Characteristics of patients with COPD in three motivational stages related to smoking cessation☆
Introduction
Smoking is the main cause of chronic obstructive pulmonary disease (COPD) [1], [2]. A recent study shows that 66.7% of the elderly smoking men (76–77 years) develop COPD [3]; consequently, smoking cessation is a core treatment element [4]. Successful quitting reduces the deterioration of lung function, improves the COPD prognosis, and may increase life expectancy [5], [6], [7], [8]. Although patients with COPD may suffer more from nicotine dependence than smokers in the general population, the motivation to quit smoking does not differ between these two groups [9]. Suffering from respiratory complaints also increases the intention to quit smoking [10].
The present study aims to analyze motives of Dutch COPD smokers in order to identify relevant beliefs for inclusion in cessation materials tailored to this specific group. We used an integrated change model (the I-change model) [11], [12], [13], derived from the attitude–social influence–self-efficacy model [14], which consists of the integrated ideas of several social cognition models [15], [16], [17], [18], [19], [20]. The I-change model (Fig. 1) discerns three phases of the behavioral change process: the premotivational phase (determined by becoming aware of the problem and a person's own level of risk behavior), the motivational phase (becoming motivated to change, determined by attitudes, social influence perceptions, and self-efficacy beliefs) and the postmotivational phase (goal-setting processes, influences of self-efficacy beliefs, action plans, and skill building). Four distal types of influence determine these phases: behavioral factors (e.g., acquisition of skills and previous experience with the same and related behaviors), psychological factors (e.g., self-esteem, anxiety, and depressed affect), biological factors (e.g., gender, age, and disease variables) and social and cultural variables (e.g., parenting styles, social climate, and socioeconomic status).
Previous studies using the model found a differential significance of attitudes, social influences, and self-efficacy expectations. The result was a so-called ∅-pattern, showing that transitions from an unmotivated to a motivated phase were best predicted by attitudes, while transitions from motivation to action were best predicted by self-efficacy. Evidence of these patterns was found cross-sectionally, longitudinally, and experimentally [21], [22], [23]. Recently, the impact of the importance of action plans or implementation intentions as a specific form of goal has been reported in various publications for health behaviors in general [24] as well as for smoking [25]. However, research pertaining to COPD smokers integrating these various concepts is not available yet. Data about the potential role of action plans for successful quitting are important in fine-tuning materials for smoking cessation for smokers in general and for COPD patients in particular.
The primary goal of this study is to reveal the main differences between the COPD patients in three motivational stages. These differences are found in COPD symptom severity, attitudes, social influences, self-efficacy expectations, and action plans. The secondary goal is to facilitate the development of recommendations for interventions aimed at encouraging smoking COPD patients to quit.
Section snippets
Design and population
This study is a cross-sectional survey that uses a short questionnaire to detect smoking patients with COPD listed in general practices, followed by a more extensive questionnaire. Recruitment took place in nine districts in The Netherlands among practices using one of four suitable general practice electronic information systems.
Software using anatomical therapeutical chemical (ATC) prescription codes and international classification of primary care (ICPC) diagnosis codes to identify patients
Response
Of the 1566 smoking patients detected, 753 (48.3%) gave informed consent. These patients did not differ from the remainder of the 1566 smoking patients detected regarding age and sex. Medical ethical rules forbade processing more information about the non-responders. A total of 672 of the 753 patients (89.2%) returned the questionnaire. Four questionnaires were not completed, four patients reported that they were non-smokers, 31 patients (4.7%) reported that they had quit smoking. Consequently,
Discussion
The present study investigates the motivation of patients with COPD to stop smoking and considers whether these patients in different motivational stages could be identified on the basis of health indicators, attitudes, social influences, self-efficacy beliefs, and action plans. Regarding the stages of change, we found that many were motivated to quit smoking (22.5%) within 1 month. Our group of smokers in preparation is larger than the group of preparers (approximately 7.0%) in the Dutch
Acknowledgements
This study was financed by the Dutch Asthma Association, Netherlands Organisation for Health Research and Development (ZonMW), Pharmacia, and Glaxo SmithKline.
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The work was performed at the Centre for Quality of Care Research (WOK) in Maastricht and Nijmegen.