Cognitive changes in cardiovascular patients following a tailored behavioral smoking cessation intervention

Abstract

Background

Action aimed at changing smoking behavior to prevent cardiovascular patients from further impairing their health is advisable. Cognitive behavioral interventions can be effective in this regard since they attempt to influence cognitive determinants that presumably lead to smoking cessation. The Minimal Intervention Strategy for Cardiology patients (C-MIS) is such an intervention, tailored to the patients' readiness to change. Our aim is to investigate whether the C-MIS is successful in changing patients' cognitions such as attitudes, social influence, self-efficacy and intention to quit during a 1-year period.

Methods

Smoking outpatients (N = 315) with cardiovascular disease were included. They were randomized and received either Nicotine Replacement Therapy (NRT) or NRT + C-MIS. At baseline (T1), sociodemographic and clinical characteristics were measured. Cognitions and quitting behavior were assessed at baseline and at four follow-up measurements.

Results

Comparing treatments, the C-MIS did not affect pros of quitting, pros of smoking and social influence. We did find small effects of the C-MIS on intention to quit and self-efficacy, although only for higher-educated patients.

Conclusion

The C-MIS appears successful in affecting intention to quit and self-efficacy abilities, but only for patients with higher education levels. Initial positive changes in cognitions may also emerge in a medical intervention, such as the provision of NRT.

Introduction

Smoking is related to an increased risk of sudden death, myocardial infarction, peripheral vascular disease and stroke [1], [2], [3]. In patients with cardiovascular disease, the risk of a new acute cardiovascular event declines substantially when they quit smoking [4]. Therefore, action aimed at changing smoking behavior in order to prevent cardiovascular patients from further impairing their health is advisable. Numerous studies [5], [6], [7] have shown that the use of theory-based behavioral interventions to establish smoking cessation can be effective, although such studies within cardiovascular patients are still scarce [8], [9].

Frequently applied behavioral interventions are largely based on comparable social cognitive approaches that assume that smoking behavior can be changed by influencing one or more of the underlying cognitive determinants. Social cognitive theories like the Theory of Reasoned Action [10], the expanded Theory of Planned Behavior [11], and the Attitude, Social Influence and Efficacy (ASE) model [12] postulate that behavior can be predicted by behavioral intention, which in turn is influenced by proximal cognitive determinants. Although these models emphasize slightly different proximal determinants and operationalizations sometimes differ, they have three main cognitive dimensions in common: attitudes, perceived social influences and self-efficacy expectations [13]. Attitude can be described as an expression of a person's expected positive (pros) and negative (cons) outcomes of performing a given behavior. Social influence refers to the influence a person receives, concerning the behavior, from his or her direct environment, and self-efficacy refers to a person's judgment of his/her capability to perform a certain behavior.

These cognitive determinants have shown to be important factors in the explanation and prediction of behavioral intentions and smoking behavior [14], [15], [16], [17]. Godin et al. [14], for instance, verified the basic assumptions underlying the theory of planned behavior for the prediction of cigarette smoking, intention and smoking behavior among adults. They found that self-efficacy, attitudes and social influence predicted intention, whereas self-efficacy predicted behavior. Also, Dijkstra and De Vries [18] examined the extent to which self-help interventions change specific cognitions and the extent to which changes in such cognitions are related to behavioral changes. They reported that some types of information lead to specific cognitive changes, while other types have more generalized cognitive effects. They also found that different cognitive changes were related to different types of quitting activity.

An example of a theory-based behavioral intervention, which has been applied to cardiac patients, is The Minimal Intervention Strategy for Cardiology patients (C-MIS), which is tailored to the patients' readiness to change [19], [20], [21]. Since the C-MIS attempts to change patients' cognitions in order to achieve smoking cessation, the extent to which cognitions are indeed affected is of interest. Do cognitions change and if so, do altered cognitions remain changed or will they relapse to their former level after a short or longer period of time? This information is important for improving and/or adapting elements of the applied intervention, and theory-based behavioral interventions in general.

Most researchers studying smoking cessation in cardiac and cardiovascular patient groups are mainly interested in (cognitive) predictors of quitting behavior [20], [22], [23], [24], [25], [26], [27] or in the effectiveness of a particular smoking cessation intervention in terms of the number of quitters [19], [20], [28]. When cognitive or behavioral change in cardiovascular patients is measured, researchers particularly report about transitions in intentions or stages of change (e.g., from pre-contemplation to contemplation), and not about all single cognitions underlying intentions and stages [29], [30]. Furthermore, changes in intentions and/or stages are mostly examined at one single follow-up measurement only, for instance, at 3 or 6 months after an intervention in combination with abstinence measures [7], [26], [27], [28], [31], [32], [33], [34].

There is little literature about the development of cognitions over time as a result of a cognitive behavioral intervention. With regard to smoking cessation, we identified only two studies. Gibbons and colleagues [35], [36] examined smoking-relevant health-risk perceptions among smokers before, during and after a quit attempt. However, both studies mainly addressed the cognitive changes that occurred after smoking relapse and neither study addressed the full range of proximal cognitive predictors of intention and behavior: the pros of quitting, pros of smoking and self-efficacy.

In this article, we used five consecutive measurements to investigate the extent to which cognitions in cardiovascular patients change during a 1-year period as a result of a behavioral tailored smoking cessation intervention. Furthermore, we examine whether cognitive change is influenced by sociodemographic, clinical and/or behavioral factors.