Postgraduate Course Feedback

1. Postgraduate Course Feedback Smokers with chronic illness: a qualitative analysis of barriers, motivation to quit and tailored interventions for smoking cessation in smokers with and without COPD Dr Camille Alexis-Garsee, Martha Burton, Prof. Olga van den Akker - Middlesex UniversityDr Hazel Gilbert – University College LondonThe study was funded by the IPCRG, UKRRF

2. Overview Why is smoking cessation important for smokers with COPD? How can tailored interventions help? This study Themes identified Conclusion

3. Introduction • COPD – Chronic Obstructive Pulmonary Disease • Smoking is a major cause of COPD as it accelerates the rate of decline in pulmonary function beyond that seen with aging (Burchfiel et al., 1995) • Smokers with COPD are less likely to quit than those without impaired lung function • NICE guidance • Reviews: combination of behavioural support and pharmacotherapy most effective for cessation • Wagena et al., (2004); van der Meer et al. (2003); Piresyfantouda et al. (2013); Tønnesen, (2013).

4. Introduction • Tailored interventions are based on information collected from each person by an assessment questionnaire, the data is then entered into a computer programme in order to generate unique personalised reports for the individual • Previous research has found some success with this type of intervention (Noar et al, 2007; Lancaster & Stead, 2005) • The computer tailored intervention evaluated in this study, has significantly increased 7-day point abstinence rates and 1 month prolonged abstinence rates at the six month follow-up (Sutton & Gilbert, 2007)

5. The Aim • To understand COPD smokers’ experiences when trying to quit and to obtain participants’ perception of the computer-tailored feedback developed for smoking cessation

6. Method • Six GP practices representing small (n<2500) and large (n>10,000) list sizes in North London • 360 smokers 35-65, with and without mild to moderate COPD were identified using the practice computer systems • Participants • Of those invited, 56 opted out of the study • 40 smokers completed and returned questionnaires (response 12.2%) and 26 agreed to be interviewed and completed the study Design: Qualitative study with smokers recruited from GP Practices in North London

7. Method • Measures • Questionnaire: intention, motivation, dependence, self-efficacy, advantages and disadvantages of quitting, MRC Dyspnoea Scale • Interviews • 26 interviews – all received £30 for 90 minute interview, plus additional £10 for travel; Semi-structured interview guide • Data Analysis • Interviews entered into N’vivo 8. Thematic analysis conducted (Braun and Clarke, 2006)

8. Results

9. Results – Thematic Map

10. Results – Thematic Map

11. ResultsTheme 1: Barriers and Motivation to Quit – Use of Cigarettes • ‘[Smoke] forty to sixty a day, now. I was ten, I was, yeah, but because of the problem I got now [COPD] it’s, it’s stress, and you know thinking about like, there is no cure for what I got, you know. Like that stresses me a lot and instead of stopping yeah, I keep on smoking, you know.’ [P13: M, 43, COPD]

12. Barriers and Motivation To Quit – Health and Illness • ‘My lungs were messed up. And err I was told that in 2005 and she said ‘you’ve got to stop smoking now, not in the future, now is your best chance.’ But I never noticed it was hurting me so much then I could still breathe and I thought, well I carried on.’ [P21: M, 55, COPD]

13. Barriers and Motivation - Social Support – Family and friends • ‘But the difficulty is that I live with a, a partner and it’s like erm it’s something we enjoy doing together and err if I, if I’m , if I’m determined to say ‘no, no, I’ve really go to stop doing this’ erm the other one’s not of the same mind.’ [P5: M, 62, COPD]

14. Barriers and Motivation - Social Support: Lack of guidance from GP • ‘No, no, no, no, no. He’s not. He [GP] just tell you like ‘you got that and err the reason err you have to stop smoking, there is nurse over there, you can go and find, find your way and erm look for help’ that’s it. You know what I mean? So he just like make you more upset, angry.’ [P13: M, 43, COPD]

15. Barriers and Motivation – Denial, Fear and Excuses • ‘It hurts, it hurts a little bit because I know at the end of the day even if I give up smoking I know there’s a possibility I’m still going to end up on oxygen, you know I do know that.’ [P9: F, 54, COPD] • ‘that’s err and that’s what’s making me now think, I, I, I really need to stop. But then I’m, but I’m also scared of stopping. Because even if I still, still stop smoking who’s to say that I won’t get cancer? Who’s to say that I won’t get any of these things once I do stop smoking?’ [P22: F, 41, COPD]

16. Barriers and Motivation – Denial, Fear and Excuses • ‘...because my mother smokes. And she smokes, my mother is 80 and she smoked probably for 60 years. And there’s nothing wrong with her health so this is another reason.’ [P1: F, 47, No COPD]

17. Theme 2: A New Experience – Positive Impact – ‘Someone’s interested in me!’ • ‘Because it’s the first time that anybody has ever done anything like, that has actually been tailored to my needs. It makes sense like. It’s, to me it’s like somebody’s actually, actually taken a personal interest in me, you know, and what is best for me like. And that’s the first time I’ve ever had anything like that.’ [P28: M, 55, No COPD].

18. A New Experience: More relevant advice • ‘This is something designated to me. (Flips pages) And erm, and I think it’s a, it’s a marvellous idea, better than, better than just going to see the practice nurse and her, her saying you know ‘oh we’ll try, we’ll try you with these patches and that’. [P11: M, 64, No COPD]

19. Positive impact – prompting behaviour change • ‘Yeah, it offers you, gives good advice there. Yes, I, I’m reading it and listen to the advice and err, yeah I stop from 60 a day I drop down to 25. It’s good no?’ [P35: M, 66, COPD] • ‘I don’t think it’s something I could just do on my own, I think I would need someone, go to these no smoking clinics and get support from them. I believe I need that sort of help.’ [P19, F, 52, No COPD]

20. A New Experience – Strategies to improve to encourage cessation: don’t send in isolation! • ‘Yeah and you can actually get feedback, although it, maybe having them both, maybe having the leaflet, reading through it and then being able to like you know if there’s any questions there that I need answered be nice to have that answer yeah.’ [P22: F, 41, COPD]

21. A New Experience – Strategies to improve to encourage cessation: positive reinforcing information after failing to quit • ‘I’d just say don’t leave a big gap, I’d emphasise the fact that, that people once they’ve had a failed attempt they tend to leave it for ages, they go ‘oh I can’t do it, I’m never going to be able to stop.’ And it’s not until 6 months later or a year later or 5 years later they wake up again and go ‘oh I better have another attempt.’ But, you should just, just try and encourage them to, even if you have failed put them down again, 2 weeks later, or 3 days later or even 3 hours later have another go.’ [P21: M, 55, COPD]

22. Conclusion • Though many would like to quit smoking, they find it difficult to do so and a stand-alone computer-tailored intervention may not be the best way forward • May prompt some to think about quitting and initiate behaviour change but would be better to combine with more intensive support (Tønnesen, 2013) • Highlights importance of support mechanisms for smokers wanting to quit

23. Conclusion • Limitations: views may not be representative; only small number formal COPD diagnosis recruited • Recommendations: GPs role; encourage smokers to quit at every opportunity; spirometry in those at risk; want a more tailored and personal approach from health professionals; further research on effects of different types of interventions for COPD smokers

24. References • Baron KP. To smoke or not to smoke: predictors of smoking behaviour in people with head and neck cancer and chronic obstructive pulmonary disease. Diss Abs Inter: Sec B: The Sc and Engin 2003; 64:954. • Kerr S, Watson H, Tolson D, Lough M, Brown M. Smoking after the age of 65 years: a qualitative exploration of older current and former smokers' views on smoking, and smoking cessation resources and services. Health and Social Care in the Comm 2006; 14(6):572-582. • Noar SM, Benac CN, Harris M. Does Tailoring Matter? A Meta-Analytic Review of Tailored Print Health Behavior Change Interventions. Psychol Bulletin 2007; 133(4):673-693. • Piresyfantouda, R, Absalom G, Clemens F. Smoking Cessation Interventions for Chronic Obstructive Pulmonary Disease – A Review of the Literature. Respir Care 2013; DOI:10.4187/respcare.01923 • Shahab L, Jarvis MJ, Britton J, West R. Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample. Thorax 2006; 61:1043-1047.

25. References • Sutton S, Gilbert H. Effectiveness of individually tailored smoking cessation advice letters as an adjunct to telephone counseling and generic self-help materials: a randomised controlled trial. Addiction 2007; 102(6):994-1000. • Tonnesen P, Carrozzi L, Fagerstrom KO et al. Smoking cessation in pateints with respiratory diseases: a high priority, integral component of therapy. Eu Respir J 2007; 29(2):390-417. • van der Meer RM, Wagena E, Ostelo RWJG, Jacobs AJE, van Schayck OP. Smoking cessation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2001(updated 2003); 1:1-28. • Wagena EJ, van der Meer RM, Ostelo RJ, Jacobs JE, van Schayck CP. The efficacy of smoking cessation strategies in people with chronic obstructive pulmonary disease: results from a systematic review. Respir Med 2004; 98:805-815.