An Analysis of Smoking Patterns and Cessation Efforts Among Canadian Forces Veterans: An Exploration of the Transtheoretical Model

Transcription

1 An Analysis of Smoking Patterns and Cessation Efforts Among Canadian Forces Veterans: An Exploration of the Transtheoretical Model Charles Nelson, Ph.D., C.Psych 1, 2 Kate St. Cyr, M.Sc. PPH 2 Rita Wiltsie, M.Ed. 2 Jeanine Lane, B.H.Sc. (Candidate) Ken Lee, M.D., FRCPC 2 Jane Gallimore, R.N., BSW 2 Don Richardson, M.D., FRCPC 2,3 David Haslam, M.D., FRCPC 2,3 Alexandra McIntyre-Smith, Ph.D. 2 Shannon Gifford, Ph.D., C. Psych 2 Dana Martel, M.S.W 2 Nancy Cameron, R.N., M.Ed Department of Psychology, University of Western Ontario, London ON 2. Parkwood Hospital Operational Stress Injury Clinic, London ON 3. Department of Psychiatry, University of Western Ontario, London ON 1

2 Partial funding for this research was provided by a CAN ADAPTT research grant. Commercial Disclosure Statement I, Charles Nelson, have no commercial relationships to disclose. 2

3 Parkwood Hospital London, Ontario, Canada 3

4 About the Clinic 1 of 10 outpatient clinics in Canada 93% male 74.6% veterans 17.8% still serving 1.9% RCMP 5.7% family members Mean age at intake: 45 years Mean years of service = 18 years Average number of deployments = 3 (range: 0 20)

5 Operational Stress Injury Clinics What s an OSI? Any persistent psychological difficulty resulting from service with the Canadian Forces or RCMP E.g., PTSD, MDD, PDA, other significant difficulties that may not meet criteria for a DSM IV diagnosis Intended to be non stigmatizing term recognizing that military service carries the risk of psychological as well as physical harm 5

6 Background Canadian Forces members face significant challenges in coping with peace keeping and combat roles Upon returning home, the stress associated with adapting to their civilian roles and responsibilities is often met with a tenuous adjustment process. 6

7 Background (continued) Transitional stress often leads to increased tobacco use The prevalence of smoking among military veterans is higher than for non veterans and higher for those seeking care within the Veterans Affairs system than for other veterans (McKinney et al, 1997) 7

8 Research Objectives Establish factors that affect smoking patterns among Canadian Forces members and Canadian Veterans seeking treatment for Operational Stress Injuries Identify factors that contribute to smoking cessation among this group 8

9 Methods Study Participants 225 current and former Canadian Forces (CF) and Royal Canadian Mounted Police (RCMP) members were invited to participate in the fall of individuals (39.1%) completed the questionnaires 76.1% (N = 67) reported smoking at some point in time during their lifetime 31.8% (N = 28) were current occasional or frequent smokers. Therefore, the final sample size = 28. 9

10 Methods Ethics Approval This study was approved by the Health Sciences Research Ethics Board at the University of Western Ontario, the Clinical Research Impact Committee at Parkwood Hospital, and the Lawson Health Research Institute. 10

11 Methods Data Collection All participants were mailed the screening package, along with the letter of information, a stamped, addressed return envelope, and instructions on how to complete the questionnaires and return them to the study investigators. In some cases, individuals who did not return their questionnaires participated in a phone survey 11

12 Measures A single page questionnaire assessed current smoking level, age of smoking initiation, number of previous quit attempts, and prior advice sought or received from health professionals to quit smoking 12

13 Measures continued Decisional Balance Inventory: Pros and Cons of Smoking subscale (Velicer et al, 1985) Perceived "cons" such as "I'm embarrassed to have to smoke" are weighed against coping "pros" including "Smoking helps me concentrate and do better work" Scores for the cons are summed and subtracted from the scores for the pros to obtain an aggregate score. Higher scores indicate more importance to the pros to the cons, or a positive balance to smoking 13

14 Measures continued Smoking: Self Efficacy/Temptation (Short Form) (Velicer et al, 1990) Assesses types of situations that cause respondents to be tempted to smoke: positive affect/social situations, negative affect situations, and habitual/craving situations Respondents rate how tempted they are to smoke from one (not at all tempted) to five (extremely tempted) A total score is achieved by summing the responses to each of the nine items 14

15 Data Analysis T tests and Pearson's correlations examined bivariate relationships between smoking status, stage of change, decisional balance subscale scores, and selfefficacy/temptation subscale scores. Stepwise linear regressions investigated multivariate relationships between total DBI and SSET SF scores, smoking status, and psychiatric diagnoses 15

16 Results Demographic Variables 89.3% (N = 25) = male 89.3% (N = 25) = CF veterans. The remaining three were currently serving CF members Mean age = years; range 22 to 63 years 85.7% of the sample (N = 24) met DSM IV criteria for PTSD. 100% had comorbid psychiatric diagnoses. The most common comorbidities were PTSD and major depressive disorder (MDD) (N = 22; 78.6%) Nine individuals (32.1%) also had diagnoses of alcohol or substance abuse or dependence 16

17 Results Smoking Variables 14.3% (N = 4) were current occasional or social smokers. 60.7% (N = 17) were current frequent smokers (who smoked less than 25 cigarettes/day) 25.0% (N = 7) were current frequent smokers (who smoked more than 25 cigarettes/day) Mean age of smoking initiation = years (SD = 3.323, range = 8 25 years) Mean number of previous lifetime quit attempts was 5.18 (SD = 3.422, range = 0 15) Mean number of past year quit attempts lasting longer than 24 hours = 2.88 (SD = 7.825, range = 0 40) 82.1% (N = 23) reported receiving advice to quit smoking from a health professional, while 50.0% (N = 14) reported asking for advice related to quitting 17

18 Results TM Stage of Change Because all participants in the final sample were current smokers, the action and maintenance stages of change were excluded from the final analyses. 28.6% (N = 8) were in the pre contemplation stage of change (not thinking of quitting in the next six months) 46.4% (N = 13) were in the contemplation stage (thinking of quitting in the next six months) 25.0% (N = 7) were in the preparation stage of change (thinking of quitting in the next thirty days). 18

19 Results # of Previous Quit Attempts Precontemplators reported fewer mean quit attempts in the past year than contemplators [1.43 (SD =1.902) vs (SD = ); t = (18).0498, p = 0.625] Precontemplators also reported fewer mean quit attempts than preparers [1.43 (SD = 1.902) vs (SD = 2.714); t (11) = 1.354, p = 0.203] However, neither of these relationships were statistically significant. 19

20 Results DBI Precontemplators had a lower mean score on the cons subscale of the DBI than contemplators [3.14 (SD = 2.854) vs (SD = 3.754); t (18) = 1.987, p = 0.062] or preparers [3.14 (SD = 2.854) vs (SD = 3.155); t (12) = 3.288, p = 0.006]. Precontemplators also had a higher mean score on the pros subscale of the DBI than contemplators [6.75 (SD = 3.284) vs (SD = 2.954); t (18) = 0.532, p = 0.601] and preparers [6.75 (SD = 3.284) vs (SD = 1.952); t (13) = 1.831, p = 0.090]. 20

21 Results DBI continued Finally, precontemplators had higher mean total scores on the DBI than contemplators [4.43 (SD = 2.936) vs (SD = 4.634); t (17) = 2.390, p = 0.029] and preparers [4.43 (SD = 2.936) vs (SD = 4.071); t (12) = 4.594, p = 0.001] These results indicate that precontemplators place more importance on the perceived pros of smoking than the either the contemplators or the preparers. 21

22 Results SSET SF There was no significance difference between precontemplators and contemplators on the mean total SSET SF score [32.50 (SD = 4.408) vs (SD = 7.250); t (19) = 0.067, p = 0.947] The difference between precontemplators and preparers was miniscule [32.50 (SD = 4.408) vs (SD = 8.018); t (13) = 0.283, p = 0.781] These results demonstrate that smoking temptation does not significantly change across the early TM stages of change. 22

23 Results Impact of Substance Use Problems Individuals who had a diagnosis of alcohol or substance abuse or dependence (N = 9) had: a lower mean score on the DBI cons subscale [4.44 (SD = 3.609) vs (SD = 3.740); t (25) = 1.619, p = 0.118] a higher mean scores on the DBQ pros subscale [8.38 (SD = 1.768) vs (SD = 2.587); t (25) = 3.723, p = 0.001] And a higher mean total DBQ score [4.38 (SD = 3.292) vs (SD = 4.531); t (24) = 3.597, p = 0.001] 23

24 Results Impact of Substance Use Problems continued These individuals also had a higher mean score on the SSET SF than those who did not have any reported substance use problems [35.44 (SD = 3.539) vs (SD = 7.321); t (26) = 1.493, p = 0.148] This indicates that individuals with substance use problems are: more likely to be slightly more tempted to smoke in a variety of situations than individuals without substance use problems, to place more importance on the perceived pros of smoking than individuals without substance use problems. 24

25 Results Regressions Posttraumatic stress disorder (PTSD) and depression symptom severity were entered into a stepwise regression evaluating their effect on mean DBI total scores. After controlling for current smoking status, neither of the variables were significant. A separate stepwise regression was conducted to assess the impact of PTSD and depression symptom severity on mean SSET SF scores. After controlling for current smoking status, neither of the variables were significant. 25

26 Results Regression Measure Variable Pearson correlation Sig. (1 tailed) DBI total score SSET SF total score Depression symptom severity PTSD symptom severity Depression symptom severity PTSD symptom severity

27 Results Whole Sample An ANOVA was run to determine if there were differences in age, PTSD symptom severity, and depressive symptom severity between current, former, and nonsmokers Current smokers had significantly greater PTSD and depression symptom severity than either the former smokers or the nonsmokers. This has important clinical implications for increasing rates of smoking cessation within this population, if it truly is being used as a maladaptive coping mechanism. 27

28 Conclusions The outcomes of this seed grant demonstrate the need for a military specific smoking cessation program. The findings also have clinical implications; in particular, that individuals with a history of addictive behaviours (i.e. alcohol or substance abuse or dependence) are particularly vulnerable to delayed smoking cessation Any intervention designed for military populations should take into consideration the high prevalence of psychiatric comorbidities, which may slow or hinder the achievement of smoking cessation, and military culture, which may facilitate smoking initiation and maintenance 28

29 Conclusions In summary, it appears that the factors that affect smoking maintenance in military populations include a strong positive balance to smoking, as evidenced by the mean DBI scores, and problems relating to misuse of alcohol and other substances. 29

30 Next Steps Future research is planned, and additional funding will be sought (i.e. from CIHR). We hope to proceed with an intervention, and will be seeking participation from other OSI clinics within the network to participate in the intervention. 30

31 Thanks for listening! Any questions? 31

32 PARKWOOD HOSPITAL OPERATIONAL STRESS INJURY CLINIC Charles Nelson, Ph.D., C.Psych Operational Stress Injury Clinic (OSIC), Parkwood Hospital - St. Joseph s Health Care London. London, Ontario, CANADA. 32