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Risk factors for smoking abuse after heart transplantation
Risk Factors for Smoking Abuse After Heart Transplantation A. Basile, S. Bernazzali, F. Diciolla, F. Lenzini, G. Lisi, M. Maccherini, V. Mangini, E. Nesti, and M. Chiavarelli ABSTRACT Patients (n ⫽ 103) were studied before heart transplantation with regard to smoking habits by means of a clinical interview, and 81 were submitted to Minnesota Multiphasic Personality Inventory (MMPI). After a mean time of 50.8 ⫾ 24.2 months from transplant, they were once again interviewed to ascertain their smoking habits after intervention. Nonsmokers (35 of 103) were still nonabusers. Of the remaining 68 patients who ceased smoking before heart transplant, 12 (17.6%) had returned to tobacco abuse. Dividing these 68 patients into two groups based upon the length of smoking cessation before heart transplant (less than 1 year: short term [ST] more than 1 year: long term [LT]), we noticed that the ST group showed a much greater rate of reabuse (8 of 20, 40%) than the LT group (4 of 48, 8.3%, P ⫽ .006). Analyzing six scales of MMPI, we found a statistically different score for self-control ability (scale K) in ST and LT smokers compared to nonsmokers (45.5 and 45.5 vs 51.2, P ⫽ .026), and for difficult adaptation (scale Ma) in ST compared both to LT smokers and nonsmokers (ST 57, LT 50.5, NS 47.6; P ⫽ .042 LT vs ST, P ⫽ .0005 ST vs NS). We concluded that patients who have recently decided to stop smoking and show after MMPI compilation a score of ⬎50 for K and ⬍50 for Ma scale have a higher risk of reabuse and need a greater effort by the transplant team to reinforce their will to stop smoking.
A
CTIVE SMOKING is the main preventable cause of death and illness in Italy, as well as in all Western countries. In Italy, as evidenced in the latest ISTAT database,1 almost 12 million Italians are smokers (31.5% of the whole male population and 17.2% of the female population), with 85,000 deaths attributable to tobacco abuse every year. Although smoking is considered one of the most dangerous risk factors for cardiovascular disease, our clinical experience shows its prevalence in patients suffering from terminal heart disease before and after transplantation. Derangements in the emotional set of such patients before2,3 and after4 – 6 operation can lead to smoking cessation due to the wish to be included in the waiting list, but such a decision can be weak and combined with low compliance and incorrect behavior,7 tobacco abuse can restart, leading to worse prognosis. We intended to study how personality and timing of smoking cessation can influence tobacco abuse postoperatively in heart-transplanted patients. MATERIALS AND METHODS Patients (n ⫽ 103) submitted to heart transplantation (HTX) between 1994 and 2003 in Siena and still alive at the time of the © 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 36, 641– 642 (2004)
present study were considered. They were 82 men and 21 women (20.4%), with mean age at HTX of 54.4 years (range 27 to 69). At initial psychological examination (before HTX), 35 were nonsmokers (NS; mean age 54.3, range 27 to 69, 21 men, 14 women); 48 were ex-smokers with prolonged period of cessation (more than 1 year, LT; mean age 54.8, range 31 to 65, 42 men, six women), and 20 were smokers who had recently (less than 1 year, mean 4.4 months, range 3 to 10, ST) ceased tobacco abuse (mean age 53.6, range 36 to 65, 19 men, one women). All patients had a clinical psychological evaluation before HTX, and 81 (78.6%) also performed the Minnesota Multiphasic Personality Inventory (MMPI) test. Of these 81 patients, 28 were NS (28/35, 80%), 38 were LT (38/48, 79.2%), and 15 were ST (15/20, 75%). MMPI by Hathaway and McKinley8 is used to evaluate and describe personality of single subjects. It is a questionnaire of almost 300 items, to which the patients must answer “true” or “false.” The structure of the test enables the examiner to obtain From the Dipartimento Cardiotoracico (S.B., F.D., GL., M.M., M.C.) UO Psicologia (A.B., F.L., V.M., E.N.) Azienda Ospedatiera Universitaria Senese, Siena, Italy. Address reprint requests to Assunta Basile, MD, UO Psicologia, Azienda Ospedaliera Universitaria Senese, V le Bracci, 53100 Siena, Italy. E-mail: [email protected] 0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.02.054 641
642
BASILE, BERNAZZALI, DICIOLLA ET AL Table 1. MMPI Scores
MMPI scales
K Hs D Hy Pd Ma
NS
LT ex-smokers
ST ex-smokers
51.2 70.3 67.6 66.0 51.3 47.6
45.5* 69.0 68.0 65.0 51.2 50.5**
45.5* 65.2 63.0 65.2 54.5 57.0***
*P ⫽ .026, LT and ST vs NS; **P ⫽ .042 LT vs ST; ***P ⫽ .005 ST v. NS.
values for three validity scales and 10 clinical scales. For our purposes, we analyzed one validity scale (K, Correction), and five clinical scales (Hs, Hypocondriasis; D, Depression; Hy, Conversion Hysteria, Pd, Psycopathic Deciate; and Ma, Hypomania), describing the personality features mostly associated with abuse habits. At the time of the present study, all the patients were submitted to a new clinical interview to ascertain actual tobacco habits. Statistical analysis was performed by means of ANOVA for differences between the three groups and by Students-NewmanKeuls test in case of found differences. Percentage value were confronted by 2 test.
RESULTS
Mean time from HTX to final evaluation was 51.4 ⫾ 22.0 months (range 5 to 100) in NS, 51.0 ⫾ 21.68 (range 4 to 94) in LT, and 49.4 ⫾ 28.9 (range 10 to 93) in ST (f.05, P ⫽ .952). Smoking reabuse rates in NS was 0/35, and in the ex-smokers group as a whole (ST ⫹ LT) 17.6% (12/68); in LT group 8.3% (4/48); and in ST group 40% (8/20) (P ⫽ .006). Comparing the MMPI scores for the previously described scales, a significant prevalence was seen of lower degree of self-control ability (K scale) in the ex-smoker groups compared to the NS group, and a worse adaptation (Ma scale) in ST compared to LT and NS (Table 1). The ST group shows also a trend, not statistically significant, to higher noncompliant habit (Pd scale). DISCUSSION
In the Heart Transplantation Centre in Siena, patients who are to be included in the waiting list are examined for family characteristics and lifestyle, paying attention to previous smoking habits. They are informed about the risks of tobacco smoking both on an individual basis and during group counseling before HTX. Literature is concordant about some typical psychological features of patients awaiting HTX: they are exposed to feelings of inefficacy and powerlessness, cope with a experience of impending death, and reduce their perspective for the future.2,3 Often rage, anxiety, and depression are observed in such patients, reaction symptoms to the critical clinical conditions.4 HTX represents a strong hope for life, and for this goal changes in pretransplant lifestyle are easily accepted, including smoking cessation. In the post-HTX phase, psychological
adaptation to the new situation will depend on clinical conditions, social interactions,5 coping features,4 and autoefficacy of the subject.6 Personality disturbances pre-HTx and a troubled clinical course after HTX are important factors for quality of life after transplant and can lead to a better or worse compliance.9 Our 17.6% of ex-smokers restarting abuse after HTX compares favorably with US rates (19%)10 for smokers as a whole, while the higher rate of 40% for ST is similar to that of the Tutin group of Balestroni.7 It is our opinion that LT ex-smokers who decided to stop smoking long before being considered for HTX had matured their conviction for eliminating a true risk for their own health, while the ST patients stopped tobacco abuse due to bad clinical condition and to fear of not being included in the waiting list. This shows a false change in lifestyle, one not done on a stepwise decisional basis, as recommended by Schwarzer and Fucts6 but forced by the terminal cardiac disease at high emotional value. The restarting of tobacco abuse in such patients is justified by a scarce self-control ability (K scale), by the lack of compliance to the restriction imposed by the therapeutical regimen (Pd scale), by difficult positive adaptation (Ma scale), and by self-defense mechanisms against health events. We concluded that patients who ceased smoking only a few months before being included in the waiting list for HTX, showing MMPI scale values of more than 50 for K scale and less than 50 for Ma scale, are at risk for tobacco reabuse, and require from the transplant staff a stronger and longer psychological support pre-HTX, to be prolonged after intervention.8 REFERENCES 1. Rapporto ISTAT 2001 sugli stili di vita Table 14.1. Available from www.istat.it/Banche-dat/Indicatori/04/indext.html 2. Chiesa S: II trapianto d’organo: crisi e adattamento psicologico. Psichiatria e Medicina 10:15, 1989 3. Cazzullo CL, Invernizzi G: Aspetti psicodinamici della dialisi e del trapianto renale. Minerva Chirurgica 30:877, 1975 4. Rupolo G, Poznanski C: Psicologia e psichiatria del trapianto d’organi. Masson: Torino; 1999 5. Kober B, Kuchler T, et al: A psychological support-concept and quality of life in research in a liver transplantation program: an interdisciplinary multicenter study. Psychotherapy and Psychosomatics 54:117, 1990 6. Schwarzer R, Fuchs R: Autoefficacia e comportamenti a rischio: In Bandura A (ed): II senso di autoefficacia. Aspettative su di se´ e azione. Trento; Erickson Edizioni: 1996, p 313 7. Balestroni G, Bosimini E, Centofanti P, et al: Stile di vita e aderenza ai trattamenti raccomandati dopo il trapianto. Ital Heart J Suppl 3:652, 2002 8. House RM, Trzepacz PT, Thompson TL: Psychiatric consultation to organ transplant services. Reviews of Psychiatry 9:515, 1990 9. Grady KL, Jalowiec AJ, White-Williams C: Patient compliance at one and two years after heart transplantation. J Heart Lung Transplant 17:383, 1998 10. Mosticoni R, Chiari G: Una descrizione obiettiva della personalita`. OS: Firenze; 1979
A
CTIVE SMOKING is the main preventable cause of death and illness in Italy, as well as in all Western countries. In Italy, as evidenced in the latest ISTAT database,1 almost 12 million Italians are smokers (31.5% of the whole male population and 17.2% of the female population), with 85,000 deaths attributable to tobacco abuse every year. Although smoking is considered one of the most dangerous risk factors for cardiovascular disease, our clinical experience shows its prevalence in patients suffering from terminal heart disease before and after transplantation. Derangements in the emotional set of such patients before2,3 and after4 – 6 operation can lead to smoking cessation due to the wish to be included in the waiting list, but such a decision can be weak and combined with low compliance and incorrect behavior,7 tobacco abuse can restart, leading to worse prognosis. We intended to study how personality and timing of smoking cessation can influence tobacco abuse postoperatively in heart-transplanted patients. MATERIALS AND METHODS Patients (n ⫽ 103) submitted to heart transplantation (HTX) between 1994 and 2003 in Siena and still alive at the time of the © 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 36, 641– 642 (2004)
present study were considered. They were 82 men and 21 women (20.4%), with mean age at HTX of 54.4 years (range 27 to 69). At initial psychological examination (before HTX), 35 were nonsmokers (NS; mean age 54.3, range 27 to 69, 21 men, 14 women); 48 were ex-smokers with prolonged period of cessation (more than 1 year, LT; mean age 54.8, range 31 to 65, 42 men, six women), and 20 were smokers who had recently (less than 1 year, mean 4.4 months, range 3 to 10, ST) ceased tobacco abuse (mean age 53.6, range 36 to 65, 19 men, one women). All patients had a clinical psychological evaluation before HTX, and 81 (78.6%) also performed the Minnesota Multiphasic Personality Inventory (MMPI) test. Of these 81 patients, 28 were NS (28/35, 80%), 38 were LT (38/48, 79.2%), and 15 were ST (15/20, 75%). MMPI by Hathaway and McKinley8 is used to evaluate and describe personality of single subjects. It is a questionnaire of almost 300 items, to which the patients must answer “true” or “false.” The structure of the test enables the examiner to obtain From the Dipartimento Cardiotoracico (S.B., F.D., GL., M.M., M.C.) UO Psicologia (A.B., F.L., V.M., E.N.) Azienda Ospedatiera Universitaria Senese, Siena, Italy. Address reprint requests to Assunta Basile, MD, UO Psicologia, Azienda Ospedaliera Universitaria Senese, V le Bracci, 53100 Siena, Italy. E-mail: [email protected] 0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.02.054 641
642
BASILE, BERNAZZALI, DICIOLLA ET AL Table 1. MMPI Scores
MMPI scales
K Hs D Hy Pd Ma
NS
LT ex-smokers
ST ex-smokers
51.2 70.3 67.6 66.0 51.3 47.6
45.5* 69.0 68.0 65.0 51.2 50.5**
45.5* 65.2 63.0 65.2 54.5 57.0***
*P ⫽ .026, LT and ST vs NS; **P ⫽ .042 LT vs ST; ***P ⫽ .005 ST v. NS.
values for three validity scales and 10 clinical scales. For our purposes, we analyzed one validity scale (K, Correction), and five clinical scales (Hs, Hypocondriasis; D, Depression; Hy, Conversion Hysteria, Pd, Psycopathic Deciate; and Ma, Hypomania), describing the personality features mostly associated with abuse habits. At the time of the present study, all the patients were submitted to a new clinical interview to ascertain actual tobacco habits. Statistical analysis was performed by means of ANOVA for differences between the three groups and by Students-NewmanKeuls test in case of found differences. Percentage value were confronted by 2 test.
RESULTS
Mean time from HTX to final evaluation was 51.4 ⫾ 22.0 months (range 5 to 100) in NS, 51.0 ⫾ 21.68 (range 4 to 94) in LT, and 49.4 ⫾ 28.9 (range 10 to 93) in ST (f.05, P ⫽ .952). Smoking reabuse rates in NS was 0/35, and in the ex-smokers group as a whole (ST ⫹ LT) 17.6% (12/68); in LT group 8.3% (4/48); and in ST group 40% (8/20) (P ⫽ .006). Comparing the MMPI scores for the previously described scales, a significant prevalence was seen of lower degree of self-control ability (K scale) in the ex-smoker groups compared to the NS group, and a worse adaptation (Ma scale) in ST compared to LT and NS (Table 1). The ST group shows also a trend, not statistically significant, to higher noncompliant habit (Pd scale). DISCUSSION
In the Heart Transplantation Centre in Siena, patients who are to be included in the waiting list are examined for family characteristics and lifestyle, paying attention to previous smoking habits. They are informed about the risks of tobacco smoking both on an individual basis and during group counseling before HTX. Literature is concordant about some typical psychological features of patients awaiting HTX: they are exposed to feelings of inefficacy and powerlessness, cope with a experience of impending death, and reduce their perspective for the future.2,3 Often rage, anxiety, and depression are observed in such patients, reaction symptoms to the critical clinical conditions.4 HTX represents a strong hope for life, and for this goal changes in pretransplant lifestyle are easily accepted, including smoking cessation. In the post-HTX phase, psychological
adaptation to the new situation will depend on clinical conditions, social interactions,5 coping features,4 and autoefficacy of the subject.6 Personality disturbances pre-HTx and a troubled clinical course after HTX are important factors for quality of life after transplant and can lead to a better or worse compliance.9 Our 17.6% of ex-smokers restarting abuse after HTX compares favorably with US rates (19%)10 for smokers as a whole, while the higher rate of 40% for ST is similar to that of the Tutin group of Balestroni.7 It is our opinion that LT ex-smokers who decided to stop smoking long before being considered for HTX had matured their conviction for eliminating a true risk for their own health, while the ST patients stopped tobacco abuse due to bad clinical condition and to fear of not being included in the waiting list. This shows a false change in lifestyle, one not done on a stepwise decisional basis, as recommended by Schwarzer and Fucts6 but forced by the terminal cardiac disease at high emotional value. The restarting of tobacco abuse in such patients is justified by a scarce self-control ability (K scale), by the lack of compliance to the restriction imposed by the therapeutical regimen (Pd scale), by difficult positive adaptation (Ma scale), and by self-defense mechanisms against health events. We concluded that patients who ceased smoking only a few months before being included in the waiting list for HTX, showing MMPI scale values of more than 50 for K scale and less than 50 for Ma scale, are at risk for tobacco reabuse, and require from the transplant staff a stronger and longer psychological support pre-HTX, to be prolonged after intervention.8 REFERENCES 1. Rapporto ISTAT 2001 sugli stili di vita Table 14.1. Available from www.istat.it/Banche-dat/Indicatori/04/indext.html 2. Chiesa S: II trapianto d’organo: crisi e adattamento psicologico. Psichiatria e Medicina 10:15, 1989 3. Cazzullo CL, Invernizzi G: Aspetti psicodinamici della dialisi e del trapianto renale. Minerva Chirurgica 30:877, 1975 4. Rupolo G, Poznanski C: Psicologia e psichiatria del trapianto d’organi. Masson: Torino; 1999 5. Kober B, Kuchler T, et al: A psychological support-concept and quality of life in research in a liver transplantation program: an interdisciplinary multicenter study. Psychotherapy and Psychosomatics 54:117, 1990 6. Schwarzer R, Fuchs R: Autoefficacia e comportamenti a rischio: In Bandura A (ed): II senso di autoefficacia. Aspettative su di se´ e azione. Trento; Erickson Edizioni: 1996, p 313 7. Balestroni G, Bosimini E, Centofanti P, et al: Stile di vita e aderenza ai trattamenti raccomandati dopo il trapianto. Ital Heart J Suppl 3:652, 2002 8. House RM, Trzepacz PT, Thompson TL: Psychiatric consultation to organ transplant services. Reviews of Psychiatry 9:515, 1990 9. Grady KL, Jalowiec AJ, White-Williams C: Patient compliance at one and two years after heart transplantation. J Heart Lung Transplant 17:383, 1998 10. Mosticoni R, Chiari G: Una descrizione obiettiva della personalita`. OS: Firenze; 1979