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A comparison of younger-aged and older-aged women in a behavioral self-control smoking program
PTiENT
EdUCATiON
ANd COUrWE~iNc, Patient Education
ELSEVIER
and Counseling
23 (1994) 91-96
A comparison of younger-aged and older-aged women in a behavioral self-control smoking program Peggy O’Hara* ‘, Sharon “University
of Miami
School of Medicine.
1029 N. W. 15th Street, bUniversity
of Pittsburgh,
Deportment R-669,
School of Medicine.
(Received
15 November
A. Portserb of Epidemiology
Miumi,
Deportment
1992; accepted
FL 33136.
und Public
qf P.~ychiutry.
I7 January
Heulih.
USA Pittsburgh,
PA USA
1994)
Abstract This study examines differences in motivation for quitting smoking, withdrawal experiences and weight changes in younger and older aged women who entered a smoking cessation program designed specifically for women smokers. In an assessment prior to quitting smoking 26 women aged 20-49 years (younger-aged women) and 19 women aged 50-75 years (older-aged women) did not show differences in number of prior quit attempts or their dependence on nicotine (as measured in the Fagerstrom Tolerance Questionnaire). The older aged women smoked for a significantly greater number of years but smoked fewer cigarettes per day than the younger women. In a self-report questionnaire the two age groups differed in their reasons stated for wanting to give up cigarettes and symptoms of illness they experienced related to smoking. The average weight gains for women who quit smoking were minimal (3.5 lb, younger; 3.9 lb, older; I lb = 0.453 592137 kg) although more younger women than older women reported they expected difficulty with weight gain after cessation. Changes in withdrawal experiences were not significantly different at any point during the initial phase of quitting (24, 48 and 72 h). Keywords;
Smoking
cessation;
Young female smokers;
Older female smokers
1. Introduction The fastest growing segment of the USA population is elderly women. Current demographic information projects that by the year 2000 the population will consist of 19 million older women versus 12 million older men. By 2050 the women in the over 65year age group will increase by 42% Ill. * Corresponding
073%3991/94/$07.00 SSDf
author.
0
0738-3991(94)00627-X
1994 Elsevier Science Ireland
The future health problems of this population will include many chronic diseases related to lifestyle habits. As the current number of women who are smoking reach these age groups, the incidence of lung cancer, other smoking related cancers and chronic obstructive pulmonary disease are projected to increase dramatically in older aged women and cardiovascular diseases will be an even greater health threat. In 1983, 31% of the females aged 45-64 were smoking and 13% of those over 65 were still smoking. The women who were smoking
Ltd. All rights reserved
92
P. O’Hara. S.A. Portser / Patient Educ. Count 23 (1994) 91-96
in the late 1970s who were in their 30s showed an increase in the numbers of cigarettes smoked per day (over 2Yday) [2]. The trends of heavier smoking habit, low quit rates and an increase in the numbers of women in this age group lead us to the conclusion that the older woman smoker is and will continue to be a major public health risk for decades to come. Older men and women smokers who have smoked for many years may not even attempt quitting because of their perception that the benefits of quitting may not be worth the discomfort they may have in giving up the habit. Studies [3-51 have shown that smokers in their 50s 60s and 70s who stopped smoking had direct effects of improvement on their health status. Lung cancer death rates and rates of decline in lung function were both reduced after 5 years of quitting. There is some evidence to show that it is more difficult for female smokers over age 50 to quit smoking than younger smokers or older male smokers. Quit rates in the population of 45-64year-old smokers show that men in this age group reduced smoking rates from 52”/0to 36”/0from 1965 to 1983 and women in this age group changed their rates of smoking from 32%) to 31%. Among males over age 65 smoking rates were reduced from 28”/;, to 22%; yet female smokers in this age group increased their rates from 10% to 13% [6]. In clinical trials and intervention programs which compared gender differences in smoking cessation, females have shown less success in achieving and maintaining abstinence [7,8]. The older smoker is thought to be more highly dependent on nicotine than the young smoker and more likely to experience severe withdrawal symptoms than a younger smoker. Gunn [9] evaluated withdrawal symptoms and their effects on stopping smoking in a population of male and female smokers aged 19-74 who quit smoking after two or three sessions in a smoking clinic program. Study results showed that older males who have difficulty quitting smoking show less severe withdrawal than females over 50 years. The older, female smokers reported the most severe withdrawal of age and gender, but the number of years the women smoked was not a predictor of the ability to stop smoking. In the present study, we compared younger and
older aged women who entered a smoking cessation clinic program designed specifically for women smokers. The multi-component behavioral self-management program was based on social learning theory principles targeting both smoking behavior and nicotine dependence. Strategies included cognitive and environmental restructuring, stress management and weight management techniques. We evaluated motivation for quitting, withdrawal experiences, and weight changes after quitting in an attempt to determine if women’s age influenced the smoking cessation experience. 2. Method 2.1. Subjects All participants were women who enrolled in a smoking clinic program designed specifically to target women. Posters and news articles described the program as a behavioral self-management program for women who want to quit smoking while working on weight management and stress management skills. Forty-five respondents joined small support groups of 8-10 women that met for a 3month period. The average age of the women was 47.5 years, they had smoked for 29 years, and averaged 27 cigarettes per day. Of the women who completed the self report, 23 reported good health status, and 7 subjects were under current medical care (not for smoking related illness). Three of the forty-five women were referred to the program by their physicians. 2.2. Procedures Each woman was contacted by telephone for a brief assessment of current smoking status. The women were scheduled for an individual assessment to collect measures of body weight, expired carbon monoxide and baseline smoking levels. A complete smoking and quitting history was taken and questionnaires were completed on reasons for smoking, nicotine dependence and collection of baseline withdrawal scores. The women quit smoking during the first group session in the following week and attended group meetings four consecutive days. Session topics included nicotine effects on body weight and the withdrawal syndrome, cigarette advertising and its influence on
93
P. O’Hara, S.A. Portser / Patient Educ. Couns. 23 (1994) 91-96
women, proper snacking and eating habits, coping in high risk situations and benefits of physical activity. After the initial week of quitting smoking they attended weekly follow-up sessions for 7 additional weeks and one final session at the 12th week of the program. Seven of the final sessions included relapse prevention techniques and strategies for maintaining long-term cessation. At each session body weights were taken and carbon monoxide measures were collected using an Energetics Science Ecolyzer (TM). A level of ~6 parts per million (ppm) with a self report of smoking one or more cigarettes indicated a current smoker in this study. Withdrawal symptoms were collected using the Shiffman-Jarvik Questionnaire [lo]. In the event of a slip or relapse since the prior visit a relapse assessment form was completed. The relapse assessment included open-ended questions to collect information on circumstances surrounding the smoking event (place, time, activity, mood, consumption of alcohol, other smokers present, anticipatory events and frequency of such high risk situations). The twelve group sessions were 1 h in length and focused on two areas of primary concern to women who quit smoking: weight gain and managing stress without the use of cigarettes. There was a great deal of support provided to members of the group through its frequent contact and open discussion. 3. Results The women ranged in age from 27 to 75 years. Older women were defined as those participants
Subject characteristics
of younger-aged
and older-aged
women smokers Younger-aged (n = 26)
Age Number
of years smoked
Number of cigarettes per day Number of prior quit attempts Nicotine Tolerance Scores *P 50.05. **p ~0.0005.
aged 50-75 years (61 f 7.6, mean f SD). The 50-year cut-off was selected to coincide with the change in menopausal status (mean, 49 years) and comparisons with other studies using the 50 year criterion [7]. There were 19 older women enrolled in the program. Younger women were defined as those participants aged 20-49 years (38 f 6.1). There were 26 younger women enrolled (Table 1). There was a significant difference (P < 0.0005) in the number of years the women smoked when the data was analyzed by r-tests. The younger women averaged 19.7 f 6.8 years of smoking and the older women smoked for an average of 44.2 f 6.4 years. The numbers of cigarettes smoked per day was significantly different (P < 0.05) in paired t-test comparisons. Younger women smoked on average 28.6 f 9.9 cigarettes while the older women smoked an average of 23.4 f 8.9 cigarettes per day. There was no difference when the number of prior quit attempts was compared between the two age groups. Both groups of women averaged three prior quitting attempts. Nicotine Tolerance Questionnaire (FTQ) [ 111 scores were not significantly different between younger women (7.1 f 1.3) and older women (6.5 f 1.9) although both could be classified as highly dependent smokers. Women who completed the initial assessment ranked their reasons for giving up cigarettes. Fourteen possible reasons for wanting to give up cigarettes were listed. Women were asked to give a numeric rating of 1 through 14 to indicate the most (1) to least (14) reason for quitting smoking.
38 (6.1) 19.7 (6.8) 28.6 (9.9) 3.2 (3.1) 7.1 (1.3)
who completed women
quit week (mean (S.D.)) Older-aged (n = 19) 61 (7.6) 44.2 (6.4) 23.4 (8.9) 3.5 (2.7) 6.5 (1.9)
women
1
l2.193** 1.797* 0.40 I I.160
P. O’Hara. S. A. Porrser / Patient Edut. Cows. 23 (1994) 91-96
94
Table 2 Reasons for quitting
smoking
(ranked
by older and younger
women)
Younger
Older
I am concerned lung cancer
about
the possibility
of
Smoking is a dirty habit causing bad breath, stains, etc. Someone important wants me to quit (i.e. husband, friends, etc.)
(56”/11)
I have experienced
(74%)
(56%)
I
(61%)
(50%)
I
Fifty percent or more of the younger women ranked one of the following as their primary reason: concern about lung cancer (56%); the idea that smoking is a dirty habit causing bad breath, stains, etc. (56%); and someone important to me wants me to quit (husband, friends, etc.) (50%). Over fifty percent of the older women chose the following as a primary reason for quitting smoking: having experienced some health problem related to smoking (74%); concern about lung cancer (61%); wanting benefits of a more active lifestyle which smoking hinders (52%); and someone important to me wants me to quit (52%) (Table 2). 3.1. Results of symptoms of disease At the assessment, both groups completed a selfreport questionnaire which asked for the presence of symptoms, diseases or risks of disease associated with smoking. Women were asked to check illness or symptoms they currently experienced
Table 3 Self-reports
on the presence
of symptoms,
Symptoms: cough, wheezing. shortness exercise tolerance, chest pain,
diseases
of breath,
some health problem related to smoking am concerned about the possibility of lung cancer want the benefits of a more active lifestyle which smoking hinders
and on a 5-point Likert scale rated their level of concern about those illnesses. On this questionnaire women reported their concerns of the effects of smoking on other factors, such as children, facial wrinkles and risks associated with use of birth control pills (Table 3). Eighty-eight percent of the younger women reported having symptoms present which were related to smoking (i.e. cough, wheezing, chest pain, etc.) while 89% of the older women reported those symptoms. Only 23% of the younger women reported they had, either past or present, smoking related diseases (i.e. bronchitis, many colds/flu, etc.) compared with 53% of the older women. Numbers of women who reported the presence of risk factors for smoking illness (i.e. abnormal chest X-ray, abnormal lung function tests, etc.) were higher in the older women (58%) than in younger women (50%). Concerns for the effects of smoking on children, facial wrinkles and risks as-
or risks ot disease in women who completed
decreased
Diseases: bronchitis, emphysema, many colds/flu, asthma, heart trouble, high blood pressure, cancers, ulcers. hardening of the arteries, Risk of disease: abnormal ECG tracing, abnormal chest X-ray. abnormal lung function tests, high cholesterol, family history of heart attacks or cancer, Other: effects of smoking on children, facial wrinkles. and risks associated with birth control pills.
(52%)
Younger-aged women (n = 26)
Older-aged
23 (88%)
17 (89%)
6 (23%)
IO (53%)
I3 (50%)
I I (58%)
20 (77%)
I2 (63%)
quit week (n = 45) women (n = 19)
P. O’Hara, S.A. Portser/ Patient Educ. Couns. 23 (1994) 91-96
sociated with birth control pills were acknowledged by 77% of the younger women and 63% of the older women. 3.2. Results of withdrawal questionnaire scores Withdrawal experiences were reported on the Shiffman-Jarvik Withdrawal Questionnaire at sessions designated as baseline, quit day and 24,48 and 72 h after quitting smoking. At each session total withdrawal scores were compiled for women in both age groups. In t-test comparisons differences between withdrawal scores of older and younger women were not significant at any of the sessions. 3.3. Attendees vs. drop-outs All 45 entrants completed the initial quit week. Twenty-six (58%) entrants went on to complete the 3 month program. Program attendees were defined as those who attended the final session at the end of the 3 months. Drop-outs were defined as those who failed to attend the final visit. Fourteen younger women or (31%) were program attendees while 12 older women or (27%) completed the final session. Program attendees and drop-outs were compared by age, number of years smoked, number of cigarettes smoked per day, number of prior quit attempts and nicotine tolerance scores. No signilicant differences were evident. However, there was a tendency for drop-outs to be younger, have smoked a fewer number of years, but smoke more cigarettes per day than program attendees. 3.4. Smoking status Abstinence was defined as having a CO level of r6 p.p.m. and a self report of not smoking since the initial quit day of the program. The 14 younger women who completed the program all reported and were validated as abstinent. Of the 12 older women 9 were abstinent and 3 had relapsed. 3.5. Results of weight change Of the women who completed the 3-month program the average weight gain of abstinent younger women was 3.5 f 3.2 lb (1 lb = 0.453 592137 kg) and the older women gained an average of 3.9 f 3.7 lb throughout the 3-month program. Results of weight change measures among the 9
95
abstinent older women showed an average gain of 4.9 f 3.8 lb. The few older women who relapsed and attended the final session showed an average weight gain of 1 lb. In the pre-assessment, the women were asked the question, ‘If you are successful in quitting cigarettes, do you foresee negative effects of weight change one month after quitting?’ Sixty-eight percent of the women responded ‘yes’to the question that weight gain after quitting smoking would be a problem for them. Of the younger women, 72”/0 answered ‘yes’, and of the older women 68% answered ‘yes’, that weight gain after quitting would be a problem for them. At the 1 month follow-up, 14 of the 16 older women measured showed body weight increases ranging from l-8 lb. Of the 18 younger women measured at 1 month after quit day, 11 showed weight gains of l-7 lb. 4. Discussion At the present time there is little available in the behavioral intervention literature which focuses on treatment for older women’s health concerns. Research indicates that behavior change may improve the health status of this significant and growing segment of the population, yet current information on the older adult in behavior change programs is sparse. Smoking cessation is one area of treatment that is known to improve the health status of older as well as younger adults. Health benefits are realized within only a few years for adults who have smoked for decades. Current smoking interventions have only recently begun to address issues specific to the female smoker. The current study has shown that there may be different concerns and physiological changes among women smokers in different age groups. Preliminary data indicate that differences in self-efficacy, motivations for entering treatment and weight changes after quitting smoking may be important factors to consider in designing smoking treatments relevant to both age and gender of the participants. The study has several implications for treating the older woman in behavioral self-management smoking intervention programs. The results of the assessment of disease symptoms and the risk of
96
P. O’Hara. S.A. Portser / Patient Educ. Couns. 23 (1994) 91-96
smoking related disease showed that older women who entered cessation experienced more smoking related diseases than younger women. Younger women were more concerned with the effects of smoking on children, facial wrinkles and cardiovascular risks associated with birth control pills than the older women. Both groups of women reported a high number of smoking related symptoms (cough, wheezing, chest pain) which is not surprising, since both groups indicated that health concerns are still the primary reason for wanting to stop smoking. Weight change after cessation of smoking is an important consideration for women in their initial decision to quit as well as to remain non-smokers. Over the past decades the emphasis on thinness has created major health concerns with regard to weight control in populations of young women. Many women report that a concern about weight gain actually prevents them from giving up cigarettes [ 121. However, we do not know if concerns about weight gain are specific to younger women and how important weight change is to the older woman when making a decision to quit smoking. Data from the present study showed that more of the younger than the older women thought that they would gain weight after quitting smoking. The pattern of weight change shows that the young women maintained current body weights initially and that older women gradually increased in weight over 3 months of treatment. However, the two groups did not show differences in the amount of weight change by the end of the treatment program. Withdrawal data did not show significant differences between the younger and older women quitters in the first 72 h after quitting. There is some prior evidence to show that older women do experience a more severe withdrawal from quitting smoking than younger women and even older men. It should be noted that in the current study there were differences in the number of cigarettes smoked per day between the younger and older women smokers. The younger women in this study smoked an average of 29 cigarettes per day. Their scores on the Fagerstrom Nicotine Tolerance Questionnaire indicated they were highly dependent smokers upon entering the study. The question of difficulty in quitting and severity of withdrawal in the older woman smoker is a question that needs
attention and further research in studies designed to answer those questions. Due to high relapse rates among women smokers, long-term women’s quitting trends in the older age groups are decreasing at one of the slowest rates of any segment of the smoking population. At the same time this population is increasing in numbers and risk for smoking related diseases. These are clearly specific concerns in this age group that may have a significant impact on their success in smoking cessation. 5. References I
2
3
4
5
6
I
8
Wisocki PA, Keuthen, NK: Later life. In: Blechman E. Brownell K eds. Handbook of Behavioral Medicine for Women, pp. 48-58 1988. New York: Pergamon Press. Stoto. MA: Changes in Adult Smoking. Behavior in the United States: 1955 to 1983. Cambridge, MA: The Institute for the Study of Smoking Behavior and Policy, Harvard University, 1986. Jajich CL, Ostfeld AM, Freeman DH: Smoking and coronary heart disease: mortality in the elderly. J Am Med Assoc 1984: 252: 2831-2834. Doll R, Hill AB: Mortality in relation to smoking: ten years’ observations of British doctors. Part II. Br Med J 1964; i: 1399-1410. Tashkin DP. Clark VA, Coulson AH et al: The UCLA Population Studies of Chronic Obstructive Respiratory Disease: VIII. Effects of smoking cessation on lung function. A prospective study of a free-living population. Am Rev Respir Dis 1984: 130: 707-715. Gordon NP, Cleary PD: Smoking Cessation in a National Probability Sample Cohort 1979-1980: Health Attitudes Practices. and Smoking Behavior Associated with Quit Attempts and Behavior Change at One Year. Cambridge MA: Harvard University. John F. Kennedy School of Government, Institute for the Study of Smoking Behavior and Policy, 1986. O’Hara P: The Lung Health Study: Two Year Results of An Intervention for Smokers at High Risk of COPD. Paper presented at the 8th World Conference on Tobacco on Health, Buenos Aires. March 1992. Gritz ER, Berman BA: Women and smoking: toward the year 2000. In: Lisansky ES, Gomberg ES. Nirenburg TD. eds. Women and Substance Abuse. Alex Publishing Co. (in press). Gunn RC: Reactions to withdrawal symptoms and success in smoking cessation clinics. Addict Behav 1986; I I: 49-53. Shiffman S. Jarvik M: Smoking withdrawal symptoms in 2 weeks of abstinence. Psychoparmacology 1976; 50: 35-39. Fagerstorm KO: Measuring degree of physical dependence to tobacco smoking with reference to individualization of treatment. Addict Behav 1978: 3: 235-241. US Department of Health and Human Services, Public Health Service. 1980. The Health Consequences of Smoking for Women. A Report of the Surgeon General. Washington DC: US Government Printing Office.
EdUCATiON
ANd COUrWE~iNc, Patient Education
ELSEVIER
and Counseling
23 (1994) 91-96
A comparison of younger-aged and older-aged women in a behavioral self-control smoking program Peggy O’Hara* ‘, Sharon “University
of Miami
School of Medicine.
1029 N. W. 15th Street, bUniversity
of Pittsburgh,
Deportment R-669,
School of Medicine.
(Received
15 November
A. Portserb of Epidemiology
Miumi,
Deportment
1992; accepted
FL 33136.
und Public
qf P.~ychiutry.
I7 January
Heulih.
USA Pittsburgh,
PA USA
1994)
Abstract This study examines differences in motivation for quitting smoking, withdrawal experiences and weight changes in younger and older aged women who entered a smoking cessation program designed specifically for women smokers. In an assessment prior to quitting smoking 26 women aged 20-49 years (younger-aged women) and 19 women aged 50-75 years (older-aged women) did not show differences in number of prior quit attempts or their dependence on nicotine (as measured in the Fagerstrom Tolerance Questionnaire). The older aged women smoked for a significantly greater number of years but smoked fewer cigarettes per day than the younger women. In a self-report questionnaire the two age groups differed in their reasons stated for wanting to give up cigarettes and symptoms of illness they experienced related to smoking. The average weight gains for women who quit smoking were minimal (3.5 lb, younger; 3.9 lb, older; I lb = 0.453 592137 kg) although more younger women than older women reported they expected difficulty with weight gain after cessation. Changes in withdrawal experiences were not significantly different at any point during the initial phase of quitting (24, 48 and 72 h). Keywords;
Smoking
cessation;
Young female smokers;
Older female smokers
1. Introduction The fastest growing segment of the USA population is elderly women. Current demographic information projects that by the year 2000 the population will consist of 19 million older women versus 12 million older men. By 2050 the women in the over 65year age group will increase by 42% Ill. * Corresponding
073%3991/94/$07.00 SSDf
author.
0
0738-3991(94)00627-X
1994 Elsevier Science Ireland
The future health problems of this population will include many chronic diseases related to lifestyle habits. As the current number of women who are smoking reach these age groups, the incidence of lung cancer, other smoking related cancers and chronic obstructive pulmonary disease are projected to increase dramatically in older aged women and cardiovascular diseases will be an even greater health threat. In 1983, 31% of the females aged 45-64 were smoking and 13% of those over 65 were still smoking. The women who were smoking
Ltd. All rights reserved
92
P. O’Hara. S.A. Portser / Patient Educ. Count 23 (1994) 91-96
in the late 1970s who were in their 30s showed an increase in the numbers of cigarettes smoked per day (over 2Yday) [2]. The trends of heavier smoking habit, low quit rates and an increase in the numbers of women in this age group lead us to the conclusion that the older woman smoker is and will continue to be a major public health risk for decades to come. Older men and women smokers who have smoked for many years may not even attempt quitting because of their perception that the benefits of quitting may not be worth the discomfort they may have in giving up the habit. Studies [3-51 have shown that smokers in their 50s 60s and 70s who stopped smoking had direct effects of improvement on their health status. Lung cancer death rates and rates of decline in lung function were both reduced after 5 years of quitting. There is some evidence to show that it is more difficult for female smokers over age 50 to quit smoking than younger smokers or older male smokers. Quit rates in the population of 45-64year-old smokers show that men in this age group reduced smoking rates from 52”/0to 36”/0from 1965 to 1983 and women in this age group changed their rates of smoking from 32%) to 31%. Among males over age 65 smoking rates were reduced from 28”/;, to 22%; yet female smokers in this age group increased their rates from 10% to 13% [6]. In clinical trials and intervention programs which compared gender differences in smoking cessation, females have shown less success in achieving and maintaining abstinence [7,8]. The older smoker is thought to be more highly dependent on nicotine than the young smoker and more likely to experience severe withdrawal symptoms than a younger smoker. Gunn [9] evaluated withdrawal symptoms and their effects on stopping smoking in a population of male and female smokers aged 19-74 who quit smoking after two or three sessions in a smoking clinic program. Study results showed that older males who have difficulty quitting smoking show less severe withdrawal than females over 50 years. The older, female smokers reported the most severe withdrawal of age and gender, but the number of years the women smoked was not a predictor of the ability to stop smoking. In the present study, we compared younger and
older aged women who entered a smoking cessation clinic program designed specifically for women smokers. The multi-component behavioral self-management program was based on social learning theory principles targeting both smoking behavior and nicotine dependence. Strategies included cognitive and environmental restructuring, stress management and weight management techniques. We evaluated motivation for quitting, withdrawal experiences, and weight changes after quitting in an attempt to determine if women’s age influenced the smoking cessation experience. 2. Method 2.1. Subjects All participants were women who enrolled in a smoking clinic program designed specifically to target women. Posters and news articles described the program as a behavioral self-management program for women who want to quit smoking while working on weight management and stress management skills. Forty-five respondents joined small support groups of 8-10 women that met for a 3month period. The average age of the women was 47.5 years, they had smoked for 29 years, and averaged 27 cigarettes per day. Of the women who completed the self report, 23 reported good health status, and 7 subjects were under current medical care (not for smoking related illness). Three of the forty-five women were referred to the program by their physicians. 2.2. Procedures Each woman was contacted by telephone for a brief assessment of current smoking status. The women were scheduled for an individual assessment to collect measures of body weight, expired carbon monoxide and baseline smoking levels. A complete smoking and quitting history was taken and questionnaires were completed on reasons for smoking, nicotine dependence and collection of baseline withdrawal scores. The women quit smoking during the first group session in the following week and attended group meetings four consecutive days. Session topics included nicotine effects on body weight and the withdrawal syndrome, cigarette advertising and its influence on
93
P. O’Hara, S.A. Portser / Patient Educ. Couns. 23 (1994) 91-96
women, proper snacking and eating habits, coping in high risk situations and benefits of physical activity. After the initial week of quitting smoking they attended weekly follow-up sessions for 7 additional weeks and one final session at the 12th week of the program. Seven of the final sessions included relapse prevention techniques and strategies for maintaining long-term cessation. At each session body weights were taken and carbon monoxide measures were collected using an Energetics Science Ecolyzer (TM). A level of ~6 parts per million (ppm) with a self report of smoking one or more cigarettes indicated a current smoker in this study. Withdrawal symptoms were collected using the Shiffman-Jarvik Questionnaire [lo]. In the event of a slip or relapse since the prior visit a relapse assessment form was completed. The relapse assessment included open-ended questions to collect information on circumstances surrounding the smoking event (place, time, activity, mood, consumption of alcohol, other smokers present, anticipatory events and frequency of such high risk situations). The twelve group sessions were 1 h in length and focused on two areas of primary concern to women who quit smoking: weight gain and managing stress without the use of cigarettes. There was a great deal of support provided to members of the group through its frequent contact and open discussion. 3. Results The women ranged in age from 27 to 75 years. Older women were defined as those participants
Subject characteristics
of younger-aged
and older-aged
women smokers Younger-aged (n = 26)
Age Number
of years smoked
Number of cigarettes per day Number of prior quit attempts Nicotine Tolerance Scores *P 50.05. **p ~0.0005.
aged 50-75 years (61 f 7.6, mean f SD). The 50-year cut-off was selected to coincide with the change in menopausal status (mean, 49 years) and comparisons with other studies using the 50 year criterion [7]. There were 19 older women enrolled in the program. Younger women were defined as those participants aged 20-49 years (38 f 6.1). There were 26 younger women enrolled (Table 1). There was a significant difference (P < 0.0005) in the number of years the women smoked when the data was analyzed by r-tests. The younger women averaged 19.7 f 6.8 years of smoking and the older women smoked for an average of 44.2 f 6.4 years. The numbers of cigarettes smoked per day was significantly different (P < 0.05) in paired t-test comparisons. Younger women smoked on average 28.6 f 9.9 cigarettes while the older women smoked an average of 23.4 f 8.9 cigarettes per day. There was no difference when the number of prior quit attempts was compared between the two age groups. Both groups of women averaged three prior quitting attempts. Nicotine Tolerance Questionnaire (FTQ) [ 111 scores were not significantly different between younger women (7.1 f 1.3) and older women (6.5 f 1.9) although both could be classified as highly dependent smokers. Women who completed the initial assessment ranked their reasons for giving up cigarettes. Fourteen possible reasons for wanting to give up cigarettes were listed. Women were asked to give a numeric rating of 1 through 14 to indicate the most (1) to least (14) reason for quitting smoking.
38 (6.1) 19.7 (6.8) 28.6 (9.9) 3.2 (3.1) 7.1 (1.3)
who completed women
quit week (mean (S.D.)) Older-aged (n = 19) 61 (7.6) 44.2 (6.4) 23.4 (8.9) 3.5 (2.7) 6.5 (1.9)
women
1
l2.193** 1.797* 0.40 I I.160
P. O’Hara. S. A. Porrser / Patient Edut. Cows. 23 (1994) 91-96
94
Table 2 Reasons for quitting
smoking
(ranked
by older and younger
women)
Younger
Older
I am concerned lung cancer
about
the possibility
of
Smoking is a dirty habit causing bad breath, stains, etc. Someone important wants me to quit (i.e. husband, friends, etc.)
(56”/11)
I have experienced
(74%)
(56%)
I
(61%)
(50%)
I
Fifty percent or more of the younger women ranked one of the following as their primary reason: concern about lung cancer (56%); the idea that smoking is a dirty habit causing bad breath, stains, etc. (56%); and someone important to me wants me to quit (husband, friends, etc.) (50%). Over fifty percent of the older women chose the following as a primary reason for quitting smoking: having experienced some health problem related to smoking (74%); concern about lung cancer (61%); wanting benefits of a more active lifestyle which smoking hinders (52%); and someone important to me wants me to quit (52%) (Table 2). 3.1. Results of symptoms of disease At the assessment, both groups completed a selfreport questionnaire which asked for the presence of symptoms, diseases or risks of disease associated with smoking. Women were asked to check illness or symptoms they currently experienced
Table 3 Self-reports
on the presence
of symptoms,
Symptoms: cough, wheezing. shortness exercise tolerance, chest pain,
diseases
of breath,
some health problem related to smoking am concerned about the possibility of lung cancer want the benefits of a more active lifestyle which smoking hinders
and on a 5-point Likert scale rated their level of concern about those illnesses. On this questionnaire women reported their concerns of the effects of smoking on other factors, such as children, facial wrinkles and risks associated with use of birth control pills (Table 3). Eighty-eight percent of the younger women reported having symptoms present which were related to smoking (i.e. cough, wheezing, chest pain, etc.) while 89% of the older women reported those symptoms. Only 23% of the younger women reported they had, either past or present, smoking related diseases (i.e. bronchitis, many colds/flu, etc.) compared with 53% of the older women. Numbers of women who reported the presence of risk factors for smoking illness (i.e. abnormal chest X-ray, abnormal lung function tests, etc.) were higher in the older women (58%) than in younger women (50%). Concerns for the effects of smoking on children, facial wrinkles and risks as-
or risks ot disease in women who completed
decreased
Diseases: bronchitis, emphysema, many colds/flu, asthma, heart trouble, high blood pressure, cancers, ulcers. hardening of the arteries, Risk of disease: abnormal ECG tracing, abnormal chest X-ray. abnormal lung function tests, high cholesterol, family history of heart attacks or cancer, Other: effects of smoking on children, facial wrinkles. and risks associated with birth control pills.
(52%)
Younger-aged women (n = 26)
Older-aged
23 (88%)
17 (89%)
6 (23%)
IO (53%)
I3 (50%)
I I (58%)
20 (77%)
I2 (63%)
quit week (n = 45) women (n = 19)
P. O’Hara, S.A. Portser/ Patient Educ. Couns. 23 (1994) 91-96
sociated with birth control pills were acknowledged by 77% of the younger women and 63% of the older women. 3.2. Results of withdrawal questionnaire scores Withdrawal experiences were reported on the Shiffman-Jarvik Withdrawal Questionnaire at sessions designated as baseline, quit day and 24,48 and 72 h after quitting smoking. At each session total withdrawal scores were compiled for women in both age groups. In t-test comparisons differences between withdrawal scores of older and younger women were not significant at any of the sessions. 3.3. Attendees vs. drop-outs All 45 entrants completed the initial quit week. Twenty-six (58%) entrants went on to complete the 3 month program. Program attendees were defined as those who attended the final session at the end of the 3 months. Drop-outs were defined as those who failed to attend the final visit. Fourteen younger women or (31%) were program attendees while 12 older women or (27%) completed the final session. Program attendees and drop-outs were compared by age, number of years smoked, number of cigarettes smoked per day, number of prior quit attempts and nicotine tolerance scores. No signilicant differences were evident. However, there was a tendency for drop-outs to be younger, have smoked a fewer number of years, but smoke more cigarettes per day than program attendees. 3.4. Smoking status Abstinence was defined as having a CO level of r6 p.p.m. and a self report of not smoking since the initial quit day of the program. The 14 younger women who completed the program all reported and were validated as abstinent. Of the 12 older women 9 were abstinent and 3 had relapsed. 3.5. Results of weight change Of the women who completed the 3-month program the average weight gain of abstinent younger women was 3.5 f 3.2 lb (1 lb = 0.453 592137 kg) and the older women gained an average of 3.9 f 3.7 lb throughout the 3-month program. Results of weight change measures among the 9
95
abstinent older women showed an average gain of 4.9 f 3.8 lb. The few older women who relapsed and attended the final session showed an average weight gain of 1 lb. In the pre-assessment, the women were asked the question, ‘If you are successful in quitting cigarettes, do you foresee negative effects of weight change one month after quitting?’ Sixty-eight percent of the women responded ‘yes’to the question that weight gain after quitting smoking would be a problem for them. Of the younger women, 72”/0 answered ‘yes’, and of the older women 68% answered ‘yes’, that weight gain after quitting would be a problem for them. At the 1 month follow-up, 14 of the 16 older women measured showed body weight increases ranging from l-8 lb. Of the 18 younger women measured at 1 month after quit day, 11 showed weight gains of l-7 lb. 4. Discussion At the present time there is little available in the behavioral intervention literature which focuses on treatment for older women’s health concerns. Research indicates that behavior change may improve the health status of this significant and growing segment of the population, yet current information on the older adult in behavior change programs is sparse. Smoking cessation is one area of treatment that is known to improve the health status of older as well as younger adults. Health benefits are realized within only a few years for adults who have smoked for decades. Current smoking interventions have only recently begun to address issues specific to the female smoker. The current study has shown that there may be different concerns and physiological changes among women smokers in different age groups. Preliminary data indicate that differences in self-efficacy, motivations for entering treatment and weight changes after quitting smoking may be important factors to consider in designing smoking treatments relevant to both age and gender of the participants. The study has several implications for treating the older woman in behavioral self-management smoking intervention programs. The results of the assessment of disease symptoms and the risk of
96
P. O’Hara. S.A. Portser / Patient Educ. Couns. 23 (1994) 91-96
smoking related disease showed that older women who entered cessation experienced more smoking related diseases than younger women. Younger women were more concerned with the effects of smoking on children, facial wrinkles and cardiovascular risks associated with birth control pills than the older women. Both groups of women reported a high number of smoking related symptoms (cough, wheezing, chest pain) which is not surprising, since both groups indicated that health concerns are still the primary reason for wanting to stop smoking. Weight change after cessation of smoking is an important consideration for women in their initial decision to quit as well as to remain non-smokers. Over the past decades the emphasis on thinness has created major health concerns with regard to weight control in populations of young women. Many women report that a concern about weight gain actually prevents them from giving up cigarettes [ 121. However, we do not know if concerns about weight gain are specific to younger women and how important weight change is to the older woman when making a decision to quit smoking. Data from the present study showed that more of the younger than the older women thought that they would gain weight after quitting smoking. The pattern of weight change shows that the young women maintained current body weights initially and that older women gradually increased in weight over 3 months of treatment. However, the two groups did not show differences in the amount of weight change by the end of the treatment program. Withdrawal data did not show significant differences between the younger and older women quitters in the first 72 h after quitting. There is some prior evidence to show that older women do experience a more severe withdrawal from quitting smoking than younger women and even older men. It should be noted that in the current study there were differences in the number of cigarettes smoked per day between the younger and older women smokers. The younger women in this study smoked an average of 29 cigarettes per day. Their scores on the Fagerstrom Nicotine Tolerance Questionnaire indicated they were highly dependent smokers upon entering the study. The question of difficulty in quitting and severity of withdrawal in the older woman smoker is a question that needs
attention and further research in studies designed to answer those questions. Due to high relapse rates among women smokers, long-term women’s quitting trends in the older age groups are decreasing at one of the slowest rates of any segment of the smoking population. At the same time this population is increasing in numbers and risk for smoking related diseases. These are clearly specific concerns in this age group that may have a significant impact on their success in smoking cessation. 5. References I
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3
4
5
6
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Wisocki PA, Keuthen, NK: Later life. In: Blechman E. Brownell K eds. Handbook of Behavioral Medicine for Women, pp. 48-58 1988. New York: Pergamon Press. Stoto. MA: Changes in Adult Smoking. Behavior in the United States: 1955 to 1983. Cambridge, MA: The Institute for the Study of Smoking Behavior and Policy, Harvard University, 1986. Jajich CL, Ostfeld AM, Freeman DH: Smoking and coronary heart disease: mortality in the elderly. J Am Med Assoc 1984: 252: 2831-2834. Doll R, Hill AB: Mortality in relation to smoking: ten years’ observations of British doctors. Part II. Br Med J 1964; i: 1399-1410. Tashkin DP. Clark VA, Coulson AH et al: The UCLA Population Studies of Chronic Obstructive Respiratory Disease: VIII. Effects of smoking cessation on lung function. A prospective study of a free-living population. Am Rev Respir Dis 1984: 130: 707-715. Gordon NP, Cleary PD: Smoking Cessation in a National Probability Sample Cohort 1979-1980: Health Attitudes Practices. and Smoking Behavior Associated with Quit Attempts and Behavior Change at One Year. Cambridge MA: Harvard University. John F. Kennedy School of Government, Institute for the Study of Smoking Behavior and Policy, 1986. O’Hara P: The Lung Health Study: Two Year Results of An Intervention for Smokers at High Risk of COPD. Paper presented at the 8th World Conference on Tobacco on Health, Buenos Aires. March 1992. Gritz ER, Berman BA: Women and smoking: toward the year 2000. In: Lisansky ES, Gomberg ES. Nirenburg TD. eds. Women and Substance Abuse. Alex Publishing Co. (in press). Gunn RC: Reactions to withdrawal symptoms and success in smoking cessation clinics. Addict Behav 1986; I I: 49-53. Shiffman S. Jarvik M: Smoking withdrawal symptoms in 2 weeks of abstinence. Psychoparmacology 1976; 50: 35-39. Fagerstorm KO: Measuring degree of physical dependence to tobacco smoking with reference to individualization of treatment. Addict Behav 1978: 3: 235-241. US Department of Health and Human Services, Public Health Service. 1980. The Health Consequences of Smoking for Women. A Report of the Surgeon General. Washington DC: US Government Printing Office.