Short-Term Effects of Using Pedometers to Increase Daily Physical Activity in Smokers: a Randomized Trial

Short-Term Effects of Using Pedometers to Increase Daily Physical Activity in Smokers: A Randomized Trial

Deme´tria Kovelis PT, Juliana Zabatiero PT, Karina Couto Furlanetto PT, Leandro Cruz Mantoani PT, Mahara Proenc¸a PT, and Fabio Pitta PhD

BACKGROUND: In adults it is recommended that the minimum of 10,000 steps/day should be performed in order to consider an individual as active. The pedometer, a small device that counts steps, has been used to monitor and/or motivate physical activity in various populations. OBJEC- TIVE: To investigate the short-term effects of a protocol using a pedometer or an informative booklet to increase daily physical activity in apparently healthy smokers who reached or did not reach the minimum public health recommendation of 10,000 steps/day. METHODS: Subjects were who wore a pedometer every day ,(23 ؍ randomly assigned to 2 groups: group pedometer (GP, n who received ,(17 ؍ during 1 month, aiming to achieve 10,000 steps/day; and group booklet (GB, n a booklet with encouragement to walk as much as possible in everyday life. Each group was subdivided according to their baseline daily physical activity level: active (subjects who achieved 10,000 steps/day), and inactive (those who did not achieve this minimum). RESULTS: Only the physically inactive GP increased significantly its daily physical activity (pre vs post 7,670 [6,159– 9,402] steps/day vs 10,310 [9,483–11,110] steps/day, P < .001), with a concomitant increase in the 6-min walking test (6MWT) distance (mean and interquartile range 540 m [501–586 m] vs 566 m In GP, ⌬ post-pre steps/day correlated significantly with baseline number .(03. ؍ m], P 604–525] but not with 6MWT. In the inactive subjects (summing GP and ,(01. ؍ ؊0.63, P؍ of steps/day (r GB), there were significant correlations between steps/day and cigarettes/day, pack-years, and -؊0.55, ؊0.40, and ؊0.59, P < .05 for all). Furthermore, improve؍ Fagerstro¨m questionnaire (r ment in steps/day in the inactive subjects of GP was correlated with baseline cigarettes smoked per -and 0.53, P < .05 for all). CON 0.65 ,0.51 ؍ day, pack-years, and Fagerstro¨m questionnaire (r CLUSIONS: Physically inactive smokers improve their daily physical activity level by using a simple tool (pedometer), and larger improvement occurs in subjects with the lowest levels of physical activity. Key words: smoking; motor activity; locomotion; pamphlets. [Respir Care 2012;57(7): 1089–1097. © 2012 Daedalus Enterprises]

Introduction of preventable death by the World Health Organization.1 Associated with smoking, physical inactivity also has an Smoking is the cause of high rates of morbidity and mortality worldwide, and is considered the leading cause te´rio da Sau´de, Brazil. Couto Furlanetto PT was supported by Conselho Nacional de Desenvolvimento Científico e Tecnolo´gico, Brazil.

Dr Pitta presented a version of this paper at the Annual Congress of the The authors are affiliated with Laborato´rio de Pesquisa em Fisioterapia European Respiratory Society, held September 18–22, 2010, in Barce- Pulmonar, Departamento de Fisioterapia, Universidade Estadual de Lon- lona, Spain. drina, Londrina, Parana´, Brazil. Ms Proenc¸a is also affiliated with Labo- rato´rio de Estudos do Aparelho Muco-Secretor, Programa de Mestrado Correspondence: Fabio Pitta PhD, Departamento de Fisioterapia, Uni- em Fisioterapia, Departamento de Fisioterapia, Universidade Estadual versidade Estadual de Londrina, Rua Robert Koch, 60 Vila Operaria, Paulista, Presidente Prudente, Sa˜o Paulo, Brazil. Londrina, Parana´, 86038–440 Brazil. E-mail: [email protected].

This research was partly supported by Fundac¸a˜o Arauca´ria/Parana´, Minis- DOI: 10.4187/respcare.01458

RESPIRATORY CARE • JULY 2012 VOL 57 NO 7 1089 SHORT-TERM EFFECTS OF USING PEDOMETERS TO INCREASE DAILY PHYSICAL ACTIVITY IN SMOKERS important role in the development of high morbidity and mortality rates. The concept that regular physical activity QUICK LOOK can prevent or delay the onset of various chronic diseases Current knowledge has solid scientific support.2 Therefore, the combination of physical inactivity and smoking generates deleterious A pedometer can be used to monitor and motivate physical activity in patients with cardiorespiratory disease. health effects. This was well illustrated by Garcia-Aymerich An active subject is defined as someone achieving a et al,3 who showed that regular physical activity in smok- minimum of 10,000 steps per day. ers is associated with less pronounced decline in lung function over time, and consequently a lower risk for devel- What this paper contributes to our knowledge opment of COPD. Physically inactive smokers may improve their daily Recently, reduction of physical activity in daily life, as physical activity level by using a pedometer. Subjects well as the factors that influence this reduction, has been with the lowest level of physical activity may have the the object of study in several populations.4-8 In adults it is largest improvement with use of the pedometer. recommended that at least 30 min of daily moderate physical activity is necessary to maintain physical fitness,2 or that a minimum of 10,000 steps/day should be achieved to consider an individual as physically active.9 Since quan- activity and changes in exercise capacity, nicotine depen- tification is imperative, the use of motion sensors has been dence, and smoking habits after the intervention. recommended in order to obtain an accurate assessment of daily physical activity. Motion sensors are instruments used Methods to detect body movement and consequently quantify phys- Recruitment, Study Design, and Subjects ical activity in daily life for a period of time in an objective manner.10 Among these instruments, pedometers stand out; Seventy-six smokers were recruited by the current re- they are simple, small, low cost, and easily applicable searchers, through advertisements in the media, buses, and devices that count an individual’s steps in a given period health centers. The announcement invited asymptomatic of time.11 Pedometers have been used not only to monitor or mildly symptomatic smokers, over 18 years old and of the individual’s number of steps in daily life,12 but also as both sexes, to participate in a program of physical activity a motivational tool for increasing physical activity of sev- promotion. eral populations.13-17 Inclusion criteria were: current smokers (regardless of In recent years the scientific literature showed some duration of smoking) over 18 years old, of both sexes, studies concerning promotion of regular physical activity normal spirometry (ie, without spirometric alterations), and 18,19 18 in smokers. The study by Green et al concluded that absence of pathological conditions that could influence the social initiatives can be successfully applied to increase performance of physical activities in daily life (eg, cere- physical activity, along with reduction of tobacco use. brovascular, rheumatic, or orthopedic disease). Exclusion 19 Prochaska et al, in a randomized controlled trial, con- criteria were: inability to understand or cooperate with the cluded that physical activity promotion in addition to a application of questionnaires and other tests, and failure to smoking cessation program was associated with increased attend the final evaluation. The study was approved by our daily physical activity levels and to persistence of smoking Ethics Committee in Research, and data were collected abstinence in individuals who stopped smoking. However, from June 2008 to April 2010 at our research laboratory. in smokers there are still no studies that have compared All subjects gave formal consent to participate in the study changes in daily physical activity levels obtained by dif- by signing an informed consent term prior to their inclu- ferent motivational interventions, such as encouragement sion. to increase the number of steps/day using pedometers and In a longitudinal design, the included smokers were informative booklets. submitted to a series of assessments immediately before Furthermore, it is unclear whether physically inactive and immediately after the completion of a 1-month proto- smokers have more substantial increases in daily physical col that aimed to increase their daily physical activity by activity after intervention, in comparison to already phys- using pedometers or informative booklets. Both before and ically active smokers. Therefore, the purpose of this study after the protocol, the tests included lung function (spi- was to analyze the effects of a motivational protocol to rometry), functional exercise capacity (6-min walking test increase daily physical activity using pedometers or infor- [6MWT]), nicotine dependence, and smoking habits, be- mative booklets in smokers, achieving or not the minimum sides the quantification of daily physical activity with a recommendation of 10,000 steps/day. Secondarily, it aimed pedometer (steps/day). The methodology involved in the to study the relationship between changes in daily physical tests is described in more detail below.

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After the initial assessment, subjects were randomly di- value was used for analysis. The reference values were vided through blocks of 10 opaque concealed envelopes those from Gibbons et al.23 into 2 groups: group pedometer (GP, n ϭ 39) and group booklet (GB, n ϭ 37). Allocation and random sequence Assessment of Physical Activity in Daily Life were generated by a researcher not involved in the present study, whereas assignment to the interventions was done The individual level of daily physical activity was as- by the current researchers. GP subjects were instructed to sessed through 6 days of monitoring with a pedometer, use a pedometer daily for a 1-month period in order to from Sunday to Friday. The subjects were instructed to achieve the minimum of 10,000 steps/day as a target. Sub- reset the device and place it at the waist just after waking jects were also instructed to record the number of daily up, and remove it just before bedtime. In addition, subjects steps achieved by the end of each day, as well as any were also instructed to remove the device only when bath- information they judged necessary about their daily phys- ing or when extremely necessary, and not to manipulate ical activity. The accuracy of all pedometers was tested the buttons or any other part of the instrument at any time prior to the study onset. GB subjects received a booklet during the day, at risk of losing data. Concomitantly with highlighting information about the benefits of walking reg- the pedometer, subjects received a diary in which they ularly and encouragement to walk as much as possible in reported the time they started using the device in the morn- daily life, however, with no written control of their phys- ing, the time in the evening that they removed it, and the ical activity. The booklet also contained information about number on its display at the time. In the diary, the subject the dangers of smoking. It was self-explanatory, with some also reported if the pedometer was removed during the drawings, pictures, and simple tips on how to increase day, for how long, and why. According to the diary data, physical activity in daily life, such as: taking the staircase the number of steps/day was obtained, and the daily phys- instead of the elevator; giving preference to walk rather ical activity level was determined by the average of the than drive when shopping or going somewhere closer to 6 days of assessment. Pre-protocol assessment was per- home; walking the dog more often; taking advantage of formed in the week immediately before initiation of the spare time and weekends not only to rest but also for 1-month period. Post-protocol assessment consisted of ei- walking and hiking, instead of sitting in front of the tele- ther the last week of the 1-month period in GP or the first vision for a long time. The procedure of delivering the week after the 1-month period in GB. booklet included reading only parts of the pamphlet where The pedometer used was the Yamax Digiwalker SW- the importance of physical activity was highlighted, but as 200 (Yamax, Tokyo, Japan), which has been extensively happens in most motivational booklets, subjects were in- tested by several authors and has been considered one of structed to read on their own during the period of one the most reliable pedometers on the market.24,25 month and turn the tips into proposals of change of daily habits. Smoking Habits In order to stratify the included subjects according to their level of physical activity in daily life, the baseline Subjects were questioned about their basic smoking hab- number of steps/day was used to divide the subjects of its (ie, time since they initiated smoking, and number of both GP and GB into 2 subgroups: physically active (sub- cigarettes/day). From these data the number of pack-years jects who achieved a daily average of 10,000 steps in the was calculated (multiplying the number of total years of initial assessment) and physically inactive (subjects who smoking by the number of packs smoked per day). did not achieve this daily average). The degree of nicotine dependence was assessed by the Fagerstro¨m Tolerance Questionnaire.26,27 It is an easily Lung Function Assessment (Spirometry) understood and quickly applied instrument, and consists of 6 items. The test score allows the classification of nicotine Simple spirometry was performed according to the Amer- dependence into 5 levels: very low (0–2 points), low (3–4 ican Thoracic Society and European Respiratory Society points), moderate (5 points), high (6–7 points), and very guidelines.20 The device used was the Spirobank G (MIR high (8–10 points). —Medical International Research, Rome, Italy), and reference values were those from the Brazilian population.21 Statistical Analysis

Functional Exercise Capacity Assessment The primary outcome of the study was the number of steps/day. Secondary outcomes included lung function vari- The 6MWT was carried out according to international ables, 6MWT, and smoking habits. standards22 in a 30 meter corridor. Two tests were per- Statistical software (GraphPad Prism 5.0, GraphPad Soft- formed, with at least 30 min of interval, and the highest ware, San Diego, California) was used. Due to the rela-

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Fig. 1. Overview of the study.

tively small sample size, nonparametric statistical analysis Table 1. Characteristics of the Study Groups was performed, and results are presented as median and Group Pedometer Group Booklet interquartile range. For intra-group analysis (pre and post- P protocol), the Wilcoxon signed-rank test was used. Com- (n ϭ 23) (n ϭ 17) parisons between groups were performed using the Mann- Age (y) 51 (44–56) 52 (45–57) .55 Whitney test. Correlations were evaluated using the Male/female 8/15 10/7 .22 Spearman correlation coefficient. Comparison between the BMI (kg/m2) 24 (22–28) 26 (23–31) .27 number of drop-outs and male/female subjects in each FEV1/FVC 80 (76–85) 81 (74–86) .91 group was performed with the Fisher exact test. Compar- (% predicted) isons of proportions taking into consideration the occupa- Cigarettes/day 20 (16–20) 20 (17–35) .19 Pack years 35 (19–64) 34 (17–43) .78 tional status and the improvement in physical activity were Fagerström (0–10) 5 (5–7) 5 (3–7) .66 performed with the chi-square test. All tests had a signif- 6MWT (m) 542 (501–593) 566 (525–612) .28 Յ icance level of P .05. 6MWT 80 (74–88) 82 (76–88) .52 (% predicted) Results Steps/Day 9,346 (7,158–11,800) 8,779 (,5749–11,020) .85

Values are presented as median (interquartile range), except male/female, which are presented Sixteen GP and 20 GB subjects did not complete the as number. study. The study flow chart (including the reasons for BMI ϭ body mass index 6MWT ϭ 6-min walk test distance dropping out) is described in Figure 1. Therefore, the final Fagerström ϭ Fagerström Tolerance Questionnaire for nicotine dependence assessment consisted of 23 individuals in GP and 17 in GB. The proportion of drop-outs in the 2 groups (GB 54% and GP 41%) was not statistically different (P ϭ .35). described in Table 1. Occupational status of the sample There was no significant difference between GP and GB was as follows: 7.5% (3) of the participants were retired, in the baseline assessment. The groups’ characteristics are 5% (2) were students, 15% (6) were housewives, and 72.5%

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Table 2. Comparison Between the Subdivision of Group Pedometer and Group Booklet in Physically Active and Physically Inactive Subjects

Group Pedometer Group Booklet

Active Inactive P Active Inactive P (n ϭ 8) (n ϭ 15) (n ϭ 8) (n ϭ 9) Age (y) 51 (36–51) 51 (48–58) .53 53 (46–55) 51 (43–59) .81 Male/female 6/2 9/6 .66 4/4 3/6 .64 BMI (kg/m2) 22 (21–25) 25 (24–28) .09 25 (23–26) 29 (23–34) .20

FEV1/FVC (% predicted) 77 (74–81) 81 (77–87) .17 81 (77–85) 80 (73–86) .74 Cigarettes/day 20 (20–25) 20 (12–25) .35 20 (14–30) 30 (18–40) .20 Pack years 35 (19–64) 34 (18–47) .83 34 (17–43) 27 (21–76) .67 Fagerström (0–10) 6 (5–7.5) 6 (5–7.5) .19 5 (2.5–7) 5 (3.5–7.5) .54 6MWT (m) 554 (517–600) 540 (501–586) .63 563 (511–607) 566 (526–625) .74 6MWT (% predicted) 83 (75–88) 79 (74–86) .74 82 (78–89) 82 (75–82) .89 Steps/day 12,330 (10,990–12,640) 7,670 (6,159–9,402) Ͻ .001 11,020 (10,830–12,670) 5,982 (3,770–7,971) Ͻ .001

Values are presented as median (interquartile range), except male/female, which are presented as number. BMI ϭ body mass index 6MWT ϭ 6-min walk test distance Fagerström ϭ Fagerström Tolerance Questionnaire for nicotine dependence

(29) worked mostly at administrative tasks, sales staff, and technical jobs, at a variety of companies and public institutions, such as retail shops, schools, banks, and health institutions. When comparing the proportion of formally employed workers versus non-workers (retired, students, and housewives) between the groups GP and GB, there was no significant difference (workers in GP 74% [17 out of 23] and in GB 82% [14 out of 17], P ϭ .47). No participant changed his/her occupational status during the Fig. 2. Comparison between number of steps/day pre and post protocol in the physically active and inactive subgroups of group period of the study. When taking into consideration the pedometer. worker/non-worker status and the presence/absence of improvement in physical activity in daily life in both groups (GP and GB) and in the whole group, no statistical differ- change in the number of steps (⌬ steps/day) between GP ence was found. active and inactive subgroups showed a statistically sig- Out of the 23 smokers included in the GP, 8 were clas- nificant difference (Ϫ257 [–1,061 to –934] steps/day vs sified as physically active and 15 as inactive according to 2,019 [1,676–4,415] steps/day, respectively, P ϭ .001). the baseline assessment of physical activity in daily life. These values are equivalent to a 2% average reduction in The only difference between the physically active and in- steps/day in the active subgroup and a 26% average inactive subgroups in the GP was the number of steps/day crease in the inactive subgroup. (P Ͻ .001), with no other baseline differences. Out of the Also in the GP, 100% of subjects initially classified as 17 smokers included in the GB, 8 were classified as phys- ϭ ically active and 9 as inactive according to the baseline inactive (n 15) showed an increase in the number of ϭ assessment of physical activity in daily life. Once again, steps/day after the protocol, and 53% (n 8) exceeded the the only difference between the physically active and in- target of 10,000 steps/day initially proposed, while another ϭ active subgroups was the number of steps/day (P Ͻ .001), 27% of them (n 4) reached at least 9,500 steps/day (ie, Ͻ with no other baseline differences (Table 2). they reached a difference of 5% of the target). In the GP the physically active group showed no sig- In GB the physically active group showed no significant nificant change in the number of steps/day after the pro- change in the number of steps/day (pre vs post 11,020 tocol (12,330 [10,990–12,640] steps/day vs 12,010 [10,830–12,670] steps/day vs 12,180 [11,490–14,120] [10,610–12,950] steps/day, P ϭ .84). On the other hand, steps/day, P ϭ .64). The physically inactive group also the physically inactive group showed a significant increase showed no significant change in the number of steps/day in the number of steps/day after the protocol (7,670 [6,159– after the protocol (5,982 [3770–7971] steps/day vs 6,848 9,402] steps/day vs 10,310 [9,483–11,110] steps/day, [3,415–9,346] steps/day, P ϭ .16). The ⌬ steps/day be- P Ͻ .001), as shown in Figure 2. The post-pre protocol tween GB active and inactive subgroups showed no sta-

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very high dependence, 30% moderate, and 22% low and very low). No significant decrease was found in the number of cigarettes smoked per day after the protocol in GP (pre vs post 20 [16–20] cigarettes/day vs 20 [12–20] cigarettes/day, P ϭ .15), as well as in GB (20 [17–35] cigarettes/day vs 20 [15–30] cigarettes/day, P ϭ .31). There was no significant correlation between steps/day and the level of nicotine dependence (cigarettes smoked per day, pack-years, and Fagerstro¨m Tolerance Question- naire) in the whole group of smokers (n ϭ 40) at baseline. For further sub-analysis, we added together the active subjects from both GP and GB (n ϭ 16) and inactive subjects from both GP and GB (n ϭ 24), also at baseline. In active subjects there was no significant correlation between steps/ Fig. 3. Correlation between protocol post and pre changes in steps/ day and level of nicotine dependence (r Ͻ 0.13 and P Ͼ .50 day (⌬ steps/day) and baseline (ie, pre-protocol) number of steps/ for all). On the other hand, in the inactive subjects, there day in the physically inactive subgroup of group pedometer (r were significant correlations between steps/day and ciga- ϭϪ0.63, P ϭ .01) rettes smoked per day, pack-years, and Fagerstro¨m questionnaire (r ϭϪ0.55, Ϫ0.40 and Ϫ0.59, P Յ .05 for all). Furthermore, improvement in steps/day in the inactive subjects of GP (the main target population of the intervention) was correlated with baseline cigarettes smoked per day, pack-years, and Fagerstro¨m questionnaire (r ϭ 0.51, 0.65, and 0.53, P Յ .05 for all).

Discussion

Fig. 4. Comparison between 6-min walking test (6MWT) values pre The present study showed that the pedometer, a simple and post protocol in the physically active and inactive subgroups and relatively inexpensive step counter, can be effectively of group pedometer. used to promote the increase of daily physical activity in apparently healthy but physically inactive smokers. More- tistically significant difference (844 [–924 to 2,181] steps/ over, a negative relationship was observed between base- day vs 866 [–524 to 2,790] steps/day, respectively, P ϭ .89). line physical activity and post-protocol change, showing In the GP physically inactive subgroup there was a sig- that the subjects who benefit the most from pedometer use nificant negative correlation of ⌬ steps/day with the base- as a motivational factor are those with lower levels of line number of steps/day (r ϭϪ0.63, P ϭ .01, Fig. 3). In physical activity. Since no participant changed his/her oc- the GB physically inactive subgroup there was no signif- cupational status during the study period, it is likely that icant correlation of ⌬ steps/day with any baseline out- the improvement in steps/day derives indeed from the pe- come. dometer’s motivational role. These findings yield impor- In GP there was a significant increase of 6MWT in the tant clinical implications, since the use of pedometers is a physically inactive subgroup (pre vs post 540 [501–586] m relatively simple and promising therapeutic option to coun- vs 566 [525–604] m, P ϭ .03) (Fig. 4). The improvement teract the disastrous combination of smoking and physical in the 6MWT did not correlate significantly with ⌬ steps/ inactivity, and can be used in comprehensive public health day in this same group (r ϭ 0.28, P ϭ .30). There was no campaigns. Since the use of pedometers does not primarily improvement of the 6MWT in the GP physically active aim at smoking cessation, a combined intervention of pe- subgroup (554 [517–600] m vs 582 [475–622] m, P ϭ .31). dometers with a smoking cessation program involving In GB the 6MWT also increased only in physically inac- counseling and pharmacologic treatment can further en- tive subjects (566 [526–625] m vs 600 [558–647] m, hance the beneficial effects of this instrument. P ϭ .004), but not in the physically active ones (563 Prochaska et al19 aimed at using the increase in physical [511–607] m vs 580 [510Ϫ658] m, P ϭ .15). activity as an adjunct factor to smoking cessation, and a Regarding smoking habits, the majority of smokers pre- small subgroup of their sample used the pedometer with sented moderate to high nicotine dependence in the GP the objective of motivating subjects to increase their num- (47% high and very high dependence, 6% moderate, and ber of steps/day. In fact, a 16% average increase in daily 47% low and very low) as well as in GB (48% high and physical activity was observed in this subgroup. However,

1094 RESPIRATORY CARE • JULY 2012 VOL 57 NO 7 SHORT-TERM EFFECTS OF USING PEDOMETERS TO INCREASE DAILY PHYSICAL ACTIVITY IN SMOKERS despite these promising results, a characteristic of this study would have a considerably higher cost, which could hinder was the fact that the studied subjects were also receiving the implementation of this protocol as a public health strat- pharmacologic treatment for smoking cessation, and there- egy. One of the most important implications of this study fore it cannot be determined if the daily physical activity is precisely the fact that a simple and low cost tool can increase was due to the use of pedometers, the smoking provide a significant increase in daily physical activity in cessation itself, or a combination of both factors. More- subjects at high risk, such as physically inactive smokers, over, according to the same study, the profile of the pa- which allows the application of comprehensive interven- tients who effectively benefit from the pedometer use in tions and tangible short-term benefits in terms of public order to increase physical activity could not be identified. health. The present study is the first to use pedometers as the only In addition to the increase in daily physical activity after intervention in smokers, and the first to divide smokers the protocol, the initially inactive subgroup also improved according to their baseline physical activity level, which functional exercise capacity assessed by the 6MWT, al- fills the gaps in the study by Prochaska et al19 and gener- though there was no correlation between changes in these ates 2 important implications: 2 outcomes. This is possibly due to the fact that the subjects in general already had a preserved exercise capacity • An intervention using only pedometers (ie, not accom- at baseline, as demonstrated by the relatively normal val- panied by other smoking cessation measures) can sig- ues of 6MWT in terms of percentage of the predicted nificantly increase the level of daily physical activity of values (see Table 1). A previous study30 noted that the apparently healthy smokers. distance covered by smokers in the 6MWT was signifi- • The subgroup who actually benefits from the routine use cantly lower than expected, indicating more severe exer- of pedometers is composed of those smokers who are cise tolerance limitation in that population and suggesting physically inactive. that smoking may promote important changes in their functional ability. However, that study used a different formula And, perhaps even more important, the lower the base- to calculate predicted values, in comparison to the present line number of steps/day, the greater the increase reached one. Also, that study was limited by presenting its data in in the physical activity level, to the point that the vast absolute and predicted values in meters, although the per- majority of these subjects reach or closely approach the centage of the predicted values would better reflect the minimum daily physical activity recommendation. subjects’ functional disability. Moreover, the present study As mentioned earlier, the study by Prochaska et al19 had also supports the concept that daily physical activity and a 16% average increase of the number of steps/day in functional exercise capacity do not necessarily reflect the smokers submitted to the use of pedometers as a motiva- same domain: functional exercise capacity indicates what tional factor. In this study, physically active smokers the individual is capable of doing, while the daily physical showed an insignificant reduction in the number of steps/ activity indicates what the individual actually does.31 day after the protocol (2% on average), whereas physically In the same line of reasoning, inactive subjects of GB in inactive smokers had a significant increase (26% on aver- the present study showed significant improvement in func- age). This discrepancy in numbers between the 2 studies is tional exercise capacity, yet not accompanied by a signif- clearly due to the fact that the present study divided the icant increase in daily physical activity. Although the book- subjects into physically active or inactive, since for the let is more accessible and even less expensive than a whole group (adding active and inactive subgroups), there pedometer, GB showed a modest (and nonsignificant) in- was an 18% average increase, similar to the 16% observed crease in daily physical activity. Furthermore, there was a in the study by Prochaska et al.19 slightly higher drop-out rate in this group, compared to the The association between smoking and a sedentary life- GP. In combination, these factors may indicate that the style is already known; since smoking is described as more booklet was not as effective as the pedometer to counteract prevalent in sedentary people, physical exercise is consid- physical inactivity in smokers. ered a protective factor against the onset of smoking.28,29 At baseline, the present results showed negative corre- However, in this study, about 60% of smokers were clas- lation between physical activity and smoking habits in sified as inactive. This classification was based only on the sedentary (ie, inactive) smokers, in accordance with the subjects’ number of steps/day, but not on the intensity in previous literature.32 Interestingly, we have added to the which this walking activity was performed. Possibly, if an literature the fact that the smokers with worse smoking activity monitor had been used to quantify the intensity of habits (and consequently lower physical activity levels) the physical activities, the proportion of smokers classified are more likely to improve their physical activity level as physically inactive may have been higher, and the re- after using the pedometer for 1 month, even without results could have been even more encouraging. However, ducing their cigarette consumption during this period of the use of another more technologically advanced device time. As previously discussed, a combined intervention of

RESPIRATORY CARE • JULY 2012 VOL 57 NO 7 1095 SHORT-TERM EFFECTS OF USING PEDOMETERS TO INCREASE DAILY PHYSICAL ACTIVITY IN SMOKERS pedometers with a smoking cessation program involving 4. Pitta F, Troosters T, Spruit MA, Probst VS, Decramer M, Gosselink counseling and pharmacologic treatment might be a very R. Characteristics of physical activities in daily life in chronic ob- interesting venture for future research. structive pulmonary disease. Am J Respir Crit Care Med 2005;171(9): 972-927. One possible limitation of the present study was the 5. Watz H, Waschki B, Meyer T, Magnussen H. Physical activity in relatively small number of participants. No sample size patients with COPD. Eur Respir J 2009;33(2):262-272. was determined prior to initiation of the study. However, 6. Piepoli MF. Exercise rehabilitation in heart disease: the real “poly- the study was powered enough to show relevant and sta- pill” for primary and secondary prevention. Monaldi Arch Chest Dis tistically significant differences in the proposed outcomes, 2005;64(2):88-93. 7. Gill JM, Cooper AR. Physical activity and prevention of type 2 notably the primary one. Furthermore, the dropout rate diabetes mellitus. Sports Med 2008;38(10):807-824. was relatively high; however, similar rates have been pre- 8. Bonner A, Wellard S, Caltabiano M. The impact of fatigue on daily viously described in the literature concerning smokers.33,34 activity in people with chronic kidney disease. J Clin Nurs 2010; We hypothesized that at least one factor may be related to 19(21-22):3006-3015. this: despite being smokers, these subjects were apparently 9. Tudor-Locke C, Hatano Y, Pangrazi RP, Kang M. Revisiting “How healthy by definition, and therefore could have been less many steps are enough?” Med Sci Sports Exerc 2008;40(7 Suppl): S537-S543. prone to pursue a change in daily habits and persevere in 10. Pitta F, Troosters T, Probst VS, Spruit MA, Decramer M, Gosselink it. On the other hand, we cannot rule out that the high R. Quantifying physical activity in daily life with questionnaires and dropout rate and relatively small sample size may limit the motion sensors in COPD. Eur Respir J 2006;27(5):1040-1055. external validity and generalization of the findings. 11. Bravata DM, Smith-Spangler C, Sundaram V, Gienger AL, Lin N, Lewis R, et al. Using pedometers to increase physical activity and improve health: a systematic review. JAMA 2007 Nov 21;298(19): Conclusions 2296-2304. 12. Tudor-Locke C, Williams JE, Reis JP, Pluto D. Utility of pedometers These results suggest that physically inactive smokers for assessing physical activity: convergent validity. Sports Med 2002; 32(12):795-808. increase their daily physical activity when submitted to a 13. Araiza P, Hewes H, Gashetewa C, Vella CA, Burge MR. 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