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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 84-91

Contributing factors which led to relapse of tobacco-seeking behaviour among stroke survivors, in a selected tertiary care hospital, New Delhi


1 PG Studnet, College of Nursing, AIIMS, New Delhi, India
2 Principal(actg.) College of Nursing, AIIMS, New Delhi, India
3 Department of Neurology, AIIMS, New Delhi, India
4 Department of Psychiatry and NDDTC, AIIMS, New Delhi, India

Date of Web Publication21-Jan-2020

Correspondence Address:
Dr. Sandhya Gupta
Department of Mental Health Nursing, College of Nursing, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IOPN.IOPN_32_19

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  Abstract 


Background: The outcome of treatment of stroke depends on removal of modifiable risk factors, such as stopping tobacco seeking behavior which is important factor to prevent reoccurrence of stroke. Aim: To identify contributory factors and relapse of tobacco seeking behavior among tobacco users recovering from stroke. Methodology: An exploratory, cross sectional study on 164 tobacco user post-stroke patients seeking treatment from AIIMS, New Delhi, India. Tools: A demographic data sheet, Pattern of Tobacco Use semi-structured proforma, MFTS, MF-ST Version scale, Checklist to assess factors contributing relapse of tobacco seeking behavior and NIHS scale were used for the study. Results: Mean age of post-stroke patients was 50.56±1.27 years. Slightly less than half (45%) of the patients relapsed to tobacco use post-stroke attack after initial abstinence whereas 54.87% (n=90) of the patients did not relapse to tobacco use. Most of the subjects gave some reasons of relapse like craving or uncontrollable desire. A little over one third of the patients reported symptoms such as irritability, sadness, poor concentration, constipation and non availability of tobacco cessation treatment which they reported led to their relapse of tobacco use. Most of the subjects reported that they were still not ready for enrolling in Tobacco Cessation treatment Programme (60.3%). A significant difference was found between relapse of tobacco seeking behavior with MF-ST (smokeless) scale (p<0.001) than MF-TS (smoking) scale (p<0.05). Conclusion: The prevalence of tobacco users getting attack of stroke is four times higher than non-tobacco users. Even though patients are warned by doctor to stop smoking, they continue to use tobacco and to be under risk of reoccurrence of stroke and other complications.

Keywords: Poststroke patients, quitting tobacco use, relapse of tobacco use, tobacco cessation program


How to cite this article:
Kataria N, Gupta S, Padma Srivastava M V, Jhanjee S. Contributing factors which led to relapse of tobacco-seeking behaviour among stroke survivors, in a selected tertiary care hospital, New Delhi. Indian J Psy Nsg 2019;16:84-91

How to cite this URL:
Kataria N, Gupta S, Padma Srivastava M V, Jhanjee S. Contributing factors which led to relapse of tobacco-seeking behaviour among stroke survivors, in a selected tertiary care hospital, New Delhi. Indian J Psy Nsg [serial online] 2019 [cited 2020 Jul 5];16:84-91. Available from: http://www.ijpn.in/text.asp?2019/16/2/84/276354




  Introduction Top


According to World Health Organization,[1] stroke is defined as a condition caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot (2015). The risk factors associated with stroke are nonmodifiable and potentially modifiable. The nonmodifiable factors include gender, age, race and heredity. Modifiable factors are lifestyle, habits including smoking, hypertension, diabetes mellitus, asymptomatic carotid stenosis, obesity, oral contraceptive use, physical inactivity, sickle cell disease, heart disease, atrial fibrillation, heavy alcohol consumption, hypercoagulability, and hyperlipidemia. Smokers are 1.6 times more likely to have a cerebral infarction than a nonsmoker; so, cigarette smoking is an important risk factor for cerebral infarction in young adults in USA.[2] There is also dose–response relationship between cigarette smoking and ischemic stroke risk.[3] Patients with ischemic stroke due to cranial vascular disease were at higher risk from smoking than has previously reported stroke, after smoking cessation, the relative risk declined gradually over 10 years.[4]

Need for study

No studies were published on this area in Indian setting, hence, there is need to examine this area specifically to findout the way forward for tobacco cessation in poststroke patients. The information is required on how prepare guidelines and to prevent relapse of tobacco seeking behavior and to plan for strategies for tobacco cessation for minimizing risk in poststroke patient.

Research problem

An exploratory study to identify contributing factors which led to relapse of tobacco-seeking behavior among stroke survivors, in a selected tertiary care hospital, New Delhi.


  Methodology Top


An exploratory, cross-sectional design was used for study. Setting of the study is department of neurology, tertiary care hospital, New Delhi. Study population – During the period between January 01, 2017 and December 31, 2017, 950 stroke patients were attending stroke clinic. Out of these 950 stroke patients 164 (52%) of the total tobacco user stroke patients were included. Sample – 164 patients recovering from stroke those who were ever users of tobacco and currently seeking treatment from study setting were chosen by convenience sampling technique as participants. Inclusion criteria for patient – (1) Patient who had a history of tobacco use prior to attack of stroke. (2) Patient who was having history of stroke attack at least 1 month back and were coming to Department of Neurology outpatient department from June to November 2017 for follow-up care. (3) Patient who was having 48 h of abstinence from tobacco use after stroke, came to the hospital on their own or with the help of assistance of crutches, walkers or canes, showing willingness to participate in the study, was able to understand Hindi or English language.

Ethical clearance was obtained from institutional ethics committee.

Tools

Subject datasheet for demographic profile and selected variables

A structured questionnaire was developed for the assessment of demographic profile of individuals and their tobacco use characteristics. The items included were age, gender, education, religion, marital status, occupation and income of patient and family member, number of family members, place of residence (urban and rural), presence of another smoker at home, current use of tobacco characteristics, perceived importance for intervention, and quitting attempts.

  • Tool no. 1: Modified Fagerström Tolerance Scale (MFTS) – MFTS is a standardized tool having six item tool, used to check the dependence on cigarette smoking. Patient had to give response by tick (√) mark. It yielded a minimum score from 0 to a maximum score of 10. The internal reliability (Cronbach's alpha coefficient) of the whole Modified FTS is (0.68)
  • Tool No. 2: MFTS for smokeless tobacco version scale (Modified F-ST) – MFTS for smokeless tobacco is a standardized tool having six items, used to check the dependence on smokeless type of tobacco. Responses are to be given by tick (√) mark. It yields minimum score from 0 to maximum score of 10. The internal reliability (Cronbch's alpha coefficient) of the whole modified FTS-ST is 0.68
  • Tool no. 3: Checklist – This tool was developed by researcher to assess the factors contributing to relapse of tobacco seeking behavior. It consists of 16 items. The reliability of this tool was tested by test-retest method and Crohnbach's alpha of this tool is 0.78
  • Tool no. 4: The National Institutes of Health Stroke Scale,[5] or NIH Stroke Scale (NIHSS) is a standardized tool used to check disability after stroke. The maximum possible score is 42, with the minimum score being “0.” Correlation coefficient, the κ statistic or κ coefficient is 0.92.


Validity and reliability of tool

Permission was taken from copyright authors of Modified FTS, Modified F-ST scale, and NIHSS. For tool no. 3, content validity was obtained from experts. Reliability was established by using test–retest method, for Tool no. 3 (r = 0.78).

Method of data collection

Data were collected from July to November 2017. Informed written consent was taken from the individual. Enough time was spent with the patient to establish good rapport before data collection, and data were further validated from relatives.

Data analysis

The data were analysed using SPSS 24 version (SPSS 24 Version developed by IBM, Armonk, New York, United States). The Fisher's exact test was used to find out association between relapse of tobaaco by individuals and selected demographic variables. Level of significance was setup as P ≤ 0.05.

Description of subjects

Mean age of poststroke study patients was 50.56 ± 1.27 years among study sample. Most (n = 123.75%) of the study patients were more than 45 years of age. Of 164, the 98.7% (n = 162) of the study patients were male, 35.9% (n = 59) of the study patientswere educated upto 10th class, 25.6% (n = 42) of the study patientsstudied upto 12th class whereas 19.5% (n = 32) were illiterate and 18.9% (n = 31) of the study patients upto graduation. Most (86.5%, n = 142) of the study patientsfollowed Hindu religion. Most (92%, n = 151) of the study patientswere married. Most (66.4%, n = 109) of the study patients were unemployed. Out of 164, 64 (39%) of the study patients reported the monthly family income of n = 63) of the study patients reported family income of >Rs. 10,000/- whereas 22.5% (n = 37) reported of having income of Rs. 5,000/-–Rs. 10,000/-. Most (79.2%, n = 50.6) of the study patients had six to ten members in their family. Fifty-three percent (n = 144) of the study patients live in urban area. Of 164 of the study patients, 12.20% had at least one smoker at home. One-third (39.03%) patients had smokers nearby where the study patientswas staying. Of 164 individuals, 37.1% of study patients had smoker friends with whom the patient was roaming around.

In view of the above findings, it can be interpreted that most of the study patients had stroke severity of minor stroke (1-4) on NIHSS.


  Results Top


Findings

Objective 1 – To assess the relapse of tobacco seeking behavior in tobacco users recovering from stroke.

In view of the above findings [Figure 1], it can be interpreted that slightly (45.10%) less than half of the study patients got relapsed to use of tobacco poststroke.
Figure 1: Bar graph showing relapse of tobacco-seeking behavior of study patients (n = 164)

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Objective 2 – To assess the current pattern of tobacco-seeking behavior in tobacco users recovering from stroke.

The study patients who relapsed had moderate to low level of dependence on both cigarette smoking and chewing tobacco.

Objective 3 – To identify related contributory factors for relapse of tobacco-seeking behavior among tobacco users recovering from stroke.

In view of the above findings given in [Figure 2], it can be interpreted that most of the study patients were having factors such as craving or uncontrollable desire, irritability, sadness, poor concentration, symptoms such as complaint of constipation, nonavailability of tobacco cessation treatment, loneliness, peer group or friends pressure, stressful situations such as fight at home, depression, tiredness, anxiety, performing most efficient only after taking tobacco, effect of job-related environment, situations such as crossing panwala, cigarette shop, use of alcohol, and fear of weight gain after tobacco cessation.
Figure 2: Bar graph showing factors contributing to relapse of tobacco use among individuals poststroke (n = 74)

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Objective 4 – To find the association between relapse of tobacco-seeking behavior and demographic and selected variables among tobacco users recovering from stroke. Those relapsed patients had Hindu religion, had no other smoker at home living with the patient.

As it is shown in [Table 1], most of the relapsed study patients had minor stroke severity of one to four score on NIHSS, had duration of 2–6 month for abstinence, having once in a month use of frequency of taking alcohol, had no desire to know more about tobacco cessation treatment, were not ready to join tobacco cessation treatment, and were not sure when they could join tobacco treatment.
Table 1: Association of relapse of tobacco use with clinical variables of the individuals (n=74)

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As it is shown in [Table 2], it can be interpreted that most of the study patients think intervention is very important for achieving tobacco cessation, had duration of more than 1.7 years of attack of stroke, had duration 2–6 months of abstinence, used self-help for quitting tobacco use, and had craving of tobacco; self-help alone will be helpful to quit tobacco.
Table 2: Association of relapse of tobacco use with pattern of tobacco use by individuals (n=74)

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As it is shown in [Table 3], most of the factors contributing to relapse of tobacco-seeking behaviour in individuals were craving, irritability, situations such as fight at home, peer pressure, problems such as anxiety, depression, loneliness, tiredness, use of alcohol, complaint of constipation, effect of job-related working environment, nonavailability of tobacco cessation treatment, and perform efficiently only after taking tobacco.
Table 3: Association of relapse of tobacco use by individuals with contributing factors (n=74)

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As it is shown in [Table 4], more of the relapsed study participants who have used both smoke and smokeless tobacco were having low or moderate level of dependence as compared to those who had severe dependence.
Table 4: Association of relapse of tobacco seeking behavior with extent of tobacco use by individuals (n=74)

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Major findings

  1. In the present study, 45.1% (n = 74) of tobacco users recovering from stroke relapsed to tobacco use among the study participants (n = 164)
  2. Most of the individuals gave several reasons for their relapse to tobacco use like craving or uncontrollable desire followed by little over one-third of the individuals reported irritability, sadness, poor concentration like symptoms which led to relapse. Nearly one-third of the individuals reported complaint of constipation that led to relapse of tobacco use while one fourth of the individuals reported nonavailability of tobacco cessation treatment which led to relapse of tobacco use by them. A significant association was found between relapse of tobacco use by individuals with their craving or uncontrollable desire, irritability, sadness and lack of sleep, complaint of constipation, nonavailability of tobacco cessation treatment, stressful situations such as arguments and fights at home, pressure from peer group, anxiety, depression, loneliness, tiredness, alcohol use, effect of job-related stress, and performing efficiently in job possible only after taking tobacco (P< 0.001)
  3. A significant association was found between relapse of tobacco use of individuals with not having any smoker family member living with the individual at home (P< 0.001) versus no other smoker staying with individuals (P< 0.001). Hence, there is need for giving tobacco cessation treatment within first 2 month of poststroke so that relapse to tobacco use can be prevented
  4. A significant association was found between relapse of tobacco use with those who had poststroke duration of more than 1 year and 7 months poststroke years from the time of study (November, 2017) (P< 0.02), with stroke severity score of one to five on NIHSS (P< 0.001), with 2–6 months' duration of abstinence from tobacco use poststroke (P< 0.001), with those individuals who would like to know about tobacco cessation treatment (P< 0.001), with those individuals who were ready to join tobacco cessation treatment (P< 0.001), and with those individuals who were not sure when they could join tobacco cessation treatment (P< 0.001).



  Discussion Top


In present study, it was found that there was no difference between individuals who relapsed to tobacco use with regard to their age, sex, education level, and number of cigarettes per day. This findings were similar to the findings of Nagihan Durmus¸ Koçak, Ays¸eguet al.

(2015)[6] where no significant association was found among nonrelapsed and relapsed individuals with regard to age, sex, daily number of cigarettes, and education level.

In the present study, it was found that absence of smoker at home (P< 0.004) as well as nearby (P< 0.02) was found to be associated with relapse of tobacco use poststroke by individuals. These findings are contradictory to findings of Nagihan Durmus¸ Koçak, Ays¸egu et al. (2015)[6] where the presence of another smoker in the household environment become a factor that affected relapse of tobacco use.

In the present study, no significant association of relapse of tobacco use was found with number of quit attempts made by individuals who used tobacco. These findings were contradictory to the findings of Partos et al.[7] where the number of previous failed quit attempts was reported to be a significant adverse factor for subsequent attempts to quitting tobacco.

In the present study, it was found that 45.1% (n = 74) of the individuals got relapsed to use of tobacco poststroke. Of 74 relapsed individuals, 27.43% (n = 45) relapsed to tobacco use within first 3 months' poststroke whereas 17.68% (n = 29) relapsed to tobacco use after 3 months' poststroke. These findings were similar to finding of Nagihan Durmus¸ Kocak, Ays et al. (2015)[6] where the relapse rates was 48.9% of the individuals relapsed to tobacco use within 1 month and 37.8% within first 6 months' poststroke. This finding was similar to a study done in Italy (2012)[8] where the relapse rate was 53% among stroke patients after 1-year poststroke; no smoking cessation treatment or nicotine replacement therapy was provided to the patients after discharge from hospital. This finding was similar to finding of Epstein et al.[9] where the relapse rate was 28% among patients who survived having transient ischemic attack during follow-up of 4 years and 8 months. This finding was similar to findings of Bongard et al.[10] where the relapse rates of 31% among patients post-stroke patients.

In the present study, it was found that most of the individuals had moderate or low dependence level of cigarette smoking on MFTS as well as on smokeless tobacco on Modified Fagerstrom-Smokeless Tobaccoscale. These findings were similar to Pascaul, Lledo JF, De AL Cruz, and Amoros E et al.(2006)[11] where they reported that most of individuals were having moderate dependence level of nicotine dependence.

In the present study, it was found that craving was reported as a most significant factor for relapse to individuals using tobacco poststroke. These findings were similar to findings of Dijkstra and Borland[12] where the relapse was mediated by craving and the findings of Potvin et al.[13] where impulsivity was mediated by frontocingulate mechanisms which has been linked with craving and relapse of tobacco use and the high prevalence of cigarette smoking in several psychiatric disorders that are characterized by significant levels of impulsivity.

In the present study, the individuals poststroke reported that the factors contributing to relapse of tobacco use are craving or uncontrollable desire, irritability, stressful situations like arguments and fights at home, anxiety, depression, alcohol use, pressure from peer group or friends, sadness and lack of sleep, loneliness, tiredness, and several other factors. These findings were similar to findings of Bongard et al.[10] where the habitual anger expression style may be associated with risk for smoking relapse and situational factors. These findings were similar to findings of Shiffman, et al.(2007)[14] where the most relapse crises in tobacco users was associated with anxiety, anger, and depression. One-third of the relapse crises were associated with positive feeling states of the patient and were frequently precipitated by those in the company of other smokers or having alcohol consumption; also, behavioral coping of patients was subject to situational influences that they experiences.

In the present study, a significant association was found between relapse of tobacco use with complaint of constipation (P< 0.001). These findings were similar to findings of Lagrue et al.,[15] where the complaint of constipation got relieved by transient relapse of smoking as the patient found it an effective way of dealing with constipation.

In the present study, a significant association was found between relapse of tobacco use by individuals and nonavailability of tobacco cessation treatment (P< 0.001). These finding was similar to Zhou et al.[16] where the relapse to smoking was found to be associated with craving and lack of smoking cessation aids.

In the present study, a significant association was found between relapse of tobacco use by individuals with occurance of depression (P< 0.001). These finding was similar to findings of Perez et al.[17] where the individuals who relapsed subsequent to quitting smoking after hospitalization for acute coronary syndrome had a higher level and intensity of depression. These findings were similar to the findings of Simmons et al.[18] where the relapse of tobacco use after quitting to smoking in cancer patients poststroke was found to be associated with occurance of depression in them.

In the present study, a significant association was found between relapse of tobacco use of individuals poststroke with the problem of lack of sleep (P< 0.001). This finding was similar to the findings of Boutou et al.[19] where the independent variables such as sleep disorders and midnight awakenings were associated with relapse of tobacco use, which occurs as a result of nonavailability of tobacco cessation treatment to the patients poststroke.


  Conclusion Top


Out of 164 study participants, 45.1% of the participants relapsed to tobacco use poststroke, which indicates that even though all patients were advised to stop tobacco use by treating doctor in stroke clinic, but none of the health care providers gave brief intervention for quitting tobacco use. Therefore, poststroke patients need to be enrolled for tobacco cessation treatment programme for treatment for craving, depression, anxiety, sleep disturbances, and constipation after appropriate assessments by getting consultation from psychiatric department as they have treatment facilities for quitting tobacco use. Besides advice of stopping tobacco use by patient alone, there is a need to also counsel the family of the patient to prevent passive smoking and also to give guidance regarding various tobacco-quitting services available.

Implications

Patients can use poststroke opportunity to seek more information to quit use of tobacco by tapping various sources themselves. Patients can get tobacco cessation treatment immediately poststroke so that withdrawl canbemanged efficiently and abstinence can be maintained. Nurses must assist patients for taking tobacco cessation treatment after stroke for minimizing risk and complications in future. There is need for physicians to provide brief intervention to all tobacco users irrespective of their disorder and refer for appropriate tobacco cessation treatment.

Remedial action taken

All of them were given referral to tobacco cessation clinic running in the study center after the brief intervention given to each individual by researcher to motivate the patient for quitting tobacco use.

Acknowledgment

Authors are thankful to all participants of the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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