Beliefs about health, smoking, and future smoking cessation among South Korean men hospitalized for cardiovascular disease

ISSUES IN PULMONARY NURSING

Beliefs about health, smoking, and future smoking cessation among South Korean men hospitalized for cardiovascular disease Min Sohn, RN, MPH, PhD,a Nancy A. Stotts, RN, EdD,a Neal Benowitz, MD,b,c Dianne Christopherson, RN, PhD,a Kyung Soo Kim, MD, PhD,d Yang Soo Jang, MD, PhD,e Mi Sook Ahn, RN,e and Erika Sivarajan Froelicher, RN, MPH, PhDa,f

BACKGROUND: A particularly high rate of smoking among South Korean men corresponds to high rates of cardiovascular disease. OBJECTIVES: This study evaluated South Korean men hospitalized with cardiovascular disease to explore beliefs about the health benefits of smoking cessation, to determine smoking cessation intentions, and to identify factors associated with confidence in quitting smoking. METHODS: This was a cross-sectional, descriptive study. RESULTS: Of the study’s 97 participants, only 78% believed that smoking cessation avoids or decreases the chance of developing heart disease; 93% reported their intention to quit; 74% had moderate to high confidence about quitting within the month after hospital discharge; and 88% preferred to quit by themselves without help. Significant predictors of low confidence in quitting were being married (odds ratio: 5.54, 95% confidence interval: 1.33–23.08); being alcohol dependent (odds ratio: 3.25, confidence interval: 1.20 – 8.80); and starting to smoke at or before 20 years of age (odds ratio: 2.96, confidence interval: 1.14 –7.68). CONCLUSION: The study’s participants were motivated to quit smoking for their health, but they must be educated to understand that smoking is addictive and that special intervention is needed. (Heart Lung® 2007;36:339 –347.)

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outh Korean men have the highest rate of smoking in the world (57%).1 Cardiovascular disease (CVD) was the second most common cause of death among South Korean men in 2002.2

From the aDepartment of Physiological Nursing, School of Nursing and bDepartments of Medicine, Psychiatry, and Biopharmaceutical Sciences, University of California, San Francisco, California; cDivision of Clinical Pharmacology and Experimental Therapeutics, Medical Service, San Francisco General Hospital Medical Center, San Francisco, California; dDepartment of Cardiology, Hanyang Medical Center, Hanyang University, Seoul, South Korea; eDepartment of Cardiology, Yonsei Medical Center, Yonsei University, Seoul, South Korea; and fDepartment of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, California. Funding sources: Century Club Fund and Graduate Research Fund, University of California, San Francisco, California. Reprint requests: Min Sohn, RN, MPH, PhD, Department of Physiological Nursing, N631, School of Nursing, University of California, San Francisco, 2 Koret Way, San Francisco, CA 94143-0610. 0147-9563/$ – see front matter Copyright © 2007 by Mosby, Inc. doi:10.1016/j.hrtlng.2006.11.001

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Despite the risks associated with high rates of smoking and the evidence of a high prevalence of CVD among South Korean men, researchers have rarely investigated smoking cessation in this population. Published studies reporting the benefits of smoking cessation among smokers who had CVD began to appear in the 1970s.3–7 Although their outcome measures differed, all of the studies concluded that there was a substantial benefit from smoking cessation in terms of mortality, survival rate, and recurrent rate of CVD.8 –11 Through these studies, researchers concluded that smoking cessation is probably the single most important intervention in the management of CVD. More recent data reinforce the findings of previous research. Current studies show that smoking cessation in patients with CVD reduced the rate of recurrent CVD events by 40%, after 1-year follow-up,12 and the mortality rate due to recurrent CVD events by 17%, after 20-year follow-up.13

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In the United States, pioneering studies14 –18 have examined smoking cessation in patients who were already diagnosed with CVD. To design a successful smoking cessation program based on population need and to provide health care providers with practical suggestions and cessation methods, substantial information about the study population is required. This information should include (1) cognitive and decision-making ability (eg, belief and knowledge about the hazards of smoking on health, intention or motivation to continue or stop smoking, and confidence in one’s ability to quit smoking; (2) the participants’ smoking behavior and related demographics and psychologic factors; (3) social context (environmental influences); and (4) the pharmacology of nicotine. Several efforts are under way to implement smoking cessation programs for patients who visited smoking cessation clinics in South Korea,19 –22 but no study has investigated this unique population who might realize the biggest benefit from smoking cessation. The authors have already studied hospitalized patients with CVD, focusing on demographic and psychologic factors, the violation of smoking bans in hospitals, and the pharmacology of nicotine.23,24 In this article, the authors examined the participants’ beliefs about the hazards of smoking, their intentions to quit smoking, and their confidence to quit smoking with potential predictors. Researchers have shown that confidence to quit smoking has one of the strongest associations with high rates of smoking cessation and lower relapse rates.25,26 The objectives of this study, therefore, were threefold: (1) to explore the beliefs of South Korean men about the health benefits of smoking cessation; (2) to determine their intentions to quit smoking; and (3) to identify factors associated with their confidence to quit smoking.

DESIGN AND METHODS This is a cross-sectional, descriptive study. A convenience sample of participants was recruited from two university hospitals in South Korea. Men were included in the study if they (1) were 18 years of age or older; (2) were diagnosed with CVD, including coronary heart disease (angina pectoris, unstable angina, or myocardial infarction), heart failure, valve abnormalities, or peripheral arterial disease; (3) had a history of tobacco use within the past month; and (4) had been hospitalized in a cardiology unit. Men were excluded if they (1) were unable to speak, read, or write Korean; (2) had a concurrent psychiatric disorder, such as dementia, schizophrenia, or di-

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minished consciousness; or (3) had a medically unstable condition. Medically unstable patients were excluded because their participation in the interview process would be too difficult. Approval of the study was obtained from the Committee on Human Research at the University of California, San Francisco, and from the chairs and medical staffs of the cardiology departments of the two participating South Korean hospitals. Written informed consent was obtained from the participants when they were enrolled in the study. The data were collected by a native Korean nurse scientist, and all interviews were conducted in Korean.

Instruments The authors collected data from a structured questionnaire and, by abstraction, from patients’ medical records. The questionnaire, modified from one described previously,26 –33 was translated from English into Korean by an independent translator who considered linguistic and cultural nuances. The Korean version of the questionnaire was pretested in a small group to evaluate its practicality in terms of user comprehension, length of time to administer, and user acceptance of the interview. The interview process went smoothly, and no major changes were required.

Beliefs about the health benefits of smoking cessation The investigators assessed smokers’ beliefs about the health benefits of smoking cessation by asking participants three questions or statements developed and tested by the National Cancer Institute Community Intervention Trial for Smoking Cessation in the United States in 198934 and three additional questions. In order these six questions were (1) “How likely do you think it is that you will avoid or decrease the severity of your health problems if you quit smoking?” (2) “If a person has smoked for more than 20 years, there is little benefit to quitting smoking.” (3) “My smoking is harming my health.” (4) “How likely do you think it is that you will avoid or decrease your chances of the development of lung cancer if you quit smoking?” (5) “How likely do you think it is that you will avoid or decrease the development of heart disease if you quit smoking?” (6) “How likely do you think it is that you will avoid or decrease the development of respiratory disease if you quit smoking?” The response options for questions 1, 4, 5, and 6 were very likely, likely, unlikely, very unlikely, and uncertain. The response options for statements 2 and 3 were

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strongly agree, agree, disagree, strongly disagree, neither disagree or agree, and I do not know.

Intentions regarding smoking cessation The researchers evaluated the participants’ intentions to quit smoking by using questions from instruments used in previous studies,35,36 which were modified, based on documented information in the Korean literature, to provide examples of smoking cessation methods.21,37– 40 Participants’ intentions to quit smoking were measured by the question, “Do you intend to stay off cigarettes or other tobacco products in the next month?” The participants responded on a 7-point scale ranging from 1 (definitely no) to 7 (definitely yes). In addition, the researchers evaluated the participants’ intention to participate in a smoking cessation program during hospitalization by answering either yes or no, by stating their reasons to quit smoking, and by indicating their preferred method for a future cessation attempt.

Confidence to quit smoking

Table I Demographic characteristics and diagnoses of participants (n ⫽ 97) Demographics

Age (y) High school graduate or more Married Employed full time Diagnosis at hospital admission* Myocardial infarction Angina or chest pain Unstable angina Arrhythmia Congestive heart failure Other†

%

n

Mean 54.1 (⫾9.6), Range: 29–76 74.2 72 85.6 77.3

83 75

23.7

23

21.6 20.6 15.5 8.2

21 20 15 8

12.4

12

*Not mutually exclusive. †Valve disease, hypertension, aortic aneurysm, abdominal aortic occlusion, postoperational (aortic valve replacement) wound dehision, ischemic cardiomyopathy.

The researchers measured the participants’ confidence to quit smoking by using a single-item, selfefficacy scale adopted from previous studies:36,41 “How confident are you that you will be able to stay off cigarettes once you are discharged from the hospital?” The responses were measured on a scale with scores ranging from 0 (not at all confident) to 10 (totally confident). In a previous study,25 this single-item measurement was one of the items most significantly associated with smoking cessation, and absolute confidence (10) was used as a proper cutoff point. In addition, the age when smokers first began smoking and their alcohol dependence, measured by the CAGE questionnaire, were evaluated. The CAGE questionnaire is as follows: C: “Have you ever felt you ought to Cut down on drinking?” A: “Have people Annoyed you by criticizing your drinking?” G: “Have you ever felt bad or Guilty about your drinking?” E: “Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye opener)? Answering yes to more than two of the four CAGE questions is an indicator of alcoholism.42 It has been shown that both of these factors are strongly associated with confidence to quit smoking.43

ables were evaluated for errors in data entry, and any discrepancies were verified against the original, raw data. To describe the characteristics of the study participants and to achieve study objectives 1 and 2, descriptive analysis was used with actual numbers for frequency, mean with standard deviation, median with range, and proportions. For study objective 3, multiple logistic regression was used. For logistic regression, the researchers first identified potential predictors of confidence in smoking cessation and variables that were statistically significant in studies previously reported in the literature and in univariate analysis. These variables were then evaluated by using multiple logistic regression for their independent effects on confidence in quitting. Results are presented as odds ratio (OR) with a 95% confidence interval (CI) and P ⫽ .05.

Data management and analysis

RESULTS

The Statistical Package for the Social Sciences Version 11.0 program was used for statistical analysis.44 Descriptive statistics and distribution of vari-

Data collection began in January 2004 and ended in August 2004. The study participants consisted of 97 South Korean men (mean age, 54.1 ⫾ 9.6 years)

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who were hospitalized with CVD. Most of the men had graduated from high school or had completed additional education, were married, and were employed full time (Table I). After reviewing the distribution of responses, the researchers combined the options very likely and likely; very unlikely and unlikely; strongly agree and agree; and strongly disagree and disagree.

Beliefs about smoking and the health benefits of smoking cessation Most of the men (84.5%) believed that they would avoid or reduce their chance of serious health problems if they quit smoking, and many of them (77.3%) agreed that smoking was directly harmful to their health (Table II). A smaller proportion of men (71.1%) knew that smoking cessation would even benefit people who had smoked for more than 20 years. When the men were asked about the impact of smoking on three tobacco-related diseases (respiratory disease, heart disease, and lung cancer), most of them (86.6%) believed that they could avoid or reduce their chance of developing respiratory disease if they quit smoking. Fewer men (78.3%), however, believed that smoking cessation would avoid or reduce their chance of developing heart disease, and an even smaller proportion (66.0%) believed that they would avoid or reduce their chance of developing lung cancer if they quit smoking.

Intentions regarding smoking cessation Almost all of the men (83.5%) reported that they would definitely quit smoking during the next month (Table III). The most common reason to quit (95.6%) was “for my health.” Other less frequent responses included “bad smell on my body or hair” (5.6%); “my wife or girlfriend dislikes smoking” (2.2%); “people’s negative attitude against smokers” (2.2%); “bad smell within the house” (1.1%); and “fear of more addiction” (1.1%). These responses were not mutually exclusive. Methods the men had previously used to quit smoking and methods they intended to use in the future are shown in Table IV. The most common methods the men used in the past were “my own way with no other assistance” (52.9%), followed by cigarette substitutes (17.1%), snacks (15.7%), and nicotine replacement therapy (NRT; 14.3%). In attempting future smoking cessation, most of the men (87.8%) reported that they planned to quit on their

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Table II Beliefs about the health benefits of smoking cessation (n ⫽ 97) How likely do you think it is that you will avoid or decrease serious health problems if you quit smoking? Very likely or likely Very unlikely or unlikely Uncertain My smoking is harming my health. Strongly agree or agree Strongly disagree or disagree Neither disagree nor agree or I do not know If a person has smoked for more than 20 years, there is little benefit to quitting. Strongly disagree or disagree Strongly agree or agree Neither disagree nor agree or I do not know How likely do you think it is that you will avoid or decrease the chance of getting respiratory diseases if you quit smoking? Very likely or likely Very unlikely or unlikely Uncertain How likely do you think it is that you will avoid or decrease the chance of getting heart disease if you quit smoking? Very likely or likely Very unlikely or unlikely Uncertain How likely do you think it is that you will avoid or decrease the chance of getting lung cancer if you quit smoking? Very likely or likely Very unlikely or unlikely Uncertain

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%

n

84.5 12.4 3.1

82 12 3

77.3 13.4

75 13

9.3

9

71.1

69

14.4 14.4

14 14

86.6 6.2 7.2

84 6 7

78.3 7.2 14.5

76 7 14

66.0 15.5 18.5

64 15 18

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Table III Intention to quit smoking and confidence in quitting %

n

Intention to quit smoking in the next month (n ⫽ 97) Mean 6.4 ⫾ 1.4; Median 7.0; Range: 1–7* ⱕ6 16.5 16 7 (definitely yes) 83.5 81 Confidence in quitting smoking (n ⫽ 90) Mean 8.1 ⫾ 2.6; Median 10.0; Range: 1–10* ⬍7 25.6 23 ⬎7 and ⬍10 20.0 18 ⫽10 54.4 49 *The data are not normally distributed; therefore both mean with standard deviation and median with range are presented.

own. Only a few indicated that they would try specific smoking cessation methods. Of all the men, 49 (50.5%) were willing to participate in a formal, educational, smoking cessation program, if those programs were available during their hospitalization (Table V). However, 40 men (41%) indicated that they did not want to participate in such programs, and the most common reason given was a desire to quit on their own (60%). Only 5% of those 40 men said that they were not interested in any educational or smoking cessation programs.

Confidence to quit smoking and predictors of low confidence More than half of the men (54.4%) reported absolute confidence in their ability to stop smoking, with a score of 10. For the logistic regression, the distribution of confidence in smoking cessation was reviewed and 10 was used as a cutoff point. This cutoff point was used in a previous study.25 Following a literature review and univariate analysis, five variables were identified as significantly associated with confidence in smoking cessation: age, level of education, marital status, age when smoking started, and CAGE score. On average, the men had begun smoking at approximately 20 years of age. Thirty-one men answered yes to more than two CAGE questions, which is an indicator of alcoholism.

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By using multiple logistic regression including five variables, the researchers found three independent variables that provided statistically significant, independent contributions to the prediction of outcome. They were being married (OR: 5.54, 95% CI: 1.33–23.08), having a CAGE score of two or more (OR: 3.25, 95% CI: 1.20 – 8.80), and starting to smoke at or before 20 years of age (OR: 2.96, 95% CI: 1.14 –7.68) (Table VI). To evaluate the effects of other associated variables on the outcome variable, the researchers also tested variables highly associated with independent variables in univariate analysis. None of the other variables were statistically significant in the model.

DISCUSSION Smoking is not only the single most important and preventable risk factor for CVD but also equally important for people already diagnosed with CVD.45 The men in this study were not knowledgeable enough about the health hazards of smoking-related diseases. The researchers were intrigued by several observations. First, only 78% of the participants believed that smoking cessation would help them avoid or decrease the chance of developing heart disease. This number is lower than 82% of men and women with various diagnoses from 10 countries in a World Health Organization study,46 90% of men and women with CVD in the United Kingdom,47 and 80.5% of women with CVD in the United States.28 South Korean men may differ from the populations in these countries. In addition, only 29% of the men who had smoked regularly for an average of 33 years believed that they had smoked too long to gain health benefits from quitting. This misconception must be corrected through education. Second, almost all of the men said they intended to quit smoking during the month after they were discharged from the hospital, but 21% still smoked during index hospitalization, although their hospital had a smoking ban. The smoking rate during hospitalization is lower than 25% for medical patients in the United States48 and 35% in South Korea.38 This finding, however, is ambiguous. The lower rate may reflect the participants’ true intention to quit smoking, or it may also be attributable to the pressure of “social desirability.” Third, although the participants were highly motivated to quit smoking, they did not actively seek a proven smoking cessation method. More than half of the men (52.9%) said that they would try to stop smoking by themselves without any specific

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Table IV Past and future smoking cessation methods selected by participants* In past attempts (n ⴝ 70)†

In future attempts (n ⴝ 90)‡

Smoking cessation method

%

n

%

n

My own way with no other assistance Cigarette substitute (NosmoQ) Snacks§ NRT (nicotine gum and patch) Acupuncture Smoking cessation program or education Others

52.9 17.1 15.7 14.3 7.1 5.7 5.7

37 12 11 10 5 4 4储

87.8 4.4 4.4 4.4 2.2 0.0 2.2

79 4 4 4 2 0 2¶

NRT, Nicotine replacement therapy. *Not mutually exclusive. †Among men who tried at least one serious attempt to quit smoking in the past. ‡Among men who had the intention to quit smoking. §Snacks include candy, gum, or traditional Korean snacks, which are mostly dried beans or dried rice. 储Others: empty pipe (1), reading (1), medication (1), and watching a movie (1). ¶Others: Internet-based self-help service(1) and decreasing number of cigarettes smoked per day (1).

method. Even more men (87.8%) said that they would attempt to quit by themselves without any help. No one reported that he would attend an educational or smoking cessation program in the future. This finding is consistent with findings in previous studies, which noted that, although many intensive group smoking cessation programs are offered, most smokers prefer to quit on their own.49,50 Most of the methods the men had previously tried were not preferred methods for successful smoking cessation. Only half of the men who had previously used a cigarette substitute, snacks, NRT, or acupuncture would be willing to use them again in the future. Those men were not satisfied with the methods they had used in the past, and, disappointed by their previous attempts, they decided to try to quit on their own. The reason for failure in earlier attempts to quit is usually not the method people used but rather the addictive nature of nicotine. There is an urgent need to educate people that smoking is addictive and that special smoking cessation methods can increase their chances of achieving permanent cessation; for example, NRT, used with behavioral modification, is a reliable method to overcome nicotine addiction.51,52 Fourth, some men (12.2%) reported that they had used NosmoQs (3G Care, Seoul, South Korea), and that they would use this product again (4.4%) for smoking cessation in the future. NosmoQ is an

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herbal cigarette produced by a Korean company that is made with Eucommia ulmoides leaves. Eucommia ulmoides is an herb used in tea and herbal medication. The product looks like a conventional filtered cigarette, but, because it does not contain nicotine, it permits former smokers to continue an “inhalation behavior” resembling cigarette smoking and makes them believe that there are fewer hazards. This product can be purchased without a prescription through the Internet, and it is sold in pharmacies. In one study,53 NosmoQ was the smoking cessation aid most frequently used by more than 400 randomly selected adults in Seoul, Korea. In a randomized clinical trial with 200 South Korean office workers who wanted to quit smoking, Cheong54 randomized participants to one group using NosmoQ and another using a nicotine patch. He reported that NosmoQ was as effective as the nicotine patch in its effects on smoking cessation at 1, 3, and 6 months. Smoking cessation was evaluated by selfreports at 1 and 3 months and by a carbon monoxide in expiration at 6 months. The herbal cigarette, which was approved by the Korean Food and Drug Administration as a nonpharmacologic product, contains no nicotine, but it produces carbon monoxide as it burns. Because no data have been reported regarding the potential harmful effects of Eucommia ulmoides on patients with CVD, studies

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Table V Intention to participate in a smoking cessation program during hospitalization Do you want to participate in formal education or a program for smoking cessation during hospitalization if available?

Yes Reasons of no intention to participate in the program (n ⫽ 40) The most important thing is strong personal willingness to quit smoking, and I can quit by myself. The class will have no more useful information. I already know most about smoking. Just not interested in it. Other*

Predictor variables† %

n

50.5

49

60.0

24

22.5

9

5.0 12.5

2 5

*Others: I already quit. (2), Hearing about smoking will make me want to smoke. (1), I am too weak to attend the class. (1), I feel that attending class makes my confidence weaker. (1)

are needed to evaluate its effects on people using the herb to achieve smoking cessation. Fifth, previous studies have shown that being married was a predictor of high confidence in smoking cessation because family support has a positive influence on their attempts to quit.43,55,56 However, unexpectedly, this study found that being married, for Korean men, was a predictor of low confidence in smoking cessation. For women, Sivarajan Froelicher and colleagues26 proposed that being married was a predictor of failure to quit smoking if their spouses were smokers, because living with a smoker may make it easier for women to relapse into smoking. The smoking rate among South Korean women, however, is extremely low, making it less likely that the spouses of study participants were smokers. Why married Korean men have low confidence in smoking cessation may be attributable to their dominant status in the family, and, because they often spend considerable time at work, their fami-

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Table VI Odds ratio with 95% confidence interval using multiple logistic regression analysis with five independent variables that predict low confidence in quitting smoking*

Age ( ⱖ54 y) Education (⬍high school) Marital status (married) CAGE score (ⱖ2) Age started to smoke (ⱕ20 y)

OR

95% CI

P value

0.98 0.40–2.41 0.77 0.28–2.13

.96 .61

5.54 1.33–23.08

.02

3.25 1.20–8.80 2.96 1.14–7.68

.02 .03

OR, Odds ratio; CI, confidence interval. *The outcome variable was coded as 1: low confidence (⬍10), 0: high confidence (⫽10). †Comparisons: age (⬍54 y); education (ⱖhigh school); marital status (not married); CAGE score (⬍2); age smoking started (⬎20 y).

lies might have less influence on their decision making. Last, when the men were asked if they would participate in educational or smoking cessation programs during their index hospitalization, 51% indicated an interest. This suggests that hospitalization provides an important opportunity to use the “teachable moment” to initiate smoking cessation with these patients. Emmons and Goldstein57 documented hospital admission as a “teachable moment,” meaning that it is an ideal time to offer a smoking cessation intervention and that seizing that opportunity is effective in terms of achieving permanent cessation.52 When patients confront a serious illness and the possibility of death, they have heightened motivation to change risky behaviors. This increased motivation can maximize the effect of smoking cessation interventions.

LIMITATIONS This study has several limitations. A cross-sectional design and a convenience sample were used, precluding reliable, causal associations to be drawn, and generalizability is limited. Because the data were collected during hospitalization, while patients were under medical supervision, the patients’ strong intention to quit smoking might have resulted from their wish to give socially desirable

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answers on their questionnaires. Actual smoking cessation attempts after participants were discharged from the hospital were not assessed. Despite these limitations, this is the first study to address beliefs about smoking and health among South Korean men hospitalized with CVD, and it provides fundamental information on which to base future studies of their smoking cessation efforts. These men were acutely aware of the health hazards of smoking-related diseases and were highly motivated to quit smoking. When asked whether they would be interested in receiving intervention, they preferred to quit by themselves without any help; however, they would be willing to participate in a smoking cessation program if the program were made available during their hospital stay.

CONCLUSION On the basis of these conclusions, it is recommended that South Korean patients be educated to realize that special intervention is needed because smoking is addictive. Future research must include South Korean women who are smokers and should evaluate the harmful effects and the benefits of the herbal smoking substitute, Eucommia ulmoides, as a quitting aid for patients with CVD. To explore the natural history of smoking behavior in this population and to minimize the effect of socially desirable responses, a longitudinal follow-up study with biochemical verification would be valuable. The authors thank the following persons and institutions for their help in completing the data collection for this study: The 97 men who took part in this study; the Cardiology Department of Hanyang University Medical Center (Seoul, Korea) with Ok Hee Baek, RN; the Cardiovascular Hospital of Yonsei University Medical Center (Seoul, Korea), with Sung Soon Kim, MD; and special thanks to Hye-Un Byun. The article was edited by Susan Eastwood, ELS (D).

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