813 male smokers aged 65 years or more from the 5th and 6th Korea National Health and Nutrition Examination Survey 2010–2015. Multiple logistic regression analysis was performed to identify factors related with smoking cessation intention.

Results

Of the respondents, 26.3% had the intention to quit smoking. After adjustment for confounding factors, the intention to quit smoking was significantly associated with a history of ischemic heart disease (adjusted odds ratio, 1.88; 95% confidence interval, 1.02–3.48).

Conclusion

Identifying the factors related to the intention to quit smoking among older adults can help in developing effective smoking cessation strategies for this section of the population.

Explaining the social gradient in smoking and cessation: the peril and promise of social mobility

Smoking in high-income countries is now concentrated in poor communities whose relatively high smoking prevalence is explained by greater uptake but above all by lower quit rates. Whilst a number of barriers to smoking cessation have been identified, this is the first paper to situate cessation itself as a classed and cultural practice. Drawing on ethnographic research carried out in a working-class community in the North of England between 2012 and 2015, I theorise smoking cessation as a symbolic practice in relation to the affective experience of class and social mobility. I show that ambivalence about upward mobility as separation and loss translated into ambivalence about smoking cessation. The reason for this was that the social gradient in smoking operated dynamically at the level of the individual life course, i.e. smoking cessation followed upward mobility. A serious health problem was an appropriate reason to quit but older women continued to smoke despite serious health problems. This was linked to historical gender roles leading to women placing a low priority on their own health as well as the intergenerational reproduction of smoking through close affective links with smoking parents.

Factors associated with current smoking in COPD patients:A cross-sectional study from the Eastern Black Sea region of Turkey

INTRODUCTION

Even though smoking is a major reason for the development and progression of chronic obstructive pulmonary disease (COPD)-and quitting smoking is the only way to stop its progression-a significant number of smokers still continue to smoke after being diagnosed with COPD. The aim of this study is to compare the clinical and demographic characteristics of COPD patients who are current and former smokers and to find factors associated with their current smoking status.

METHODS

For this study, data were collected between June 2015 and August 2016; COPD patients who had been regularly visiting Hopa State Hospital's outpatient clinic over the last year or longer were included. Their demographic, clinical and functional data were recorded. Patients completed a pulmonary function test, six-minute walk test (6-MWT), COPD assessment test (CAT), and modified Medical Research Council (mMRC) dyspnea scale. Comparisons were then made according to their smoking status.

RESULTS

In total 100 patients were included in the study; with a mean age of 63.4±10.7 years and mostly males (94%). Regarding smoking status, 49% were current smokers and 51% were former smokers. Multivariate logistic regression analysis revealed that current smoking was negatively associated with age (odds ratio, OR=0.93, 95% confidence interval, CI=0.88-0.96) and Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage (OR=0.32, 95% CI=0.13- 0.79), and was positively associated with six-minute walk distance (OR =1.005, 95% CI=1.001-1.009) and CAT score (OR=1.07, 95% CI=1.009-1.13).

CONCLUSIONS

Nearly half of the COPD patients in the study continued smoking even after having been diagnosed with COPD. The younger patients, with better lung function, better exercise capacity and poor quality of life were associated with current smoking.

The experiences of smoking cessation among patients with chronic obstructive pulmonary disease in Australian general practice: a qualitative descriptive study

BACKGROUND

It is important to understand the experiences surrounding smoking cessation among patients with chronic obstructive pulmonary disease (COPD) to improve the likely success of future smoking cessation programs.

OBJECTIVE

To explore the personal experiences surrounding smoking cessation among general practice patients with COPD.

METHODS

A purposive sample of 33 general practice patients with COPD, 28 ex-smokers and 5 smokers, participated in the semi-structured telephone interviews. Thematic analysis was conducted using a predominantly deductive approach guided by the Behaviour Change Wheel framework.

RESULTS

Three inter-related themes were generated: the motivation, opportunities and capabilities among the participants to quit and maintain smoking cessation. Most quit attempts occurred without explanation or prior planning, though some attempts were motivated by the participants' family, peers or GP. Internet-based smoking cessation support programs led by general practices and involving the practice nurse were perceived as opportunities to engage in quit attempts. Most participants, both ex-smokers and smokers, demonstrated capacity to engage in multiple quit attempts. However, for many smokers, boredom, mood disturbances, the strong sense of identity as a smoker, peer reinforcement, irritability, cravings, hunger and weight gain limited capability to maintain smoking cessation.

CONCLUSIONS

Patients with COPD have motivation to quit and have demonstrated capacity to engage in multiple quit attempts. GPs and other primary care practitioners need to recognize the patients' spontaneity around quit attempts and to meet the needs of the individual patient by being ready to offer support for each attempt once the patient has made their decision to quit.

Emotional Intelligence: A Novel Outcome Associated with Wellbeing and Self-Management in Chronic Obstructive Pulmonary Disease

RATIONALE

Individuals with chronic obstructive pulmonary disease (COPD) often struggle with diminished autonomy and quality of life. Emotional factors play a crucial role in the well-being of patients with COPD; they are independently associated with critical outcomes such as dyspnea, quality of life, and health care use. Emotional intelligence is the capacity to understand and manage personal thoughts and feelings, as well as to positively influence interpersonal communication and social well-being. Emotional intelligence is a trainable skill that is extensively used in corporate business to improve well-being and performance, and it may also be significant in the self-management of emotions in patients with chronic disease. Importantly, research supports the proposition that emotional intelligence may be developed and learned at any time or any age, and training programs have been associated with increased well-being and better emotional regulation in patients with chronic disease. However, to date, no research has been done to investigate its value in patients with COPD.

OBJECTIVES

We aimed to investigate the association between emotional intelligence and two meaningful outcomes in COPD: quality of life and self-management abilities.

METHODS

Participants with moderate to severe COPD completed a disease-specific quality of life tool (Chronic Respiratory Questionnaire), the Trait Emotional Intelligence Questionnaire, the Self-Management Abilities Scale, the modified Medical Research Council Dyspnea Scale, and pulmonary function tests, and also provided information about living conditions and self-reported health care use.

MEASUREMENTS AND MAIN RESULTS

A total of 310 patients with COPD (mean age, 69 ± 9 yr; 40% female; mean FEV1%, 42.4 ± 15.8) participated in the study. Emotional intelligence was significantly and independently associated with self-management abilities (P < 0.0001) and all domains of quality of life assessed (dyspnea, fatigue, emotions, and mastery; P < 0.0001) after adjusting for age, degree of bronchial obstruction, breathlessness, and other significant confounders.

CONCLUSIONS

Emotional intelligence may represent an important attribute in COPD, as it is associated with self-management abilities and all domains of quality of life, regardless of age or disease severity. Emotional intelligence can be learned and may complement existing rehabilitation efforts. Attention to it may address the current gap that exists in the treatment of emotional components of COPD responsible for decreased quality of life and increased health care use.

Respiratory and Bronchitic Symptoms Predict Intention to Quit Smoking among Current Smokers with, and at Risk for, Chronic Obstructive Pulmonary Disease

RATIONALE

Smoking cessation is the most important intervention for patients with chronic obstructive pulmonary disease (COPD). What leads smokers with COPD to quit smoking remains unknown.

OBJECTIVES

We sought to examine the association between respiratory symptoms and other markers of COPD severity with intention to quit smoking among a cohort of patients with probable COPD.

METHODS

We conducted a cross-sectional study of subjects with COPD or fixed airflow obstruction clinically diagnosed on the basis of pulmonary function testing. The subjects were identified in the COPD Outcomes-based Network for Clinical Effectiveness and Research Translation multicenter registry. The primary outcome was the intention to quit smoking within the next 30 days (yes or no), which was examined using model building with multivariable logistic regression, clustered by study site.

MEASUREMENTS AND MAIN RESULTS

We identified 338 current smokers with COPD via the registry. Of these subjects, 57.4% (n = 194) had confirmed airflow obstruction based on pulmonary function testing. Nearly one-third (29.2%; n = 99) intended to quit smoking in the next 30 days. In adjusted analyses, compared with subjects without airflow obstruction based on pulmonary function testing, subjects with Global Initiative for Chronic Obstructive Lung Disease stage I/II COPD were more likely to be motivated to quit (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.37-2.49), with no association found for subjects with Global Initiative for Chronic Obstructive Lung Disease stage III/IV disease. Among the entire cohort, frequent phlegm (OR, 2.10; 95% CI, 1.22-3.64), cough (OR, 1.74; 95% CI, 1.01-2.99), wheeze (OR, 1.73; 95% CI, 1.09-3.18), and higher modified Medical Research Council dyspnea score (OR, 1.26 per point; 95% CI, 1.13-1.41) were associated with increased odds of intending to quit smoking. Low self-reported health was associated with decreased odds of intending to quit (OR, 0.75; 95% CI, 0.62-0.92).

CONCLUSIONS

Frequent cough, phlegm, wheeze, and shortness of breath were associated with intention to quit smoking in the next 30 days, with a less clear relationship for severity of illness graded by pulmonary function testing and self-rated health. These findings can be used to inform the content of tobacco cessation interventions to provide a more tailored approach for patients with respiratory diseases such as COPD.

Experiences of COPD patients with existing smoking cessation programs and their preferences for improvement - a qualitative analysis

Background

Smoking is a major risk factor for chronic obstructive pulmonary disease (COPD). For current smokers who are diagnosed with COPD, their first treatment option is to stop smoking. Motivation is necessary for long-term smoking cessation; therefore, when designing smoking cessation programs, the patients’ needs and preferences should be considered. We focused on COPD patients’ experiences with existing smoking cessation programs and evaluated their preferences for the improvement of these programs.

Methods

We conducted 18 guideline-based interviews with COPD patients between April and June 2014 in Germany. Each patient with COPD, who was a current or past smoker and had made at least one attempt to quit smoking in the past 5 years, was included in the study. We audiotaped, verbatim transcribed, and evaluated the interviews, using content analysis.

Results

The patients had broad and different experiences with pharmaceutical, behavioral, and alternative approaches that supported or negatively influenced the smoking cessation process. Pharmaceuticals were viewed as an expensive alternative with many side effects although they helped to stop cravings for a few moments. Furthermore, the bad structure and impersonal content of the seminars for smoking cessation negatively influenced group cohesion, and therefore degrading the patients’ motivation to stop smoking. Alternative methods, such as acupuncture and hypnosis were mostly ineffective in smoking cessation, but in some cases, served as motivational strategies.

Conclusion

Negative experiences with smoking cessation were explained by the patients’ lack of motivation or resolution. Other negative experiences, such as the structure of seminars for smoking cessation and the high price of pharmaceuticals should be addressed through policy changes to increase the patients’ motivation to quit smoking.

Smoking cessation for people with chronic obstructive pulmonary disease

BACKGROUND

Smoking cessation is the most important treatment for smokers with chronic obstructive pulmonary disease (COPD), but little is known about the effectiveness of different smoking cessation interventions for this particular group of smokers.

OBJECTIVES

To evaluate the effectiveness of behavioural or pharmacological smoking cessation interventions, or both, in smokers with COPD.

SEARCH METHODS

We searched all records in the Cochrane Airways Group Specialised Register of Trials. In addition to this electronic search, we searched clinical trial registries for planned, ongoing, and unpublished trials. We searched all databases from their inception. We checked the reference lists of all included studies and of other systematic reviews in relevant topic areas. We searched for errata or retractions from eligible trials on PubMed. We conducted our most recent search in March 2016.

SELECTION CRITERIA

We included randomised controlled trials assessing the effectiveness of any behavioural or pharmacological treatment, or both, in smokers with COPD reporting at least six months of follow-up abstinence rates.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and performed the methodological quality assessment for each study. We resolved any disagreements by consensus.

MAIN RESULTS

We included 16 studies (involving 13,123 participants) in this systematic review, two of which were of high quality. These two studies showed that nicotine sublingual tablet and varenicline increased the quit rate over placebo (risk ratio (RR) 2.60 (95% confidence interval (CI) 1.29 to 5.24) and RR 3.34 (95% CI 1.88 to 5.92)). Pooled results of two studies also showed a positive effect of bupropion compared with placebo (RR 2.03 (95% CI 1.26 to 3.28)). When pooling these four studies, we found high-quality evidence for the effectiveness of pharmacotherapy plus high-intensity behavioural treatment compared with placebo plus high-intensity behavioural treatment (RR 2.53 (95% CI 1.83 to 3.50)). Furthermore, we found some evidence that high-intensity behavioural treatment increased abstinence rates when compared with usual care (RR 25.38 (95% CI 8.03 to 80.22)) or low-intensity behavioural treatment (RR 2.18 (95% CI 1.05 to 4.49)). Finally, the results showed effectiveness of various combinations of psychosocial and pharmacological interventions.

AUTHORS' CONCLUSIONS

We found high-quality evidence in a meta-analysis including four (1,540 participants) of the 16 included studies that a combination of behavioural treatment and pharmacotherapy is effective in helping smokers with COPD to quit smoking. Furthermore, we conclude that there is no convincing evidence for preferring any particular form of behavioural or pharmacological treatment.

Predictors of Pharmacotherapy for Tobacco Use Among Veterans Admitted for COPD: The Role of Disparities and Tobacco Control Processes

BACKGROUND

Many smokers admitted for chronic obstructive pulmonary disease (COPD) are not given smoking cessation medications at discharge. The reasons behind this are unclear, and may reflect an interplay of patient characteristics, health disparities, and the receipt of inpatient tobacco control processes.

OBJECTIVES

We aimed to assess potential disparities in treatment for tobacco use following discharge for COPD, examined in the context of inpatient tobacco control processes.

PARTICIPANTS

Smokers aged ≥ 40 years, admitted for treatment of a COPD exacerbation within the VA Veterans Integrated Service Network 20, identified using ICD-9 discharge codes and admission diagnoses from 2005-2012.

MAIN MEASURES

The outcome was any tobacco cessation medication dispensed within 48 hours of discharge. We assessed potential predictors administratively up to 1 year prior to admission. We created the final logistic regression model using manual model building, clustered by site. Variables with p < 0.2 in biviariate models were considered for inclusion in the final model.

RESULTS

We identified 1511 subjects. 16.9 % were dispensed a medication at discharge. In the adjusted model, several predictors were associated with decreased odds of receiving medications: older age (OR per year older 0.96, 95 % CI 0.95-0.98), black race (OR 0.34, 95 % CI 0.12-0.97), higher comorbidity score (OR 0.89, 95 % CI 0.82-0.96), history of psychosis (OR 0.40, 95 % CI 0.31-0.52), hypertension (OR 0.75, 95 % CI 0.62-0.90), and treatment with steroids in the past year (OR 0.80, 95 % CI 0.70-0.90). Inpatient tobacco control processes were associated with increased odds of receiving medications: documented brief counseling at discharge (OR 3.08, 95 % CI 2.02-4.68) and receipt of smoking cessation medications while inpatient (OR 5.95, 95 % CI 3.19-11.10).

CONCLUSIONS

Few patients were treated with tobacco cessation medications at discharge. We found evidence for disparities in treatment, but also potentially beneficial effects of inpatient tobacco control measures. Further focus should be on using novel processes of care to improve provision of medications and decrease the observed disparities.

Recommendations to improve smoking cessation outcomes from people with lung conditions who smoke

This study aimed to gain insight into the impact of lung conditions on smoking behaviour and smoking cessation, and identify recommendations for smoking cessation and professional-patient communications. The study was led by the European Lung Foundation in collaboration with the European Respiratory Society Task Force on "Statement on smoking cessation on COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit". A web-based observational cross-sectional questionnaire was developed from a patient-centered literature review. Topics covered were: cohort characteristics; perspectives on smoking cessation; interactions with healthcare professionals; and recommendations to improve cessation outcomes. The questionnaire was disseminated via existing patient and professional networks and social media channels. The survey was available online for a period of 4 months in 16 languages. The data were analysed as a whole, not by country, with thematic analysis of the open responses. Common characteristics were: male (54%); age 40-55 years (39%); 11-20 cigarettes a day (39%); smokes within 30 min of waking (61%); and has made 1-5 cessation attempts in the previous 12 months (54%). 59% had tried cessation treatments, but, of these, 55% had not found any treatments helpful. Recommendations were: earlier intervention; discussion of the patient's smoking beliefs, behaviours and motivation; giving constructive advice; understanding addiction; informed decision-making; and treatment options. Areas for new and further research have been highlighted through exploring the smoking cessation perspectives and recommendations of people with lung conditions in Europe who smoke.

Exploring the Unmet Needs of the Patients in the Outpatient Respiratory Medical Clinic: Patients versus Clinicians Perspectives

Aim. Developing a theoretical framework explaining patients' behaviour and actions related to unmet needs during interactions with health care professionals in hospital-based outpatient respiratory medical clinics. Background. The outpatient respiratory medical clinic plays a prominent role in many patients' lives regarding treatment and counselling increasing the need for a better understanding of patients' perspective to the counselling of the health care professionals. Design. The study is exploratory and based on Charmaz's interpretation of grounded theory. Methods. The study included 65 field observations with a sample of 43 patients, 11 doctors, and 11 nurses, as well as 30 interviews with patients, conducted through theoretical sampling from three outpatient respiratory medical clinics in Denmark. Findings. The patients' efforts to share their significant stories triggered predominantly an adaptation or resistance behaviour, conceptualized as "fitting in" and "fighting back" behaviour, explaining the patients' counterreactions to unrecognized needs during the medical encounter. Conclusion. Firstly this study allows for a better understanding of patients' counterreactions in the time-pressured and, simultaneously, tight structured guidance program in the outpatient clinic. Secondly the study offers practical and ethical implications as to how health care professionals' attitudes towards patients can increase their ability to support emotional suffering and increase patient participation and responsiveness to guidance in the lifestyle changes.

Experiences of tobacco smoking and quitting in smokers with and without chronic obstructive pulmonary disease-a qualitative analysis

Background

Smokers with chronic obstructive pulmonary disease (COPD) seem to be a special subgroup of smokers that have a more urgent need to quit smoking but might find it more difficult to do so. This study aimed to explore which justifications for tobacco smoking and experiences of quitting were commonly shared in smokers with and without COPD, and which, if any, were specific to smokers with COPD.

Methods

In ten primary healthcare centres in the Netherlands, we conducted semi-structured, in-depth interviews in 10 smokers with and 10 smokers without COPD.

Results

Three themes were generated: ‘balancing the impact on health of smoking’, ‘challenging of autonomy by social interference’, ‘prerequisites for quitting’. All participants trivialized health consequences of smoking; those with COPD seemed to be less knowledgeable about smoking and health. Both groups of smokers found autonomy very important. Smokers with COPD were indignant about a perceived lack of empathy in their communication with doctors. Furthermore, smokers with COPD in particular had little faith in the efficacy of smoking cessation aids. Lastly, motivation for quitting was dominated by fluctuation and smokers with COPD specifically maintained that their vision of life was linked with quitting.

Conclusions

The participants showed many similarities in their reasoning about smoking and quitting. The corresponding themes argue for a less paternalistic regime in the communication with smokers with attention required for the motivational stage and room made for smokers’ own views, and with clear information and education. Furthermore, addressing social interactions, health perceptions and moral agendas in the communication with smokers with COPD may help to make smoking cessation interventions more suitable for them.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0382-y) contains supplementary material, which is available to authorized users.

Are predictors of making a quit attempt the same as predictors of 3-month abstinence from smoking? Findings from a sample of smokers recruited for a study of computer-tailored smoking cessation advice in primary care

AIMS

To identify predictors of quit attempts and of 3-month abstinence from cigarette smoking.

DESIGN

Secondary analysis of data gathered for a two-armed randomized controlled trial with 6-month follow-up.

SETTING

A total of 123 general practices across the United Kingdom.

PARTICIPANTS

A total of 4397 participants who completed the 6-month follow-up. Participants were categorized on self-reported smoking behaviour at 6-month follow-up as non-attempters (n = 2664), attempted quitters (n = 1548) and successful quitters (n = 185).

MEASURES

Demographic characteristics, smoking history and nicotine dependence, cognitive and social-environmental factors measured at baseline were examined as potential predictors of quit attempts and 3-month abstinence.

FINDINGS

Univariate predictors of quit attempts included commitment [odds ratio (OR) = 11.64, 95% confidence interval (CI) = 8.30-16.32], motivation (OR = 2.10, 95% CI = 1.98-2.22) and determination to quit (OR = 1.94, 95% CI = 1.83-2.05). Successful quitting was associated with being married (OR = 1.51, 95% CI = 1.11-2.05), lower social deprivation (OR = 0.47, 95% CI = 0.30-0.74), higher reading level (OR = 1.62, 95% CI = 1.19-2.21) and lower nicotine dependence (OR = 0.42, 95% CI = 0.29-0.62). Health problems related to smoking and previous quit attempts for 3 months or longer predicted both. In the multivariate analysis, the significant predictors of making a quit attempt were; later stage of readiness to quit (OR = 5.38, 95% CI = 3.67-7.89), motivation (OR = 1.48, 95% CI = 1.34-1.62) and determination to quit (OR = 1.16, 95% CI = 1.05-1.29) and health problems related to smoking (OR = 1.44, 95% CI = 1.18-1.75). For 3-month abstinence, the only significant predictor was not having health problems related to smoking (OR = 0.50, 95% CI = 0.29-0.83).

CONCLUSIONS

While high motivation and determination to quit is necessary to prompt an attempt to quit smoking, demographic factors and level of nicotine dependence are more important for maintaining abstinence.

Measurement of factors that negatively influence the outcome of quitting smoking among patients with COPD: psychometric analyses of the Try To Quit Smoking instrument

Aims

To test internal consistency and factor structure of a brief instrument called Trying to Quit smoking.

Background

The most effective treatment for patients with chronic obstructive pulmonary disease is to quit smoking. Constant thoughts about quitting and repeated quit attempts can generate destructive feelings and make it more difficult to quit.

Design

Development and psychometric testing of the Trying to Quit smoking scale.

Methods

The Trying to Quit smoking, an instrument designed to assess pressure‐filled states of mind and corresponding pressure‐relief strategies, was tested among 63 Swedish patients with chronic obstructive pulmonary disease. Among these, the psychometric properties of the instrument were analysed by Exploratory Factor Analyses.

Results

Fourteen items were included in the factor analyses, loading on three factors labelled: (1) development of pressure‐filled mental states; (2) use of destructive pressure‐relief strategies; and (3) ambivalent thoughts when trying to quit smoking. These three factors accounted for more than 80% of the variance, performed well on the Kaiser‐Meyer‐Olkin (KMO) test and had high internal consistency.

Quality of Life in Chronic Obstructive Pulmonary Disease: An Evolutionary Concept Analysis

AIM

To explore the concept of quality of life (QoL) of people with chronic obstructive pulmonary disease (COPD) in the nursing context.

BACKGROUND

The issue of QoL takes on a leading role in the COPD field because it is an incurable pathology. Despite its relevance, this concept is quite ambiguous, and there is no consensus of opinion in the literature regarding its definition.

DESIGN AND METHODS

Rodgers' method of evolutionary concept analysis was employed to delineate and clarify the concept of QoL in COPD. An electronic review was made on scientific databases from 2008 to 2013. The 75 selected articles were analyzed in order to highlight the main themes related to QoL concept.

RESULTS

The QoL appears as a dynamic and multidimensional concept that evolves with the progression of the pathology and the impairment of health status. It has both subjective and objective characteristics, intrinsic and extrinsic elements.

CONCLUSIONS

This analysis provides an overview of the QoL concept related to COPD patients that is useful as a guide to research into nursing care and for clinical practice.

Smoking addiction in chronic obstructive pulmonary disease: Integrating neurobiology and phenomenology through a review of the literature

The aim of this review is to extend professional understanding of the various mechanisms that make smoking cessation difficult for patients with chronic obstructive pulmonary disease (COPD). Smoking in people with COPD is a major challenge for health care today. In spite of significant advances in knowledge about the processes of nicotine addiction, current interventions to support smoking cessation in patients with COPD are less successful than hoped for. A wealth of literature has confirmed that nicotine addiction is a powerful force and that smoking is not simply an unhealthy lifestyle or destructive behavior. However, research based on this realization is still in its infancy. To increase understanding and to develop ways of enhancing smoking cessation in patients with COPD, we review and synthesize knowledge found in neurobiology and phenomenology. We use neurobiology to explain the neurochemical changes that take place in addiction in order to substantiate phenomenological perspectives of smoking in patients with COPD. We relate the smoking experience to the concept of "affordances"-in this context "smoking affordances"-to analyze how smoking affects action possibilities in individuals with COPD. Combining these perspectives helps to illuminate the manifold and unique issues related to smoking addiction in patients with COPD.

'It's about me'--a narrative analysis of female smokers with chronic obstructive pulmonary disease (COPD) and their relationship to smoking

BACKGROUND

Chronic obstructive lung disease is a disease that is common among the smoking population. In Sweden, more women than men are smokers. The most effective treatment to improve the symptoms of COPD is to quit smoking but still many women continue to smoke, despite their illness.

AIM

The aim of this study was to describe how a group of smoking women with chronic obstructive lung disease (COPD) experienced their everyday life and their relationship to smoking.

METHOD

A qualitative study based on narratives from six women with COPD was conducted. The narratives focused on the women's everyday life and their relationship to smoking. The interviews were analysed into four themes and a new story, based on these themes were constructed.

FINDINGS

The new story describes a woman with COPD that knows what she must do but cannot find the power within herself to take action. She talks about herself like a young bird that is going fly for the first time.

CONCLUSION

The study indicates that these women need some form of individual help to find the inner strength that they lack. Their self-respect as well as their self-image needs to be boosted in order to strengthen their belief that they are going to cope without the cigarette.

Chronic obstructive pulmonary disease and comorbidities through the eyes of the patient

Patient's attitudes and illness beliefs have shown to be of great importance in chronic obstructive pulmonary disease (COPD). As former qualitative research has mainly focused on patients with end-stage COPD, who are recruited within hospital or pulmonary rehabilitation settings, and excluding patients with disabling comorbidities, this study specifically aims to explore the perspectives of patients with COPD and comorbidities in primary care. This study was designed as a qualitative, explorative study using open patient interviews. The study was conducted at three primary care practices, East Flanders, Belgium. A total number of seven patients, diagnosed with COPD and given a minimum score of 2 on the Charlson Comorbidity Index were included. In-depth interviews were recorded and transcribed verbatim. Thematic analysis was deductive using NVivo software. Researchers' triangulation was performed. Participants show high adaptation capabilities and report quite positively about their functional status, with an emphasis on social participation and partnership. Knowledge of the causes and consequences of COPD appears rather limited, and participants predominantly show an external locus of control in relation to the reported factors influencing the disease and strategies for self-management. Patients with COPD with comorbidity integrate their illness and symptoms into their lives. However, a lack of knowledge and education may leave them more anxious and more dependent on health care than necessary. Our results indicate that health care workers should adopt a positive approach toward patient's functioning and empower and inform their patients. We believe that chronic care for patients with COPD should provide personalized rehabilitation taking into account individual patient characteristics and self-management and coping attitudes. We believe that there is a generic core to be identified, which can tackle both COPD and comorbidities. Further research is mandatory to develop these generic programs focusing on patients with complicated needs. Primary care can provide the setting for exploration.

Why do smokers diagnosed with COPD not quit smoking? - a qualitative study

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is currently one of the most widespread chronic lung diseases and a growing cause of suffering and mortality worldwide. It is predicted to become the third leading cause of death in the near future. Smoking is the most important risk factor, and about 50% of smokers develop COPD. Smoking cessation is the most important way to improve prognosis. The aim of the study was to describe difficulties of smoking cessation experienced by individuals with COPD who are unable to stop smoking.

METHODS

Ten smokers (five women) with COPD, GOLD stage II, participated in semi-structured interviews in 2010. The data were analyzed using qualitative content analysis. The participants were recruited from the Obstructive Lung Disease in Northern Sweden (OLIN) studies.

RESULTS

The participants lives were governed by a lifelong smoking habit that was difficult to break although they had knowledge about the harmful effects and the consequences of COPD. The participants described incidents in their lives as reasons for never finding the time to quit smoking. Demands to quit smoking from other people could lead to continued smoking or get them started again after cessation as they did not want to be patronized. They wanted to receive support from relatives and care providers but they wanted to make the decision to quit on their own.

CONCLUSION

For successful smoking cessation, it is important to understand the difficulties smokers are experiencing that influence their efforts to quit smoking. To achieve a successful lasting smoking cessation it might be more effective to first ensure that the smoker has the right internal motivation to make the decision to quit, then assist with smoking cessation.

Consultation performance of general practitioners when supported by an asthma/COPDC-service

Background

General practitioners (GPs) can refer patients to an asthma/COPD service (AC-service) for diagnostic assessment of spirometry and medical history and for asthma or COPD monitoring. The AC-service reports diagnostic results and additional information about disease burden (BORG-score for complaints, MRC-dyspnoea score, exacerbation rate), life style, medication and compliance, to the patient’s GP. This study explores how GPs use this additional information when discussing the patient’s disease burden and how this influences GPs’ information and education provision during consultations with asthma/COPD patients.

Method

Patients with (a suspicion of) asthma or COPD were referred to an AC-service and consulted their GPs after they had received a report from the AC-service. Retrospectively patients answered questions about their GPs’ performance during these consultations. Performances were compared with performances of the same GPs during consultations without support of the AC-service (usual care), earlier that year.

Results

Of consultations not initiated by an AC-service check-up, 91% focussed on complaints, the initial reason for the consultation. In AC-service supported follow-up consultations, GPs explored disease burden when the (BORG-)score for complaints was high - as reported by the AC-service - even when patients themselves thought it was irrelevant. GPs put significantly less effort in exploring disease burden when the Borg-score was low (BORG 3–4: 69%; BORG1-2: 51%, p = 0,01). GPs mostly ignored MRC-dyspnoea scores: attention to dyspnoea was 18% for MRC-score <3 and 25% for MRC-score ≥3 (p = 0,63). GPs encouraged physical fitness in 13% of patients. Smoking behaviour was discussed with 66% of the actual smokers but only 14% remembered a stop smoking advice. Furthermore, pharmacotherapeutic management education in AC-service supported consultations did not differ from performance in usual care according to patient evaluations.

Conclusion

Other than taking into account the severity of complaints, there was no difference between GPs’ performance in AC-service supported and in usual care consultations. AC-service reports are thus not effective by themselves. GPs should be encouraged to use the information better and systematically check all relevant aspects that characterize the disease burden of their patients.