ARTIGO ORIGINAL

The experiment of people entered into an anti-smoking program: a descriptive study

Vladimir Araújo da Silva¹, Juliana Dalcin Donini Silva¹, Carla Simone Leite de almeida¹, André Gustavo de Castro e Silva², Catarina Aparecida Sales¹, Sonia Silva Marcon¹

¹State University of Maringá
²City Hall of Maringá

ABSTRACT
Aim: To understand the experiences of people who have attempted to stop smoking by participating in an anti-smoking program. Method: A descriptive study with a qualitative approach conducted with members of an anti-tobacco program. This comprised of a semi-structured interview, and was subjected to content analysis. Results: Of the 13 subjects, four had quit smoking and nine had not. From experiences reported, three primary feelings emerged: realizing the necessity of quitting smoking; unveiling the mysteries of the process of smoking cessation; and the psychosocial implications of those who overcame their addiction. Discussion: The difficulties found by those abstaining from tobacco feature a paradox between the need to stop smoking, and the compulsive desire to continue smoking. Conclusion: The description of experiences reveals the complexity involved in quitting smoking and the importance of anti-tobacco programs, favoring the planning and implementation of these programs to increase tobacco cessation.
Keywords: Smoking; Self-Help Groups; Tobacco Use Cessation

INTRODUCTION

The World Health Organization (WHO) includes smoking in the group of ‘mental and behavioral disorders due to use of psychoactive substances’ because nicotine dependence is the central cause of addiction in long-term smokers⁽¹⁾. Shown to be the leading cause of preventable death in the world, smoking is responsible for 4.9 million deaths annually, which is the equivalent of more than 13,000 deaths per day⁽²⁾.

In Brazil, tobacco use causes around 200,000 deaths annually. Smoking is thought to be a key player in the etiology of a variety of diseases: 25% of deaths from coronary heart disease; 45% of deaths from acute myocardial infarction under 65 years old; 85% of deaths from chronic obstructive pulmonary disease; 90% of lung cancer cases; 25% of deaths from brain vascular diseases; and 30% of deaths from other cancers are thought to be due to smoking⁽²⁾.

Given the epidemiological context of the problem, the Ministry of Health (MOH), through the National Cancer Institute (INCA), coordinates the actions of the National Tobacco Control Program (PNCT). Their aim is to reduce smoking prevalence, morbidity and mortality from diseases related to tobacco through: smoking prevention; promotion of smoking cessation; protection of the health of non-smokers through a reduction in secondhand smoke exposure; and regulation of the marketing of tobacco and its related products⁽²⁾.

Therefore, its actions seek, among other things, to entice smokers to quit.

Notwithstanding, "the decision of the individual is a key factor to stop smoking, without which the commitment to change does not occur, even with family and professional support, and drug use", because, determination is required to stop cigarette use: i.e. "the drive that leads smokers to persevere in their decision to stay away from smoking, despite the adversities”^(3:3).

We also emphasize that the high prevalence of smoking is due to the fact that tobacco-related diseases are chronic; tobacco is cheap; people face difficulties when quitting smoking; nicotine dependence; and the interplay of smoking with the social, economic and cultural aspects. The physical addiction to nicotine is characterized by a difficulty in abstaining from cigarettes for a few hours, combined with an intense desire and compulsion to smoke⁽⁴⁾.

Given the above, the purpose of this study, reported below, was to understand the experiences of people who attempted to quit smoking while participating in an anti-tobacco program.

METHOD

This is a descriptive study using a qualitative approach, conducted by members of the PNCT, implemented in a Basic Health Unit (UBS) in Maringá - PR, in 2010.

PNCT is made up of a multidisciplinary team using the theoretical and methodological Cognitive-Behavioral Approach (ACC). Depending on the profile and the level of a patient’s dependency, Replacement Therapy Nicotine (TRN) can also be used. Although the program does not present rules and routines governing the specific role of each professional, all are able to use different educational and strategic actions aimed at prevention, protection and regulation of smoking cessation. The PNCT, using the manual "Stopping smoking without mysteries", helps participants to address topics such as: "Understanding why you smoke and how it affects your health"; "The first few days without smoking"; "How to overcome obstacles to remain abstinent"; and "Benefits obtained after quitting smoking"⁽⁴⁾.

At UBS above, the program was developed by a team of doctors, nurses, psychologists, nutritionists and pharmacists. The program is carried out, on average, three times per year, when there are about 12 registered patients. In 2010, there were three groups (February, May and September). Each group is divided into four weekly meetings, followed by two bi-weekly meetings and other monthly meetings⁽⁴⁾. The meetings are held on Fridays and the participation of professionals in each session depends on the program content recommended by the PNCT.

The data was collected during the months of October and November 2010, through semi-structured interviews guided by the following questions: "How long did you smoke?"; "What was the motivation that made you seek help to stop smoking?"; "Tell me about the process to quit smoking."; "What hindered and what made it easier for you could complete the steps?"; "Tell me what changed in your family life after overcoming the addiction."; and "What about the social experience?". Members of this study were enrolled in groups started in February and May 2010. The inclusion criteria were that the patient must be 18 years or older and have attended at least three meetings of program. The members were randomly selected from the program’s registration forms.

The researchers had no association with the PNCT and the UBS.

The initial contact with the participants was conducted by telephone. Interviews were previously scheduled in their homes and, after consent, were recorded and later transcribed. For the data analysis content analysis was used: a set of techniques that uses systematic and objective procedures to describe the content of the messages, enabling the researcher to understand the words and their meanings⁽⁵⁾.

The development of the study was in accordance with the Resolution of the National Health Council No. 196/96; the whole project was approved by the Standing Committee on Ethics in Human Research, State University of Maringá (Opinion No. 626/2010). All participants signed an informed consent form (ICF) in duplicate and are identified by a pseudonym: a synonym of the verb "to quit” followed by a number related the age of each member.

RESULTS

According to the records relating to the three groups enrolled at UBS in 2010, we found that 38 smokers enrolled in the program but only 32 showed up for the medical interview. Of these, 29 participated in the first session; five were already abstinent. In the second session, of the 27 participants, 13 were no longer smoking. In the third session, the groups contained 21 members; 17 had quit smoking. By the fourth session, 18 individuals had joined the group, of which 15 had quit smoking.

The 13 individuals in this study account for all of those who attended at least three meetings of the first two groups (one refused to participate). They were aged between 22 and 67 years; four of them had stopped smoking (three women and one man); and nine (six women and three men) had failed. The experiences concerning their attempts to quit smoking allowed the identification of three themes outlined below.

Realizing the necessity of quitting smoking    
The participants revealed the reasons that led them to seek help to quit smoking: expressing mixed feelings before the need to stop and the compulsive desire to continue smoking. In the transcripts of Cease, Abdicate and Leave you can comprehend that the awareness of this need arose before any physical disease resulted from exposure to tobacco, or it had an effect in family and socio-economic contexts.

I felt I already needed to quit smoking. I needed to stop it when I was already sick. I felt I was already hurting myself. (Cease, 47)

As I spent my New Year lying, unable to stand up, very bad, coughing badly, pneumonia, with a small child and another already older, I then needed to do something. That's when I decided to stop. But I did not. (Abdicate, 43)

I have to stop because it is very bad for me. I have concerns of disease already, some symptoms of tiredness, but nothing too serious. A desire to live a little longer, because only 70 years is not much. (Leave, 60)

Besides health concerns, Abstain and Intercept reported a feeling of social discrimination, perceived after the emergence of laws prohibiting the use of tobacco in public and closed places.

I was feeling broken! I was going in places then had to leave from a party, leave the room [...]. At other times, the hairdresser was a place where everybody smoked at ease [...], now you do not smoke in any environment, just outdoors, so I was feeling really bad. [I] went to a family party, had to smoke in the backyard and was there I realized I was on the sidewalk, walking from one side to the other [...]. My granddaughter will be eight years old and says: ‘Grandma, I do not like when you smoke, it smells. (Abstain, 58)

After this law, anyone who smokes is discriminated against. I've assaulted a person who discriminated me: the answer was a punch in the middle of the mouth, then later that day I said, I'll quit to end it [...]. I have to quit smoking! I tried in a way: I could not do it, and that was when I sought help. (Intercept 51)

Intercept showed in their expression and their words the outrage over their behavior to the discriminatory attitude of another person. Although not showing any symptoms that could have arisen from tobacco consumption, Suspend and Stop revealed concern about their future health: a desire to live longer with their loved ones and have a better quality of life, as shown below.

I quit smoking whilst healthy and not sick. I have kids, I want to see my kids, I want to see my grandchildren, so I decided to stop. (Suspend, 34)

To have a better quality of life. Despite that, well, I was not experiencing any health problems. [It’s] more to avoid future problems. (Stop 54)

The importance of family support when trying to overcome addiction, as well as simply being aware of the need to stop smoking and seek help, is emphasized in the language of Abandon, Interrupt and Desist.
Because of my brother, he came and said: let's try! [...] I think it is also a little willpower. And after spending that is! Ah, comes the end of the month, when money is spent up. But I have faith that I'll stop, yes. I need to stop, it's time to. (Abandon, 67).

Actually I stopped smoking because of my cousins, they forced me, not quite willingly! I think that's why, and also because of my daughter: she has allergic rhinitis. I know the dangers of smoking, but I have no shame yet. (Interrupt, 22).

I smoked for a long time and decided I wanted to stop. My daughters asked me to stop, but I said: I'll not quit smoking, I cannot. That's when this opportunity arose. (Desist, 64).

It is noticed that although families encourages smokers to seek help and participate in the program, quitting remains to be difficult.

Unveiling the mysteries of the process of smoking cessation
The interviews show the structure of the program, "Stopping smoking without mysteries", and its influence on the process of tobacco cessation. It also emphasizes the importance of therapeutic groups accompanied by medical and psychological treatment and medication (in this case, bupropion hydrochloride). Deprive and Abdicate highlight the subjectivity emerging in the period of abstinence and its interplay with the physical and psychological addictions to nicotine. This can result in difficulty quitting, even with the help of the group along with family and social support.

It was hard, complicated. I started taking the medication, but it had a bad effect on me. I could not sleep, I started to get depressed. Then I stopped the medication. I managed to quit smoking using anti-nicotine adhesive patches. Then life got busy and I did carry on. I saw a friend smoking, I said: I want to smoke only one [...] but I just quit smoking because I participated in the group. Alone I could not do it. But time is short for those when stopping is a change of habits with huge addiction. At the beginning it makes you very irritable, impatient and anxious [...]. I worked hard to not think about cigarettes. (Deprive, 48)

I was very depressed, I had all the adverse reactions of bupropion, I had everything. So I said: Ah! I'll die slowly. Then I started smoking again [...]. I think if there was a more peaceful, stable way. And another thing, if he [my husband] did not smoke, maybe it would be easier for me. (Abdicate, 43)

Is meant by Leave below that, in the company of others, and during social events or with family, where there is appreciation of cigarettes and alcohol, this can be interfering with the quitting process. Moreover, participation in groups proved vital for some, as noted in the transcripts below.
I really enjoyed participating [in the group], the testimony of people, because it is an achievement every day. My difficulty was anxiety and low self-esteem. (Restrain, 51)

If I continue with this treatment, I think I'll stop. I hope [...]. But it's worth going to the meetings. Because they advise us a lot. And it's good to talk. There are many who have left, others attend less. The bad thing is the time [of the meetings]. (Abandon, 67)

I think it was very good. I think it was useful, because they [health professionals] help so much, the conversation, the relationship that you have, an exchange of information. There are some people who already arrive there with a bad attitude, so that helps us a lot [...]. You have to cut the bad company, which has beer, because this is reason to start smoking again. It was there that I lost myself. I could have got it, but I was weak because of alcohol. (Leave, 60)

It appears in the statements below that participation in group meetings empowers individuals in their decision to quit smoking: the advice acts as a support that helps the participants and motivates them to quit smoking.

I thought it was quite useful, I met other people ... [...]. The monitoring by health professionals, which helped a lot, as well as the medication that we used [...]. The first two weeks were quite complicated; I felt a b desire to smoke. (Stop 54)

I smoked for seventeen years, there was a person [in the group] who had smoked for thirty years. I said, "It is impossible, in four sessions, for someone to stop smoking". But when I saw that I could do it ... (Suspend, 34)

The program is very good! If I could I would stay there all day. I just missed a meeting because I was sick [...]. I do not think living for away makes it difficult, because even when my foot hurts [the participant has "fish eye disease"], I take the bus and go. (Resign, 64)

Participating in the program has been good ... Too bad I do not have the time for it, because I work all day, and I'm going to school at night. (Interrupt, 22)

Reading the transcript of Intercept demonstrates that, many times, participation in the program is not sufficient to fully achieve smoking cessation:
I think you can find a lot of drugs out there, so you can become dependent. I think that only tobacco is not liable to get someone addicted in this way [...]. By participating in the program you are psychologically well, but I want to see the missing "thing" in the body. The people there guide, walk, talk, speak the pros and cons, but which, in practice, the conversation needed is another one. The body is accustomed to smoking. You quit smoking and seem to be missing something. Then you start to get nervous, anxious, aggressive [...]. Only God can help. Because it is difficult, very difficult. Addiction is bigger than me, it dominates me. (Intercept, 51)

Another difficulty reported by Abdicate and Contain refers to the psychological dependence that some individuals have:
The smoker seems that if he does not smoke, he is missing a piece of his life. It seems a disease. And increasingly doing more harm [...]. When you begin to decrease cigarette use, you seem to be missing a friend you have. So complicated. (Contain, 45)

I was sure I would never smoke again. I myself said that I wanted to hurt myself if I went back to smoking. I cried like I lost someone very dear. So, this was a very complicated relationship with cigarettes after so long. (Abdicate, 43)

Psychosocial implications in the life of those who overcame addiction
The difficulties inherent in the process of smoking cessation, after understood and overcome, can lead to improvements in a person’s quality of life, self-esteem and interpersonal relationships. Refraining from tobacco allows the individual to undergo a self-assessment of their behavior and the temporary losses resulting from the addiction, as well as to hold a better outlook on life.

I was empty, sad. I was kind of quiet, did not talk much [...]. Today when I walk by someone who is smoking a cigarette and the smoke comes near to me, it bothers me and I wonder: would I do that? [...] Now I am very certain that I'll not go back [to smoking]. But I'm in a slight depression. Nothing to change my normal life, nothing to limit me. It is not easy, but it is manageable. (Abstain, 58)

It is observed in the transcript above that because smoking (mainly cigarette smoke) can bother people who do not smoke, an ex-smoker can use this to help them continue with abstinence.

I feel that my self-esteem has improved. I solved my problems with cigarettes. Many times I stopped being me and hid behind the cigarette [...]. Sometimes my daughter arrived and I spoke: daughter, do not get close to me now that I'm smoking. My husband came and sometimes I wanted to kiss him and he would not [...]. I was bothered to annoy anyone with the smoke, the smell. Now I'm not ashamed to speak, to embrace [...]. I like myself, so I'm not coming back to smoke. (Suspend, 34)

 
A smoking habit is often a priority in the life of the smoker, serving as a shield for problems and frustrations, or as a refuge in times of trouble. However, it can sometimes come at a high price: for example, the separation of people who love each other, as pointed out by Suspend:

] The fact that I have stopped smoking has already stimulated by my wife to quit too. (Stop, 54)

Sometimes I tried to quit, it would be about an hour or two and I wanted to fight with the walls. Then I took a cigarette and started to smoke again [...]. Now, when I forget [about smoking], it is ok, but there are times that I drink a coffee [...] And again, I do not have [a cigarette] here at home. God willing, I'll get time to forget, because it's hard [...]. Now they [daughters] come [to me with], oh, what happiness ... "You can see, mom, the house is like a different place, has no cigarette smell" [...]. I do not like it when some friends come and they are smoking, but I have to live with these things. It is still very recent, [so] must be why it bothers me, but over time [I will] get used [to it] [emphasis added]. (Desist, 64)

It is highlighted that, through the interface between the family and social relationships, and the significant influence that an ex-smoker can have on their family, smoking cessation can drastically change family life.

DISCUSSION

The results show that the urge to quit smoking and the consequent search for help only occurred when individuals had already experienced some of the deleterious effects of tobacco on their physical health or their family and social relationships. Moreover, the results show the difficulties faced in trying to stop smoking, the strategies adopted to overcome them, the positive effects of smoking cessation on the lives of those who quit smoking, and the feelings experienced by those who were unable to stop smoking.

It was found, for example, that for individuals in the study, two aspects in particular sparked the desire to quit and seek help to achieve this: a health concern and a sense of social discrimination. These aspects can reinforce what has been suggested in the literature about the reasons for seeking treatment: health concerns, family pressure, medical guidance, some development of tobacco-related disease, social pressure at work, the cost of cigarettes, and religious reasons⁽⁶⁾.

Health concerns have been the subject of several anti-smoking campaigns, and the Ministry of Health, it seems, feel they have achieved their aim⁽⁷⁾. In this sense, the participants from this study highlighted the desire for a better quality of life, wanting to avoid problems that could arise from or be worsened by tobacco use.

Laws restricting a smoker’s use of tobacco may support the smoker decide to quit the habit as well as it can make smokers feel isolated and marginalized. In the past, smoking was seen as something charming, synonymous with social status and self-assertion; today it is recognized as something wrong and causes unease^(6.8).

These discriminatory feelings may be shown in the behavior of others in relation to the smoker's addiction, result in the exclusion or separation to certain environments ("smokehouses"), or marginalization resulting from the prohibition of smoking. Despite this fact, the use of tobacco in public places should be permitted according to common sense, and "there is also a moral precept equally recent for" not wanting to bother other people⁽⁹⁾. We highlight that group meetings, as recommended by PNCT, provide support for smokers who quit; however, the "motivation to kick the habit is one of the most important factors in smoking cessation and is interrelated to a range hereditary, physiological, environmental and psychological variable"^(10:595).

In this context, the family has a important role, not only acting as an incentive for the individual to seek expert help, but also to help them follow the recommendations given in the program. However, this support may become negligible if the desire to quit smoking is not from within the smoker, because "without the individual decision the process of quitting smoking does not occur... and this is associated with reflection and personal determination"^(3:447).

As a strategy to overcome some of the difficulties, participants distance themselves from other smokers, so do not participate in family gatherings and social events. Consider, however, that social isolation may not be beneficial for someone trying to overcome an addiction. It is in this context that the interviewees saw the advantage of joining the group, as they feel supported. Group therapy promotes interaction between people and facilitates the sharing of emotions, functioning as an outlet through which experiences about the difficulties and challenges can be communicated between participants. This approach, as used by health professional, can strengthen the decision to quit smoking⁽¹¹⁾.

A further difficulty faced when trying to quit smoking is an inability to attend group meetings. In fact, many smokers stopped attending, or did not start treatment at all in a UBS, citing a lack of time due to work and a clash with the opening hours of the service. These aspects, therefore, need to be discussed with individuals wanting to stop smoking because a smoker could be seen by a health team nearer to their home, giving the person support and helping them quit.

Psychological dependence was mentioned as another factor that makes quitting harder, and is related to the place that cigarette smoking has in life, observed especially when a cigarette is consumed in times of stress or euphoria. The person feels sad at the thought of quitting smoking, the "loss of a companion", because the act of smoking has associations of behaviors linked to individual and social habits, such as drinking coffee⁽⁴⁾.

From this perspective, to remain abstinent ex-smokers need to feel the benefits of stopping smoking, receiving compliments about their decision to quit, and about their appearance after the rejection of the addiction. This emphasizes that smoking cessation can increase self-esteem and improve their personal appearance, quality of living conditions, physical endurance, and appreciation of life⁽⁸⁾. For these reasons, the ex-smoker begins to feel better in every aspect of their life: physical, psychological and social. However, as the habits and rituals of smoking are stopped, individuals can begin to experience a sense of emptiness, highlighting the importance of strategies that replace this feeling for other activities that are also pleasurable. Therefore, health professionals have an important role in this step as they can help people discover which activities are best suited for them, treating each patient as unique.

Finally, another difficulty mentioned was the presence of symptoms related to abstinence, or adverse reactions to the drugs used. It should be noted that, besides the ACC group, the program also provides, in defined situations, nicotinic and non-nicotinic drug use. For the treatment of an abstinence crisis, characterized by desire (an uncontrollable desire to smoke), tension, tingling of limbs, irritation, sadness, dizziness and frustration⁽⁴⁾, non-nicotinic drugs such as bupropion are offered⁽⁴⁾. However side effects such as dry mouth, constipation, insomnia, dizziness, headache, abdominal pain, hives and rash can occur. These are usually controlled by adjusting the drug dose without requiring the discontinuation of treatment⁽¹²⁾.

However, if these side effects are present and not identified and controlled by the health team, patients may stop the therapy. Therefore, the staff involved in the program must assess participants in the program during the medical management so that its use does not pose a further problem to the individual who is trying to quit smoking.

In our evaluation of the knowledge, skills and abilities of nurses, we found there is a lack of rules and routines that define their specific function in the program. The results of the study indicate that the PNCT may constitute an important area for the improved performance of nurses. Nurses can perform individual monitoring of group participants, discussing the problems faced by each participant during tobacco abstinence, helping them discover strategies to quit, and help to implement, together with the individual and their family, an individualized care plan that will help to manage their symptoms. Additionally, they can also act to prevent of disease among at-risk groups through health promotion⁽¹³⁾.

We would like to emphasize that the results of this study indicate the need for monitoring and evaluation of actions taken in smoking cessation programs, as already reported in another study⁽¹⁴⁾: at first sight the results of PNCT were very promising. However, as we approached participants who had completed the program, we realized that many revealed that they had returned to smoking and would not participate in the study. There were others who agreed to participate and showed during the interviews how difficult it is to stay abstinent. When faced with everyday problems, they relapsed. Such incidents show the need to conduct an assessment of the effects of the program sometime after the end of the group sessions, since there are already studies showing that approximately 43% of ex-smokers eventually resume their addiction at the end of a smoking cessation program⁽⁶⁾.

CONCLUSION

The deleterious effects of tobacco may be realized in different contexts: effects related to family; health, aging and quality of life; the physiological changes resulting from addiction; the cost of cigarettes; and marginalization in society. These all converge to help the smoker decide it is time to quit smoking and seek help.

The importance aspects of the anti-tobacco program, as highlighted in our initial interviews, were the multidisciplinary care; sharing of experiences, feelings and perspectives in group meetings; and medical therapy. These can increase a person’s confidence in the program over other previous unsuccessful attempts to quit.

Of the users of the program who failed to quit, they explain this due to the physical and psychological dependencies they have to tobacco, as well as factors such as the presence of another smoker in their family or social life, adverse reactions of drugs, unemployment, financial instability, and difficulty in finding time for the group meetings.

It is evident, therefore, that smoking cessation is very complex, especially in the first weeks, and can trigger significant emotional changes. Mixed feelings are experienced, ranging from the compulsive desire to feel the lips touching the cigarette, to depression. This justifies the relevance of addressing coping strategies for stress and any abstinence syndrome experienced during the program. Nevertheless, to negate these feelings, there is often an increase in the patient's self-esteem and an improvement in interpersonal relationships because the individual becomes a positive influence on people around them in the anti-tobacco program.

Therefore, this study supports the planning and implementation of anti-tobacco programs. It should be noted that there are many trained professionals, but actually too few that offer to meet the significant demands of smokers. With regard to the ignorance of the side effects of drugs using in cessation programs, as revealed by participants, we reiterate the need for special attention on the subject during interviews and group meetings.

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Vladimir Araújo da Silva, Juliana Dalcin Donini Silva, Carla Simone Leite de Almeida e André Gustavo de Castro e Silva, had an active contribution in the project design, data collection, analysis and interpretation of data, discussion and review of the final content of the manuscript. Catarina Aparecida Sales e Sonia Silva Marcon contributed to the guidelines in developing the research, analysis and discussion of results, as well as reviewing the final manuscript for publication.

Received: 27/08/2011
Approved: 19/09/2012