Original article 1 Motivational interviewing for smoking cessation in patients with cardiac diseases Tarek A. Okashaa, Sorayia R. Abd El Fatahb, Nevein M. El Ashryb, Mahmoud M. Elhabibya, Samah A. El Wahed Ahmedb, Wafaa O. Abd El Fatah Abd Elhadyc, Dalia A. Mahmoud Morsya and Michael Elnemais Fawzyd aDepartment of Psychiatry, Faculty of Medicine, Background bPsychiatric Mental Health Nursing, Faculty of Nursing, Ain Shams University, cPsychiatric Mental Health Motivational therapy for smoking cessation given to patients with cardiac disease has a Nursing, Faculty of Nursing, Helwan University and reinforcing role that decreases smoking related precedent heath, social and financial dDepartment of Psychiatry, Al Abbasia Mental Health Hospital, Cairo, Egypt burdens. Aim Correspondence to Michael Elnemais Fawzy, MSc, Department of Psychiatry, Al Abbassia Mental Health The aim of this study was to assess the therapeutic effect of motivational interviewing Hospital, Cairo 11231, Egypt sessions on the smoking course and quitting success rates in cardiac patients Tel: + 20 122 999 9063; e-mail: [email protected] compared with patients who did not receive the sessions. Patients and methods Our study was carried out on 120 smokers with cardiac diseases at the rehabilitation clinic; Received 25 July 2015 patients were divided into an experimental group of 60 patients who received motivational Accepted 31 October 2016 interviewing sessions while monitoring their smoking severity in the pre, post and follow-up Middle East Current Psychiatry sessions and another 60 matched controls who received a single advice on cessation 2017, 24:1–7 treatment; both groups were assessed in the pre, post and follow-up session periods. A sociodemographic sheet, the Decisional Balance Scale, the Fagerstro¨m Test for Nicotine Dependence, the Readiness to Change Questionnaire, the Stress Test Questionnaire, and the Stress Management technique Questionnaire were used. Results Heart attack episodes were decreased in the experimental group by 50% after intervention with higher ‘high motivation’ to quit (98.33 and 91.66% in post and follow- up, respectively) compared with the preintervention period (1.67%). In the pre and follow-up periods, very low nicotine dependence was reported in 86.67 and 91.67% of the experimental group, respectively, compared with 8.33% in preintervention period. Also, 91.67% of the experimental group stopped smoking successfully in the follow-up period compared with 45% of the control group. Conclusion Using motivational techniques can encourage patients to quit smoking with less stress and can increase self-efficacy of patients. Keywords: cardiac, cessation, motivational interviewing, smoking, tobacco dependence Middle East Curr Psychiatry 24:1–7 & 2017 Institute of Psychiatry, Ain Shams University 2090-5408 treatments for smoking cessation, many barriers exist in Introduction thesameprocessforsomepatientsandthesecanbedivided Smoking is considered among the leading causes of death into two groups: intrinsic barriers, like lack of will and and a major factor for contracting cardiovascular diseases confidence, and extrinsic barriers, such as financial burdens (CVD). Passive smoking also increases the risk for chronic or absence of dedicated services within hospital settings obstructive pulmonary diseases. Regardless of the age of where they are needed most to help vulnerable patients [2]. smoking and amount of cigarettes smoked, quitting has different advantages for all smokers as it reverses the risk A critical aspect of motivation was identified to be for CVD and reduces mortality by 36% in postmyocardial assessing readiness to change; considering motivation as a infarction cases over 2 years. Despite the importance of state not a trait, and not static and thus something that smoking cessation as a main element among primary and can be changed from one day to another. It is noteworthy secondary CVD prevention strategies, it receives much that all patients who enter treatment are not ready to less consideration than do other risk factors [1]. change as some are ambivalent about it [3]. Factors that cause failure to reduce smoking include high Motivational interviewing is a directive, client-centered dependence on nicotine and absence of will and confidence. structured psychotherapeutic service aiming at facilitating Therefore, despite the presence of several effective and maintaining behavioral change by helping clients 2090-5408 & 2017 Institute of Psychiatry, Ain Shams University DOI: 10.1097/01.XME.0000508430.40664.fc Copyright r 2017 Institute of Psychiatry, Ain Shams University. Unauthorized reproduction of this article is prohibited. 2 Middle East Current Psychiatry exploreandresolvetheirambivalence[4].Itusesintrinsic 10.00 a.m. Research clearance was obtained from the motivation and reflective listening in rolling with resistance, scientific committee of Ain Shams University Hospitals. building decisional balance, and managing roadblocks to reach a successful change of negative behaviors [5]. Tools When motivational interviewing (MI) was given to a (1) A predesigned clinical sheet, which involved the group of 255 smokers in four sessions of patient-centered sociodemographic characteristics including age, sex, communication to explore patients’ reasons for change, marital status, level of education, occupation, they showed an expected prominent increase in cessation monthly income, smoking among family members, medication use with strengthened motivation and con- first time of smoking, past trials of smoking cessation, fidence to quit through a 3–6-month period relative to and the use of any stress management methods to the ones who were only given brief advice [6]. face withdrawal symptoms associated with smoking cessation and other life stressors. A comprehensive review of MI for smoking cessation (2) The Fagerstro¨m Test for Nicotine Dependence [9] conducted by 31 trial researches showed that MI had a (the Arabic version) [10]: It was used to measure the statistically significant effect on abstinence rates com- smokers’ nicotine dependence severity during inter- pared with controls (odds ratio = 1.45, 95% confidence ventions to identify the nicotine addiction level and interval = 1.14–1.83), where participants in MI treatment prescribe the appropriate pharmacotherapy after programs had 45% greater odds of being abstinent at referring the patient to a psychiatrist. It contains follow-up evaluation than control participants [7]. six multiple choice questions with a four-point scale Activities implemented by nurses often require professional for each. Classification of dependence is as follows: expertiseandfocusedefforttointegratethemwithinthe very low (0–2), low (3–4), moderate (5), high (6–7), clinical system of care, as nursing interventions are known to and very high (8–10). positively affect smoking cessation. Interventions had a (3) The Readiness to Change Questionnaire [11]: It significant effect on patients’ successful quit attempts. measures readiness to change the pattern of smoking Therefore, implementing evidence-based multidisciplinary and reasons for initiation, and helps in identifying the and multifaceted motivational therapies has been effective in characteristics of smokers who currently seek treat- significantly improving cessation services (57–86%). Without a ment at a smoking cessation clinic and to measure dedicated smoking-cessation program, or an updated training their level of motivation to quit smoking. The tool is of nurses about this program, nurses will lack the sufficient also designed to assess an individual’s stage of change. knowledge on smoking-cessation services [8]. It contains 12 items with three subscales: precontem- plation; contemplation; and action. The scoring The current study aimed at assessing the role of system includes a five-point rating scale for each item. psychiatry field nurses in the motivational interviewing (4) The Decisional Balance Scale [12]: It was used to therapy in smoking cessation given in specialized clinics identify pros and cons of tobacco use and cessation by like the cardiology ones. In addition, the study hypothe- asking participants about the negative and positive sized the probable successful role of using external and feelings that affect their smoking habit, which may internal motivation on the initiation and maintenance of serve to increase their reasons and motivation for smoking cessation and on decreasing its cardiac hazards. change. It has five items that cover physical, economic, social, religious, and psychological aspects. Every item is divided into six subitems (three subitems for positive feelings toward smoking and Patients and methods its cessation, and three for negative feelings). This quasi-experimental study was conducted on smokers (5) The Stress Questionnaire [13]: It assesses an with heart diseases at The Rehabilitation Clinic of Heart individual’s level of stress. This is a 10-item Disease, Cardiology Department, Ain Shams University questionnaire. Its questions apply to the previous Hospitals, located in Eastern Cairo, which serves a month only. It includes a five-point rating scale that catchment area of about one-third of Greater Cairo. It provides a range of five options of responses to serves both urban and rural areas, including areas around measure each of the 10 items for ways that people Greater Cairo as well. The rehabilitation clinic serves all may feel stress about their life and their smoking. cardiac patients who follow-up