Smoking remains a major public health problem. Experiencing a myocardial infarction (MI) can be a teachable moment that results in smoking cessation when previous efforts have failed. We tested the feasibility of providing a simulated and personalized experience of an MI to facilitate quitting smoking. Smokers, who were recruited from the community, had photographs taken of themselves, their partner, and family. These photographs were inserted into a video depicting the subject as a smoker experiencing an MI with potential consequences to themselves (death or disability) and their family. The subject watched the video and a psychologist used motivational interviewing to reinforce quitting efficacy. Thirteen subjects (11 men, 2 women) 45 ± 12 years of age with no smoking-related illness and a nonsmoking partner were studied. At week 1, 7 of 13 subjects (54%) reported stopping smoking, and the other 6 had decreased consumption. Daily cigarette consumption at week 1 decreased from 17.3 ± 9.3 at baseline to 2.7 ± 4.9 (p <0.005) and expired carbon monoxide levels from 15.7 ± 9 to 3.1 ± 3.2 parts per million (p <0.005). Seven subjects had observable responses to the video including “looking uncomfortable” and “red eyes, difficulty speaking.” Self-reports included “made me aware of the important things” and “it felt very real.” At 6 months, 7 of 13 subjects (54%) were still abstinent. Five of the 7 nonsmoking subjects used an additional antismoking aid. In conclusion, it is feasible to create a simulated and personalized teachable moment and these findings provide encouragement for evaluating this novel method for smoking cessation and other behavior modifications.
Behavior modification has been an important component in quit-smoking strategies. Although the stages-of-change model proposes that behavior change is a gradual process marked by progressive stages, the catastrophic theory describes a buildup of motivational tension, with rapid behavior change triggered by a specific event. This theory is supported by a survey of 611 ex-smokers in whom 64% had quit abruptly rather than planning to quit later. In another study, quitting was unplanned in 51.6%, and most attempts were unaided (64%) and for health reasons (64%). The theory is consistent with the “teachable moment,” an event such as a myocardial infarction (MI) or surgery that motivates patients to adopt risk-decreasing behaviors. In place of a real MI, we explored the feasibility of creating a simulated and personalized experience of an MI to facilitate quitting. We hypothesized that subjects viewing a video that simulated them having an MI, with its personal and family consequences, would have such a teachable moment.
Methods
Thirteen smoking subjects ≥25 years of age who had previously attempted to quit smoking and who were married or in a committed relationship with a nonsmoking partner were enrolled. We excluded subjects with a smoking-related illness, health workers in contact with patients with smoking-related illness or cardiovascular disease, or subjects with a psychiatric condition identified by the Mini International Neuropsychiatric Interview. Subjects were recruited by advertising in community newspapers and notice boards and by medical referral. The study was approved by the institutional human research ethics committee. Subjects and their spouses/partners provided separate informed consents, and all attended an initial enrollment session where digital photographs were taken of subjects and partners in prescribed poses. A photograph of family or loved ones was also scanned.
These photographs were inserted into prespecified sections of a previously prepared 8-minute video. The individualized video depicted the subject having an MI secondary to smoking cigarettes, with potential consequences of death or disability, and implications for the subject’s loved ones. The dramatic enactment was interspersed with a doctor describing the process of an MI, aided by animation and case vignettes of an MI caused by cigarette smoking.
At the first treatment session measurements were taken of Fagerström scores for nicotine dependence, smoking levels, and expired carbon monoxide (CO) concentrations. The video was then screened in a quiet room in the presence of the psychologist who provided motivational support and negotiated a quitting date. At week 1 (second treatment session) subjects reported on their smoking, and CO levels were remeasured. The Impact of Event Scale was administered to assess subjective distress in reaction to the video. The video was then rescreened. Telephone follow-up occurred at weeks 2, 4, 6, and 8, when the subjects reported on their smoking behavior and were provided with support to maintain or achieve smoking abstinence. At 3 months, there was a third face-to-face session, where subjects reported on their smoking and their recollection of the video and its effectiveness. CO levels were recorded and the Impact of Event Scale readministered. At 6 months, subjects were telephoned to check on their smoking status. Additional quit smoking aids were used at the request of the subject or if the investigators considered that these were required to assist in coping with nicotine withdrawal.
Paired t tests were used to compare baseline to post-treatment measurements (Sigma STAT, Jandel, San Rafael, California). The primary end point was smoking status at 6 months as determined by self-report. Secondary end points were smoking status at 1 week and at 3 months, as determined by self-report and CO level. Three subjects were not contactable despite repeated attempts, and their baseline readings were recorded as their results.
Results
The average age of subjects was 45 ± 12 years (mean ± SD) and 11 were men. Subjects had 3.8 ± 1.9 previous quit attempts, and 11 had previously used quit smoking aids. The Fagerström score was 3.7 ± 2.9. Average daily use was 17.3 ± 9.3 cigarettes, and expired CO concentration was 15.7 ± 10 parts per million.
At week 1, 7 (54%) reported not smoking, and the other 6 subjects reported decreased cigarette consumption. Average daily cigarette consumption decreased significantly ( Table 1 ). At 3 and 6 months, the number of nonsmokers remained 7 (54%), although 1 initial quitter returned to smoking, and another quit after week 1. Nonquitters who were contacted had returned to baseline levels. Compared to baseline, mean CO levels were significantly lower at 1 week and 3 months ( Table 2 ).
| Subject No. | Baseline | 1 Week | 3 Months | 6 Months | Aids Used |
|---|---|---|---|---|---|
| 1 | 17.5 | 12.5 | 0 | 0 | varenicline |
| 2 | 5 | 3.5 | 5 | 5 | — |
| 3 | 12.5 | 0 | 0 | 0 | — |
| 4 | 20 | 14 | 12 | 20 | NRT |
| 5 | 9 | 0 | 0 | (9) ⁎ | — |
| 6 | 20 | 0.3 | 0 | 0 | NRT |
| 7 | 30 | 0 | 4 | 9 | NRT |
| 8 | 15 | 0 | (15) ⁎ | 15 | — |
| 9 | 10 | 5 | 3 | 0 | NRT |
| 10 | 40 | 0 | 0 | 0 | varenicline |
| 11 | 20 | 0 | 0 | 0 | NRT |
| 12 | 15 | 0.4 | (15) ⁎ | (15) ⁎ | — |
| 13 | 11 | 0 | 0 | 0 | — |
| Mean ± SD | 17.3 ± 9.3 | 2.7 ± 4.9 ‡ | 4.2 ± 5.9 ‡ | 5.6 ± 7.2 † | |
| Quitters (%) | 0/13 | 7/13 (54%) | 7/13 (54%) | 7/13 (54%) |
⁎ Uncontactable subject. Assume baseline level of smoking.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
