A Quasi-Expimentai Study to Eumine Knowledge

nod Stage of Smokhg Change FoUowing a Smoking Intavention

in a Federai Correctionai Setting

Carey Lee Varga

A thesis submitted to the School of Nursing

in con for mi^ with the requirements for

the degree of Master of Science

Queen's University

Kingston, Ontario, Canada

copyright O Carey Lee Varga, 1997

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A Quasi Experimental Study to Examine Knowledge and Stage of Smoking Change foliowhg a Smoking Intervention

in a Federal Comeztioaal Sdtiag

Carey Lee Varga

Master of Science, 1997

School of Nursing, Queen's University

This quasi-experimental pre-test-post-test study determined if a supportive-

educative smoking cessation intervention irnpacted on smoking cessation variables among

84 prisoners in a federal correctional setting. One hundred smoking prisonen volunteered

for the study at the tirne of their Uitake into the co~ectional setting. The research

questions explored if stage of smoking change, knowledge, addiction, amount smoked,

confidence in quitting, self-reported health, and quit attempts differed between comparison

and intervention groups foilowing an intervention of five smoking cessation classes.

Concepts fiom King's (1983) nursing paradigm La2anis and FoUanan's (1984) theory of

stress and coping and the Transtheoretid Mode1 of Change (Prochaska & DiClernente,

1983) fomed the underpinnings of the intervention. Forty-two subjects remained in each

of the comparison and intervention groups when testeci immediately following (The 2)

and four weeks d e r the intervention ( T ï e 3). Results showed there were no significant

differences between cornparison and intervention pnsoners for outcome variables at T h e

1. g tests for independent samples showed signifiant differences between group means in

stage of smoking change, knowledge, amount smoked and coddence in quitting four

weeks &er the intervention @<.001). Paired g tests supported the hypothesis that four

weeks foliowing the intervention there would be increased knowledge and decreased

cigarettes smoked @<001). Paired sample t tests found no significant difEerences at four

weeks for stage of smoking change, addiction to tobacco, confidence, self-reporteci heaith

and quit attempts. This study describes the value of a nursing intervention in a

correctional setting.

Acknowlegements

To Dr. Edith Costello, my thesis advisor, who was always patient and woperative,

and always helped me get through. She gave me great advice and was able to provide me

with suggestions to guide me dong. 1 feel that it was her positive words that kept me

gohg and made this thesis possible. To my coinmittee members, Dr. Shirley Eastabrook

and Dr. Carol Roberts, my thanks for their confidence and help. To the Psychology

Department at Millhaven, Jeremy Mills, Daryl Kroner, and J i i Muirhead, thanks for ail of

your help. To Dr. Terry Smith and Queen's STATLAB for their direaion and statistical

Support.

Thanks to the Correctional Services of Canada for allowing me to wnduct my

study using offenders in a penetentiary setting. To the past Warden of =aven, Al

Stevenson, and the current Warden Lou Kelly, Associate Warden Millhaven Assessrnent

Unit Aiex Lubimuv, and Deputy Warden Paul Snyder, for supporthg my study and

allowing me to do my intervention. To the staff in the school for ailowing me a

classroom to condua my smoke cessation study. To my s u p e ~ s o r Dennis Corrigan, Unit

Manager, Millhaven Institution, for allowing me to use my leave to attend school.

To my classrnates J e d e r Lasaile for her fkiendship, helping me with my statistical

analysis and always being supportive and uplifting when things were rough. Maureen

McIlmoyl for her encouragement, support and friendship. We put a lot of effort into the

last two years and we are h d y done.

when 1

To my mother and father who are always supportive of me and urging me to finish

seem to spread myselfout too thin. Thank you for your help and support over the

years, and encouraging me to be the best 1 can be. To my son Chnstopher who has had to

share his mother with her work and school, thanks for making me happy and proud of

you. And lady to my new son Nkholas for making motherhood enjoyable and rewarding

and not keeping me up to many hours in the night to complete my thesis.

Finaily to Queen's University School of Graduate Studies and Research for

providing me with the awards that made r e h g to school easier.

Table of Contents

... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements ui

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table of Contents v

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . List o f Figures ix

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . List o f Appendices x

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glossary of Terms and Acronyrns xi

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHAPTER 1: INTRODUCTION 1

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conceptual Frameworks 4

King's Nursing Paradigm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Lazarus and FoLhnan's Theory of Stress and Coping . . . . . . . . . . . . . . . 5 The Transtheoretical Mode1 of Change (TMC) . . . . . . . . . . . . . . . . . . . . 6

ResûuchQuestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHAPTER II: LITERATURE REVIEW 10

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction 10

. . . . . . . . . . . . . . . . . . . . . . . . . . Public Health and Smoking Cessation 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Characteristics of Smokers 12

Benefits ofstopping Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Educationai Strategies 15

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Addiction 18 Swnmary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

. . . . C W T E R III: METHODOLOGY

Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Protection of Subjects' Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

. . . . . . . . . . . . . . . . . . . . . . . . Classroom Sessions (Treatment Group) 27

Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

. . . . . . . . . . . . . . . . . . . . . . . . . . . . Socio-Demographic Questionoaire 29 . . . . . . . . . . . . . . . . . . . . . Stage of Smoking Change Algorithm (SSA) 29

. . . . . . . . . . . . . . . . . . . . . . . LXe S U S Student Questionnaire (LSSQ) 30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fagerstrom Tolerance Scaie (FTQ) 31

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypotheses 32

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

CHAPTER THE RESULTS

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data Analysis 34

Subject Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 DBerences Between the Cornparison and Intervention Group at Time 1 42 Research Question1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ResearchQuestion2 48 Research Question 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 ResesrchQuestion4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Research Question 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Research Question 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Research Question 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Sumrnary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

CHAPTER V : DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Subject Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 ResearchQuestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

CHAPTER N: SUMMARY. RECOMMENDATIONS AND CONCLUSIONS ..... 70

Summary ....................................................... 70 ........................................... Signincance of Research 71 .......................................... Limitations of the Study -71

.............................................. Nursing Implications 72 Future Directions for Nursing ...................................... -73

................................................ Recommendations 73

REFERENCES ........................................................ 76

VITAE .............................................................. IO9

vii

Table 1:

Table 2:

Table 3:

Table 4:

Table 5:

Table 6:

Table 7:

TabIe 8:

Table 9:

Table 10:

Table I I :

List of Tables

Frequency Sample Characteristics of all Subjects at Time 1 (N=84) . . . 37

Measures of Central Tendency for di Subjects at Tirne 1 (N=84) . . . . . 40

t-tests to D e t e d e Significant Differences between Cornparison and -

Intervention Subjects at T i e 1 (N=84) . . . . . . . . . . . . . . . . . . . . . . . . 43

1-tests for Independent Samples at Tirne 1,2 and 3 . . . . . . . . . . . . . . . . 45

Question 1 : 1s the Stage of Smoking Change Significantly DEerent d e r

Five Education Sessions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Question 2: 1s KnowIedge Significantly DifFerent after Five Education

Sessions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Question 3 : 1s Level of Nicotine Addiction Significantiy Difrent after Five

EducationSessions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Question 4: 1s the Amount Smoked SignificantIy DEerent &er Five

Education Sessions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Question 5: 1s the Level of Confidence Significantly Ditferent d e r Five

Education Sessions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Question 6: 1s the Level of Health Sigiuncantly Different after Five

Education Sessions?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Question 7: 1s the Number of Quit Attempts SignScantiy DEerent after

5 Education Sessions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

List of Figures

Figure 1: T i e iine for data coilection and intervention . . . . . . . . . . . . . . . . . . . . 26

List of Appendices

Appendix A: Socio-Demographic Questionnaire ............................. 86

Appendix B: Stage of Smoking Change Algorithm ........................... 88

Appendk C: Life Skills Student Questionnaire .............................. 89

............................ Appendk D: Fagerstrom Tolerance Questionnaire 90

............................... Appendix E: Information and Consent Forms 92

Appendix F: Educationai Component for the Intervention Group . . . . . . . . . . . . . . . . 93

Appendix G: Letter of Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Appendix H: Histogram of Age Frequencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Appendix 1: Stages of Smoking Change Algorithm ......................... 102

Appendix J: Life Skills Student Questionnaire ............................. 103

Appendix K: Fagerstrom Tolerance Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Appendix L: Amount Smoked . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

AppendixM: Coddence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

AppendixN: Heaith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Appendix O: Quit Attempts ............................................. 108

CSC

FTQ

LSSQ

SCA

TMC

Gossary of Terms and Acronyms

Correctional Services of Canada

Fagerstrom Toleraace Questionnaire

Life Skilis Student Questionnaire

Stage of Smoking Change Algorithm

Transtheoreticai Model of Change

CHAPTER 1

INTRODUCTION

The health hazards of cigarette smoking arnong Canadians have b e n widely

documented since the United States (U.S.) first Surgeon Generai's Report on Smoking

and Health, 1961 (Best, Josie. & Walker, 196 1). Cigarette smoking is the major

preventable risk of physical morbidity and premature mortalis, in Canada and the United

States (Schabas, 199 1 ; U.S. Department of Health Services. 1986). S t a for a significant

portion of the population, the perception of the benefits of smoking seems to outweigh the

hedth hazards.

Correctionai SeMces of Canada (CSC) are obligated under the Corrections and

Conditional Release Act, section 74, to make the Federal institutions smoke fiee by April

1, 1998. Before this date institutions are to have policy and smoke cessation programs in

place to help offenders quit smoking. Mer April 1, 1998 prisoners and staff wili not be

perrnitted to smoke in any indoor or enclosed space, including vehicles, that are under the

control of CSC. Institutional heads rnust plan for the long range goal of making

institutions smoke fiee for both stafF and prisoners. In 1996 a regional cornmittee was

struck to examine how to phase in the 1998 ban on smoking for both staff and prisoners.

This pilot study was undertaken to determine if a smoking cessation intervention

was effective in moving prisoners dong a continuum of change in the smoke cessation

process, changing their knowledge about smoking and heaith, and altering other smoking

outcornes. The number of prisoners who smoke was presumed to be considerably p a t e r

than the general population. It was estimated that at t h e of intake 40% of prisoners were

2

smoking. This compareci with an estimated 27% of smokers among Ontario's general

population (Ontario Muiistry of Health, 1992). However, up until this study, there has

been no research done to determine the exact number of prisoners who srnoked, and why

they smoked. It was felt that this study was both timely and aitical to explore rasons

why prisoners smoked, and to pilot a smoking cessation intervention. Therefore, the

purpose of this study was to examine whether prisoners who srnoked were more

successfùl at quitting after receivhg a supportive-educative smoking cessation

intervention.

Sigrilficance of Problem

Over the past three decades, North America has witnessed a revolution in attitudes

toward smoking. What was once considered a normal habit has become increasingly

socially unacceptable among many groups. An ever-growing number of non-smokers are

rnuch less tolerant of smoking, and anti-smoking activists have become very vocal in their

opposition to the habit. The Federal Goverment has initiated a number of measures

designed to reduce smoking, includhg the Tobacco Products Control Act, the Non-

Smokers Health Act, and more recently the Tobacco Sales to Young Persons Act

(Cunningham, 1996). Nthough the heaith promotion and disease prevention aims are

admirable, there is little evidence that the intent has camied over to incarcerated prisoners.

As long as smokhg was viewed as a personal issue, people could argue that the

government should not interfere with tobacu, use. Perceptions have changed considerably

since research results codhning the negative effects of second hand smoke have become

public. Tobacco smoke in the environment is one of the major concems to public health

officiais, as one of every six deaths in this country is attributable to cigarette smoking

(Schabas, 1 99 1). Haif of cardiovascular deaths, Ontario's biggest mer, were attributed

to smoking (Schabas, 199 1). Almost 85% of deaths due to Iung cancer and 80% of

deaths due to chronic obstructive lung disease have been related to the use of cigarettes

(Manley, Epps, Husten, Glynn, & Shopland, 1991). In addition the costs of cancer

morbidity and mortality fiom second-hand smoke and the lost tirne for smoke-related

ailments have led to a growing number of cornplaints to workers' compensation and

human rights commissions (Ontario Minisny of Heaith, 1992).

Part of Ontario's Tobam Strategy is to assist individuais to stop smoking

(Ontario Ministry of Health, 1992). The Federal Govenunent of Canada held a similar

goal of reducing cigarette smoking to less than 15% of the population by the year 2000

(Health and Welfare Canada, 1992). Considerable work is still needed to realize the

mission statement of the national strategy which airns to produce a generation of non-

smokers by the year 2000 and beyond. Many now feel that smoking should be the object

of even greater government intervention.

Even with medical evidence linkllig cigarette smoking to major hedth problems,

individuais continue to smoke (Marshall, 1990). For mon, tobacco smoking is a coping

strategy that develops into an addiction, making quitting one of the hardest behavioural

changes to make (EeUs, 1991).

Conceptuai Frameworks

King's Nursine Paradigm

In nursing there are a number of paradigms that guide thinking and practice. In

1971 King pubfished her paradigm in Toward a Theory for Nursing. She expanded her

ideas in her 198 1 publication. King's Open Systems Framework relies on three systems:

1) the personal relating to the individual, 2) the interpersonal involving interaction

between individuals, and 3) the social involving interaction with famiiy and others in the

extemal environment. It is 2, the interpersonai system, where nurse and client can

mutuaiiy communicate information, establish goals and take action to attain goals. King

dehed health as dynamic life experiences of a human being, which irnplies continuous

adjustment to stressors in the intemal and extenial environment through optimum use of

one's resources to achieve maximum potential for daily living (p. 18 1).

She wrote about stress as an exchange of energy, either positive or negative,

benveen a person and the environment; objects, persons and events can serve as

stressors. King described nursing as nurse-client interaction, the focus of which is to help

the individual maintain health and fûnction in an appropriate way: it is a service: profession

that mets the social need. The nurse and client share information; the nurse brings special

knowledge and skills, the client brings ~e~knowledge and perceptions mg, 1983).

Integral to King's Open Systems Framework is her Goal Attainment Theory. This

involves "transaction" wherein two individuals mutudy iden* goals and reach

agreement on how to attain and realize thern. If transactions occur, nurse and client

perceive congruent srpectations and performance. Aiîhough King wrote about the

importance of coping, she does not specifically define it (1986).

Lazams and Folkman's Theory of Stress and Coninq

Smoking is âequentiy cited as a coping strategy to decrease anxiety and stress.

Lazanis and Foikman's (1984) cognitive-phenornenologid theory defines stress in the

context of the relationship between the person and the environment. Stress may be judged

as exceeding the individual's resources and consequently endange~g his or her well

being. This is not dissimilar to King's description (1986). Lazarus and FoUanan (1984)

describe coping as the cognitive and behaviouml efforts used to manage or buffer stressfbl

events that are perceived as taxir~g one's resources. The cognitive efforts include the

evaluative process of categorizing the meaning of an event and its significance for weli-

being. The theory identifies three types of cognitive appraisai: primary, secondary, and

reappraisal. If an event is perceived as stressfiil, a primary appraisal would lead the

individual to evaluate the event in relation to their well-being. During the secondary

appraisal, the individuai would assess available coping options and the adequacy of their

resources to prevent harm or to improve chances of beneficial outcome. Behavioural

coping efforts may change or become fixed with each phase of cognitive appraisal.

Reappraisal foîlows an earlier appraisal which is then changed based on new Somation

6rom the environment a d o r person (Lazarus & Foikman, 1984). Appraisals are shaped

by situation factors that contribute to making the event stressfùl for the individual and to

person factors based on their commitrnents and beliefs.

6

First time incarcerated prisoners and recidivists experience musual and threatening

change in their environments. Not only do they experience stressftl relationships between

themselves and correctionai officers, but they have lost outside supports and are faced

with unknown feiiow prisoners in confined spaces. They use as many situations and

person factors that are avdable to them as they appraise the threats around them.

Smoking may seem to be the lesser of ali e d s as they try to manage their anxiety and

stress.

The Transtheoretical Mode1 of Channe CI"T'C]

Prochaska and his colleagues have studied the stages-of-change model which

supports the proposition that smoking cessation is a conflict-laden process (Prochaska &

DiClemente, 1983; DiClemente et al., 1991). Prochaska and DiClernente's (1992) TMC

proposes that persons pass through progressively more committed steps in their attempts

to change a hedth behaviour. It is a multi level model that integrates actual behaviour and

intention to change, perceptions of the pros and cons or decisional balance, and strategies

to promote change.

Five stages of change are descnbed in TMC: precontemplation, contemplation,

preparation, action, and maintenance. By assessing the stage of change participants fall

into, smoking cessation counseilors are able to assist smoken in effectively meeting their

goals. DiClemente et al. (1 99 1) proposed that individuals in the precontemplation stage

are not currently doing the target behaviour and have no intention to do so w i t b a

reasonable future t h e period. These people do not report a desire to change their

cigarette smoking. They are defensive, with no plans to change their behaviour.

Contemplators could be expected to want to becorne non-smokers and express desires to

stop smoking in the near fiiture. The preparation stage is when the person has discussed

quining with a prirnary care worker several times during the year. This could r e d t in

them joining a smoking cessation program and being amenable to the process and

activities associated with successfiil quitting. n ie action stage includes smokers who have

quit smoking recently for approximtely two months. Ex-smokers in the action stage rnay

need support and encouragement to rernain non-smokers. They need to develop hrther

short-term strategies to ensure success in maintaining their non-smoking aatus.

The maintenance stage includes ex-smokers who have remained smoke fiee for six

months. These people may respond to additionai knowledge and oppominities to develop

skiiis in order to maintain long-term abstinence. In addition to these above five stages, a

sixth stage, relapse, nay be added. McConnaughy, Prochaska, and Velicer (1 987)

addressed the issue of relapse prevention by teaching individuals skiils to prepare them to

deal with potential relapse episodes before they ûccumed. This was based upon the belief

that advance preparation could alleviate relapse episodes, help maintain participants'

confidence and/or promote efforts to rebound from a relapse, should it occur.

Prochaska, DiClemente, and Norcross (1992) discussed two types of processes of

change. One is experiential and includes changes in the way a person feels and thinks

about their smoking. The other is behavioural which involves actudy changing aspects of

smoking behaviour. Expenential processes may mean becoming aware of alternatives to

smoking, becoming aware of the impact of smoking on self and others and experiencing

emotional reactions to smoking related events. An example of an emotional reaction

8

might be: "1 r d y wish my ceIl mate would butt out." Behavioural processes include

replacing smoking with new behaviours and seekhg support of others.

Different processes are proposed to help smokers cope with perceived stress

accordhg to their stages of change (Prochaska & DiClernente, 1992). Experiential

processes may include the strategy of consciousness raishg such as bringing into

awareness the impact of smoking on health. This is usefui for pre-contemplation and

contemplation. Behavioural processes such as developing a support syaem and leamhg

counter conditioning measures iike relaxation exercises, may be usefid in the action and

maintenance stages. TMC has had Uicreasing exposure in the health and illness literature.

King, Lazanis and Follanan and 'IUC are the h e w o r k s used in this study to develop

the supportive-educative nuning intervention designed to help prisoners understand their

srno king, their coping responses and strategies to deal with stress.

Research Questions

Is there a sigrilfiant diference in stage of smoking change 4 and 8 weeks

following incarceration between the comparison group of prisoners and those who

are given the supportive-educative smoke cessation intervention?

1s there a signifiant difference in knowledge about smoking 4 and 8 weeks

following incarceration between the cornparison group and those who are given

the supportive-educative smoke cessation intervention?

1s there a sigiuficant difference in level of nicotine addiction 4 and 8 weeks

following incarceration between the cornparison group and those who are given

the supportive-educative smoke cessation intervention?

9

4. 1s there a significant Merence in amount smoked 4 and 8 weeks foilowing

incarceration between the comparison group and those who are given the

supportive-educative smoke cessation intervention?

5. 1s there a signifiant dflerence in confidence about quitting 4 and 8 weeks

foiîowing incarceration between the cornparison group and those who are given

the supportive-educative smoke cessation intervention?

6 . 1s there a sigruficant dflerence in ~ ~ r e p o r t e d health 4 and 8 weeks following

incarceration between the comparison group and those who are given the

supportive-educative smoke cessation intervention?

7. 1s there a significant dEerence in number of quit attempts 4 and 8 weeks following

incarceration between the comparison group and those who are given the

supportive-educative smoke cessation intervention?

CHAPTERII

REWEW OF LITEMTURE

Introduction

This literature review addressed issues related to prevdence of smoking, smoking

cessation, and dropout fiom smoking cessation program. It was undertaken in part to

find out what to include in a smoking cessation intervention for prisoners. The following

areas were addressed specifically: 1) public health and smoking cessation, 2)

characteristics of smokers who successfully stop smoking, 3) benefits of stopphg

smoking, 4) educational strategies, and 5) addiction.

hblic Hedth and Smoking Cessation

U. S. Department of Health SeMces (1 990) report4 that a comprehensive

approach to reduce smoking should include public education, school and community-

based tobacco-use prevention programs, smoking cessation prograrns, work-site based no-

smoking policies and cessation programs, dong with policies and legislation which

encourage non-smoking and restrict access to, and avdability of, tobacco products.

AIthough the majority of smokers quit on their own, almost two million of the 16 million

smokers who attempt to quit each year will join some type of organized program (Fiore et

al., 1990; Schwartz, 1987). Since the 1950's when efforts to address smoking cessation

became more organized, and a wider variety of programs began to be offered, there have

been several different emphases (Schwartz, 1987). Early programs in the 1950's focused

upon educational intervention with some utilization of medications to promote smoking

cessation. This period was foliowed in the 1960's and 1970's with cummunity-based

11

prograrns using behavioual and aversive techniques, dong with individual and seIf-care

strategies. As the complex nature of smoking cessation was more clearly delineated, a

wide array of programs to meet individual needs ba-ame avdable. In addition to

refinements of earlier prognuns, there was emphasis in the 1980's and 1990fs upon

programs designed for special populations and needs.

Schwartz (1987) divided cessation methods into eight categones which refiected

current approaches to smoking cessation. These eight categories included: self-care,

clinics and groups, medication, behavioural methods, physician advice and counsehg,

hypnosis, acupuncture, and mass media and community programs. In addition to these

strategies, legislation and advocacy efforts increased in the 1990's focusing on increases in

taxes on tobacco products, restrictions on access to tobacco, and policies restricting

smoking in public places. Although there are many dEerent methods available to assist

smokers wishing to stop smoking, long-term success rates are disquieting, ranging fiom

15 to 40 percent after one year of cessation (Schwar~ 1987; Tiffany & Cepida-Benito,

1 994).

The decline in the number of smokers fiom 41% in 1962 to 25.5% in 1989

represented an achievement, which had "few paraliels in the history of public health. It

was accomplished despite the addictive nature of tobacco and powemil economic forces

promoting its use" (U.S. Department of Health SeMces, 1989, p. 95). Reductions in

smoking have not been the same among sub-groups of our society. Decreases in smoking

occurred most noticeably among white, college educated males, which suggested

educational status was an important sociodemographic predictor of smoking status. Blue

12

wUar workers and rninorities contùiued to smoke at higher rates than white males, and

market forces have targeted women mainly in the adolescent age groups so that gender

ciifferences in smoking prevalence are expected to disappear by the end of this decade

(Benowitz, 1992).

Characteristics of Smokers

Reynolds (1985) suggested that smoking cessation progrms should target efforts

more precisely to the needs and characteristics of sub-groups or issues associated with

smoking cessation. Some demographic and health history variables have been reported as

short-term success and fdure in smoking cessation attempts. For example, a number of

studies found that people who quit smoking on their own or with assistance had more

education than those who did not (Velicer, DiClernente, Prochaska, & Brandenburg,

1985). Others reported that fdure was found to be related to smoking history. Those

who smoked more and those who had smoked longer were more iikely to f d (Marlatt,

Curry, & Gordon 1988; Wdcoq Prochaska, Velicer, & DiClemente, 1985). The degree to

which clients were overweight was also related to fdure to stop smoking (Schacter,

1982).

Wojcik's (1988) review indicated that more older people than younger people quit,

and that this was generaily precipitated by a health crisis of some sort, such as aggravahg

symptoms like a smoker's cough, or tme cnsis such as a heart attack Cohen and

Lichtenstein (1990) monitored hundreds of males who suffered heart attacks and found

that 30050% of the smokers quit immediately and had very low relapse rates. Those who

did not quit, reduced their intake significantly.

Among efforts to h d more effective smoking cessation interventions,

investigators dso sought to ident* characteristics of smokers who succeeded at

rernaining non-smokers. Several promising factors have been identifid which may play a

part in the efforts to assist smokers to stop smoking (Prochaska & DiClemente, 1992;

Stretcher, Kreuter, & Korbin, 1 995). Curry, Wagner, and Grothaus (1 990) found that

current smokers with intMsic motivations (i-e., health related) were more likely to quit

successfully than were smokers with exîrinsic motivations (i.e., social innuence). Other

studies found similar difEerences between e h i c aad intrinsic factors in maintaining

smoking cessation (Gilpin, Pierce, Goodman, Burns, & Shopland, 1992). Harackiewicz,

Sansone, Blair, Epstein, and Manderlink (1 987) reported that quitters who had attributed

smoking cessation to intrinsic factors were better able to maintain theû cessation over d e

as cornpared to those identdjmg exvinsic reasons.

Early work done by Rosenblatt, Rosen, and Men (1 967) and by Schwartz and

Dubizky (1968) cited three prirnary reasons for smoking cessation: health concems,

expense, and lack of enjoyment of smoking. In more recent studies, heath concems

emerged as dominant reasons for smoking cessation (Duncan, Cummings, Hudes, Zahnd,

& Coates, 1992; Lichenstein t Cohen, 1990; Schneider, 1984; Swenson & Dalton, 1983).

Halpert and Wamer (1993) found that overaii importance of present and fbture health

were associated With increased Iikeiihood of successfid smoking cessation.

The process of deciding to quit smoking is dynamic with many smokers atternpting

to quit and relapsing on several occasions before they are able to completely stop smoking

(Benowitz, 1992; Cohen, P i c k w o ~ & Henningfïeld, 1991). Analysis of short-tem

14

smoking cessation programs demonstratecl that 7040% of participants were still smoking

one year later (Glasgow & Lichtenstein, 1987; Schwartz, 1987). Avdable data suggested

that self-changers made three to four senous quit atternpts spaced out over seven to ten

years before they successfùily quit (Prochaska & Goldstein, 1991). Cohen, Pickworth,

and Henningfeld (1989) reported that when a single attempt to quit was analysed, seK

quitters' success rates were better than those reported for formal treatment progams and

that even those who had sustained smoking cessation for over s u months had a relapse

rate clf 24%. Statistics like these have encouraged research efforts to explore the intrinsic

decisional and behaviourd processes underlying smoking cessation.

Benefits of S t o p p i m a

It can be shown that those ùidividuals who do quit despite the addictive nature of

cigarette smoking immediately reap many benefits (Health and WeKâre Canada, 1992).

Within one year of quitting, halfof the excess risk of heart disease disappears (Stretcher,

Kreuter, & Korbin, 1995). M e r 10- 1 5 years an ex-smoker is at no greater risk of a heart

attack than someone who has never smoked regulariy. Smoking cessation is one of the

most significant changes an individuai can make for their long tem health. Limiting

smoking in our society has a great impact on the fuhire of everyone. The 21st Surgeon

General's Report comprehensively addressed these benefits of stopping smoking. In

addition to the benefits to a smoker's heart the report presented these conclusions: 1)

smoking cessation provides important health benefits for men and women of all ages, 2)

smokers who quit live longer than those who continue to smoke, 3) risks of lung cancer,

other cancers, stroke and chronic lung disease are reduced by eliminating smoking, 4) the

15

risk of delivering low birth weight babies decreases to that of wornen who have never

smoked, if women aop smoking before becoming pregnant or durllig the first 3 or 4

months of pregnancy, and 5) the health benefits which result £tom smoking cessation are

far greater than any nsks associated with weight gain (which averages five pounds) or

other psychological concerns that aise foUowing quitting (US. Department of Health

Services, 1 990).

Smokers of any age obtain irnrnediate health benefits when they stop smoking by

reducing exposure to nicotine, carcinogens, and carbon monoxide (Wamer, 1989). In

addition to improving their own health, smokers with chiidren "reduce or eliminate the risk

of passive smoking-related disease arnong their children" thereby effecting multiple

benefits for the health and welfare of others (p. 142). The perceptions of non-smoking

pnsoners regarding second hand smoke, and pnsoners currently smoking on the effects of

their smoking on the other pnsoners and their families have not been studied.

Educational Strate~es

UnsuccessfÙI health-related decision making not only decreases a smoker's

chances of realizing an ongoing sense of wehess, but also results in intense regret and

hstration when avoidable setbacks occur (Janis, 1983). Eeiis (1991) noted that

fùlfilment of the health counseiior's legal and ethical obligations "must begin with an

understanding of the patient's comprehension, decisionmaking processes, and

environment" (p. 922 ). Although efforts have been made to identify the people who will

quit smoking with the help of group cessation methods, these efforts have been largely

unsuccessfil. Perhaps the wrong questions have been asked. Readiness may be a useful

16

concept for smokers and counsellon who assist smokers to quit. Until recently, the

majority of treatment groups implicity assumed readiness and focused on quittllig. If there

is such a thing as readiness, it would seem sensible to admit into treatment groups those

smokers who are ready to quit.

Educational strategies can be both cost effective and reach a wide audience. In

moa smoking education programs it has been found that simply providhg knowledge

regarding smoking cessation was not enough to change participants' behaviour. Tiffany

and Cepida-Benito (1994) found that providing different learning forums were more

beneficial for the participants who were attempting behavioural change.

Kellar (1987) found that providing printed rnaterial was usefbl because it was

available to the reader for later reference. A weakness, of usîng this forum alone may be

that materials are often written at a higher reading level than that of the target population.

For example, Kellar (1987) analysed patient education materials for persons with chronic

obstructive pulmonary disease and found that the readabiiity level averaged 1 1.8 years of

schooling. Kellar found that when tems such as "acute" and "aerosol" were removed, the

readability was reduced to Grade 9. Many individuals do not read at the level of their

completed formal education. The tacher must match the rnaterial to the learner. It has

been estimated that one of five adult north Americans is functionaiiy illiterate, reading at

or below the Grade 5 level (Keiiar 1987). For lower level readers, it has been found that

audio and visual media can be usefùl to supplement information.

Abrams, Monti, Pinto, Elder, Brown, and Jacobus (1987) used relaxation therapy

with other stress management techniques and found that these helped to change health

17

care attitudes in individuals who were not previously concerned with their health. They

found that providing smokers with s p d c smoking reiated facts in the form of

videotapes, flip charts, and diagrams was sutFcient to change intentions with regard to

smoking behaviour. Pictorid leamkg was superior to verbal for recognition and r d .

Role playing is another technique that has been used to assess motivation and

readiness to learn. It has been used to change ideas and attitudes about behaviour.

Through role playing, a desired behaviour cm be rehearsed. The person can be taught the

skilis required and gain the confidence needed to cany thern out. It is a form of rehearsal

to praaice. It is also a means of increasing retention in leaming. Role playing techniques

have been cited as usefil in teaching the poor from disadvantaged backgrounds. In the

role playing literature the effkct of tacher led and peer led programs was exarnined. It

was found that motivation to quit and attitudes to change smoking habits were reidorced

by acting out various smoking scenarios (McFall& Hammen, 1978). Palmer (1 980)

reported that there were significant attitude changes about anti-smoking carnpaigns

foilowing discussion around anti-smoking issues. Role playing enabled participants to

express feelings without fear of reprisai, enabhg them to discuss private problems, and to

leam to identi& with others. Hom (1979) usecl role playhg to m o d e smoking habits in

youngsters who then took on the role of providing uIformation to theù parents about the

dangers of smoking. Role playing led to a smdi decrease in the nurnber of students who

would otherwise have started to smoke.

Janis and Mann (1979), compared coiiege students who role played five scenes

about being told by a physician that they had lung cancer due to cigarette smoking. At a

18

two week, eight month, and eighteen month foUow-up, those uivolved in the role playing

had sigdcantly reduced their cigarette consumption. A replication of this experiment by

Mann (1979) indicated that 50% of coiIege students had cut down their cigarette use d e r

being exposed to "fear" role playing.

A survey conducted by nurse researchen to determine how rnany nurses and

nursing students smoked in 1989 indicated that 17% of nurses were current smokers and

40% were ex-smokers. Over 30% of the students were smokers and 28% were ex-

smokers. When m e n t smokers were asked to idente supportive actions by colleagues

that could be taken to assis them to quit, they indicated: encouragement, peer support

groups, inexpensive smoke cessation programs, positive approach, information, emotional

support, and listening (Mao, Gibbons, & Wong 1992). They reinforced the need for

smoke cessation programs that focus on handhg addiction, stress management, and

weight control.

Many smokers needed interventions beyond information sharing and the nsks of

smoking to effectively help them move through the stages of change. For example, they

needed assistance to identlfy change strategies, to negotiate time deadlines and to develop

contingency plans which assisted them to make successfid decisions. The most effective

intervention strategy may be dependent upon correct diagnosis of decisional patterns and

correspondhg etiology (Prochaska, DiClernente, & Norcross, 1992).

Addiction

The problems encountered by individuals when atternpting to stop smoking

received increased attention after the Surgeon General reporteci that nicotine is one of the

19

most addictive substances known (U. S. Department of Heaith Services, 1989). In that

report t h e major conclusions were presented: 1) cigarettes and other forms of tobacco

are addicting, 2) nicotine is the dmg in tobacco that causes addiction, and 3) the

phannacological and behavioural processes that determine tobacco addiction are similar to

those that determine addiction to other drugs, nich as heroin and cocaine. Pnor to this,

tobacco was generally considered "habit-forming," rather than being characterized by the

more punitive definition of "addictive," with an associated withdrawal syndrome

distinguished by physical, psychological and behavioural disturbances (Cohen, Pickworth,

& Henningfeld, 199 1 ; Fagerstrom, Heatherton, & Kozlowski, 1990).

Nicotine acts in a variety of ways pha~~cologicaily, which makes nicotine

withdrawal syndrome an important issue to consider with respect to individuais who are

not successfùl at quitting smoking. Doses of nicotine may enhance pleasure, arousal and

relaxation, with improved attention and reaction time. may also reduce anxiety

and stress, alleviate hunger, and control weight. On the other hand, nicotine increases

heart rate and disturbs h a r t rhythm, causes vasoconstriction of cutaneous and coronary

blood vessels, increases metaboiism and blood pressure, and causes increased circulation

of neurotransrnitters (Benowitz, 1992). Nicotine withdrawai could precipitate enough

physiological and psychosocial dysfunction to influence an individual to not want to

pursue their goal to stop smoking. Dysfùnctions hclude irritability, restlessness,

drowsiness, difnculty concentrating, impaired task perfomiance, anxiety, hunger, weight

gain, sleep disturbance, cravings for nicotine, and decreased circulation of

neurotransrnitters (Benowitz, 1992). Thus the use of alternative nicotine therapies may

20

be warranted for certain smoken when they are attempting to stop smoking. Srnokers

who have smoked for a long period of the , or are "heavy smokers" (>20 cigarettedday),

may have more difficuity aopping and may require adjunctive therapy (Fagerstrom,

Heatherton, & Kodowski, IWO).

There is evidence that people who smoke as iittle as haifa pack per day are tahg

in enough nicotine to show characteristics of addiction (O'Hara & Portser, 1994).

Physical dependence can be manifested as tolerance which is the need for specific doses of

a substance in order to obtain desired eEect. With physical dependence there are

characteristic withdrawal symptoms and the substance is taken to relieve or avoid

withdrawai. There may also be unsuccessfbl attempts to cut down or control use of the

substance. Thus there is variation among smokers in the amount they smoke and the type

of cigarette brand they choose according to its nicotine content. Psychological

dependence occurs when the smoker perceives cigarettes as necessary to obtain optimal

well being. Thus a great deal of t h e is spent using the substance despite knowledge that

there may be adverse effects. The Fagerstrom Tolerance Questionnaire (FTQ) provides an

indication of the discodort associated with nicotine withdrawal (Fagerstrom, 1978).

O'Hara and Portser (1994) found that smokers with high FTQ scores attributed theïr

smoking to avoiding withdrawal symptoms. Hard core smokers (smokers that smoked

more then two packs of cigarettes per day), denied fewer health effeas and reported less

howledge about the consequences of smoking.

The connection between drops in plasma nicotine levels and craving is not

inherent; it develops over tirne, with a history of smoking experience, through the

mechanism of emotional memory (Fisher, Haire-Joshu, Morgan, Rehberg, & Rost, 1990).

To Uustrate, a person may initiate smoking in a fear situation that produces a negative

emotion. Nicotine can induce muscular inhibition which rnay enhance relaxation and help

to control fear, manger, and the level of distress in a threatening situation. Smoking can

regulate the intemal milieu by dampening or augmenthg aroud induced by extemal

events and at the same time provide direct help in coping with these events. Therefore,

the individuai develops a scherna that wnsists of extemai stimulus mes (social events,

work, nothing to do, taste), internai stimulus aies (sensations f?om drops in plasma

nicotine levels), and a variety of reactions, including subjective emotional experience and

expressive motor and autonomie reactions associated with the event and with smoking.

S u m r n q

While much has been achieved over the past quarter century to reduce the rate of

cigarette smoking, the heaith consequences associated with cigarette smoking still

represent a major challenge to health professionals. More information about any subject is

retained if a variety of media are avaiiable. The degree to which people feel at risk may

a f f i their desire to cut dom. Knowledge, attitudes and betiefs are related to behaviours

and a variety of educationd strategies such as role playing and relaxation techniques have

been successfùl in preparing people for change. FUiaUy, interventions must r e c o m e and

attempt to overcome physical as weil as psychological dependence on nicotine.

CHAPTER III

METHODOLOGY

Research Design

This mdy used a quasi-experimental design to assess whether there was a

difference in smoking outcornes between two groups of smoking prisoners. A

nonrandomited control group pretest-posttest design determined whether the independent

variable, smoke cessation classes, impacted on specified response and classification

variables. A convenience sample was drawn fiom a CSC institution in south esstem

Ontario. There were two separate units in the CSC institution, one unit housed the

comparison group and the other housed the intervention group. Upon admission to the

institution the offenders were placed in either unit according to bed space availability. The

comparison group was received through the normal intake process in a CSC institution.

The intervention group was received in the sarne way and ;tgreed to participate in smoking

and health related discussion and activities.

Method

Protection of Subiects' Rights

The investigator approached prisoners to participate in the study during their

orientation class on Day 2. The investigator told them she was a nurse who was pursuing

her thesis at the university. The purpose of the study was explained to them, and they

were told that the study had been approved by both Queen's human subjects' Research

Ethics Board and the CSC Ethics Board and Administration at the CSC facility. They

were asked to consider participating if they were currently smoking. It was made

23

expiicitly clear that participation was strictly voluntary. AU subjects were informeci that

they had the right to refuse to aRSwer s p d c questions, or withdraw fkom the study at

any tirne. They were infonned that if they agreed to participate they rnight be part of a

group who would receive five information sessions in the classroom or a cornparison

group who would receive an idormation package after responding to the questionnaires at

Tirne 3. Subjects were advised that they mîght benefit fiom the study by leamllig more

about smoking and the risks to their health, new ways to cut d o m on cigarette

consumption and possible quitting techniques.

Subjects were informed that they would not be personally identifid through the

data collection process, or in any subsequent discussions outside the classroom, or

through publications. They were assured that aiI infoxmation would be held in strict

confidence by the researcher and would not be discussed with any other individual, except

in aggregate form. Their name would not be recorded with their answers on their

questiomaires. AU research data would be stored in a locked f i g cabinet in CSC. Any

possible identifier, such as the consent form, would be kept in a secured location separate

fiom the demographic data and completed questionnaires. The consent form and

questionnaires were then given to dl volunteering participants who stayed behind in the

classroom. These participants signed and received their copy of the infonned consent

(Appendk E).

Data Collection

The samphg procedure consiaed of the investigator approaching ail newly

incarcerated prisoners who were receiving their orientation in a federal institution for men

in Ontario. This occurred over a penod of two weeks until a total of 100 volunteers

agreed to participate. This CSC unit provided aii orientation, classification, and initial

testing for ail Federai offenders in Ontario. The average stay was eight weeks for most

prisoners. The stay might have varied depending on length of time it took for necessary

psychological testing, police reports, court documents, and other assessments in order to

make the decision about which institution they would ultimately be placed in.

The normal routine at this CSC institution meant that each newly incarcerated

offender reported to the school on Day 2 to attend a week of onentation. This

onentation provided idionnation conceming placement, sentencing, parole, eiigibility

dates, application for day paroles, and treatment facilities. At the end of the first class the

orientation teacher introduced the principal investigator at which time the a h of the study

was explained. AH interested volunteers stayed behind and filled out the information and

consent form (Appendix E), the Socio-Demographic questionnaire, the Fagerstrom

Addiction Questionnaire (FTQ), the Life Skills Student Questionnaire (LSSQ), and the

Stage of Smoking Change Algorithm (SSA) (Appendices A n ) . Critena for participation

in the study included the following: 1) consent to participate, 2) smoking, and 3) able to

read, understand, and speak English at the elementary level.

The subjects upon admission to this CSC institution were placed in either of two

ranges according to bed space availability. Fifty prisoners in the study were in either

range. One range housed the cornparison group and one housed the intervention group.

One prisoner in the cornparison and four prisoners in the intervention group were

transferred to their parent institution before the completion of the study. Seven subjects in

the cornparison group refused to fiii out the questior-es at Time 2 or 3. Four subjects

in the intervention group did not attend all five classes in the school and thus were

elLninated fkom data analysis. Thus, the sample wnsisted of 84 prisonen with 42 subjects

participating in both the intervention and cornparison groups.

Procedure

After the subjects were placed in either the comparison or the intervention groups,

a schedule of classroom sessions was given to the intervention group (Figure 1). Security

personnel were also informed so that the intervention group were dowed to attend the

smoking cessation classes. Ail prisoners in the study would normally have been locked up

23 hours per day until transfer to their parent institution.

Phvsicai Setting

At Time 1 the questionnaires were Wed out by aii participants in a classroom in

the prison school. The pnsoners were seated at desks. At Time 2 and Time 3, the

investigator visited members of the comparison group at their celis to administer the

questionnaires. Those receiving the educational intervention were divided up into two

groups because of security personnel's concem about having the researcher in a classroom

with more than 25 pnsoners. A TVNCR was set up at the front of the class with a

flipchart to write on. During the role playing sessions the tables and chairs were placed in

a circle to allow the participants to interact with each other.

Week 1 Week 2 Week 3 Week 4 Week 8 1 1- - 1 ._ I I

100 offenders 2 one hour 2 cme hour 1 one hour consent to classrm sessions classroam classroom session participate and for intavention sessions for for intervention fill out WWS (21 ~ e r intervention P U P S

instruments. PUP). F O W S Assign 50 to cornparison, i.e. regular intake orientation, 50 to intervention, i-e., reguiar intake plus smoke cessation and relaxation classes.

Both groups fill out instniments.

42 in each group 42 in each group fill out fill out instruments- instruments. (Cornparison group

were o f f d a howledge session and given ido. on smoking at completion of mdy) -

Figure 1. Time line for data collection and intervention.

Intervention

Classroom Sessions (Intervention Groupl

A planned smoking education cmiculum was incorpomed into the five classroom

sessions (Appendix F). Session 1 comisted of an introduction to tobacco and the effects

of cigarette smoking on health supplemented by a video on smoking fiom the Canadian

Lung Association. Goal setting was introduced and each participant was asked to fill out

their own personal goal for each week. The concept of stress and how this can be

countered by the relaxation response was introduced. Relaxation methods were reviewed.

Session 2 consisteci of a review fiom Session 1 and practice of relaxation

techniques as a method of coping with stress. The investigator explained the rationaie,

and had the class practice relaxation exercises such as muscle tensing and relaxing, deep

breathing and listening to a cassette tape with soothing music. The concept of smoking as

an addiction was introduced and was related to other addictions such as dmgs and dcohol

as maladaptive fonns of coping with stress. Participants were invited to examine how

their smoking might be related to their stress. Participants were asked to share their own

experiences and attempts at quitting. Each participant reviewed their goal, was asked to

write a s idar goal for the foilowing week and encouraged to practice their relaxation

techniques each day.

Session 3 wnsisted of a review of the relaxation techniques and discussion to

determine if they were effective in helping to aileviate stress. Another video h m the

Canadian Lung Association was used as a basis for discussion about substance abuse and

28

peer pressures to smoke. Participants taiked about their own personal experiences with

addictions. Each participant reviewed their goal and made a goal for the following week.

Session 4 consisted of review and the introduction of the concept of seKesteem.

Ways to rnake them feel more positive about themselves were disaisseci. Participants

were asked to take a partner and ask each other questions such as: 1) name two things

that you are good at, and 2) describe a success in your We. The Stop and Think Model

(Rhodes & Jacobs, 1988) was introduced as another way of coping with stress and

enhancing self esteem.

1) Stop: Ident* the problem.

2) Think: Select the goal.

3) Consequence: T M about the pros and cons.

4) Decision: Decide what to do.

5) Evaluate Outcome.

Pamphlets fiom the Canadian Lung Association were handed out to provide fiirther basis

for discussion with the subjects. They reviewed the index w d with the goal they had

filled out and made a goal for the next week.

Session 5 consisted of role playing scenarios regarding smoking (Appendix F). A

review was carried out of d l of the key concepts regardhg smoking, and stress and

cophg. Participants were asked to volunteer what they found helpfd or not regarding the

classes. At the end of this class the participants were again asked to £iU out the Socio-

Demographic Questionnaire, the Stage of Smoking Change Algorithm, the Life Skiiis

Student Questio~aire, and the Fagerstrom Tolerance Questionnaire. The hvestigator

29

rerninded the participants that they would fiil out the questionnaires again in four weeks

tirne.

The investigator contacted subjects in the cornparison group in their cells at 4

weeks time and then again in a 8 weeks thne to fdI out the questionnaires. Mer the

cornparison group filleci out the questionnaires at T h e 3 they were given the Canadian

Lung Association pamphlets on smoking and asked ifthey would like to attend a class on

smoking cessation. Thirty-two subjects nom the cornparison group participated in a

classroom get together and were given an oveMew of Session 1 dong with the two

videos on smoking.

Instrumentation

The foiiowing instruments were used : the Socio-Demographic Information

Questionnaire, the Stage of Smoking Change Algorithm, the Life Skills Student

Questionnaire, and the Fagerstrom Tolerance Questionnaire. Both groups filied out the

questionnaires at Tirne 1, Time 2, and Time 3.

Socio-Demograp hic Questionnaire

The Socio-Demographic Questionnaire was constructeci for this study (Appendix

A). This measure yielded descriptive data on the subject's age, amount smoked,

perceived health, confidence about being able to quit, nurnber of prior quit attempts, years

of education, and whether or not their ceil mate smoked.

Stage of Smoking Change Algorithm (SSA)

Stage of smoking change was measured using the SSA which places individuals in

one of five temporal phases of quitting smoking (precontemplation, contemplation,

30

preparation, action, and maintenance, Appendàc D). These stages form a simplex pattern

in which adjacent stages are more highly correlated with each other than with those m e r

removed (Mcconnaughy, Prochaska, & Velicer, 1987). In a longmiciinal study with a

sample of smokers (n= 1,466) volunteering for a smoking cessation program, DiClemente

et al. (1 991) found these stages of change correlated highly with the processes individuals

go through to achieve change. Stages of change were also found to correlate highly with

responses to the previously validated decisional balance scale (Velicer, DiClemente,

Prochaska, & Brandenburg, 1985). People who answered the "extremely important"

items reflecting gains and losses associateci with smoking were closer to the preparation

stage of change. People who answered "not important" were in the precontemplative

stage.

Further validation of the stage of smoking change algorithm occurred when

subjects' scores on the Smoking Abstinence Self-Efficacy Scale piclemente, Prochaska,

& Gibertini, 1 98 5) were compared with these stages of change. Subjeas with higher

efficacy to abstain from smoking across various cues to smoke were closer to preparation

and action stages than contemplators (DiCiemente et al., 199 1). This algorithm was given

at Times 1,2, and 3 of data collection stages. Scoring consisted of 5 meaning

precontemplation, 4 meaning contemplation, 3 meaning preparation, 2 meaning action,

and 1 meaning maintenance.

Life Skills Student Questionnaire CLSSO)

The Life Skilis Student Questionnaire (Appendk C) was developed by BotWi,

Baker, Resnick, Felauola, and BotWi (1984) for researchers interested in obtaining a

3 1

comprehensive assessrnent of substance abuse information in adolescents. The LSSQ

contains several distinct d e s . Botvk et al. (1984) reported that dl of the d e s

includiig the bowledge seaion have a test-retest reliabiliv of .66 to .78 when

adrninistered to adolescents. The authon stated that scales within the questionnaire can

be administered on their own without comprornising reliability. The LSSQ was deemed

suitable for the prison population in this study because many had no higher than readability

at the adolescent level. It contains 10 questions that are tnie or false to test a respondent's

knowledge regarding the effxts of smoking on one's health. Scoring consisted of

entering the number of correct responses, O rneaning none correct and, 10 meaning ail

correct.

Fagerstrom Tolerance Ouestionnaire mO)

The Fagerstrom Tolerance Questionnaire (Appendix B) was originaily developed

by Fagerstrom in 1978 to measure smokers' dependence on nicotine (Fagerstrom, 1978).

Fagerstrorn and Schneider (1989) maintain that daily and compulsive smokers are

dependent, in varying degrees, on nicotine. It has also been noted that dependence on

nicotine is an important bamier to success in smoking cessation, as well as a predisposing

factor for relapse following quitting (Benowitz, 1992). The FTQ consists of eight self-

report questions which are designed to measure level of dependency. Answers to

questions correlate with biochemical evidence of tobacco addiction. Fagerstrom and

Schneider (1989) reviewed 16 published and unpublished reports in which scores on the

FTQ correlated significantly with smokers' levels of exhaled carbon monoxide, plasma

nicotine and urine cotinine respectively. They concluded that the FTQ may be a justifiable

32

replacement for time consuming, expensive and invasive biomedical testing for nicotine

dependence. The FTQ has faÛ internai consistency (coefficient aipha=.53) but has been

found to correlate significantiy with follow up smoking aatus (Fagerstrom & Schneider,

1989; Lichtenstein & Mermelstein, 1986).

Fagerstrom (1982) found that subjects with high FTQ scores who were restricted

to lower yield nicotine cigaraes versus their regular brands, increased the number of low

yield cigarettes smoked (F. 77, g<.005). Fagerstrom and Schneider (1 989) also looked at

clinical application of their FTQ and reported that high FTQ scorers did better with

nicotine replacement therapy when txying to quit. They aiso found that individuai

questions correlated signincantly with total scores in their own studies. The FTQ was

selecîed for this study for its non-invasive qualities in determinhg levels of nicotine

dependence. Scoring consisteci of entering 1 for the least addictive answer and 2 or 3 for

the more addictive answer. The higher the score the more addicted the person was to

tobacco.

Hypotheses

In order to answer the research questions the following hypotheses were proposed:

1. Four and eight weeks following incarceration, stage of smoking change wili be

higher among pnsoners given the supportive-educative smoking cessation

intervention than in the cornparison group.

2. Four and eight weeks foilowing incarceration, knowledge will be higher among

prisoners given the supportive-educative smoking cessation intervention than in the

cornparison group.

33

3. Four and eight weeks foliowing incarceration, level of nicotine addiction will be

decreased in prisoners given the supportive-educative smoking cessation

intervention than in the comparison group.

4. Four and eight weeks following incarceration, amount smoked wiii be less among

prisonen given the supportive-educative intervention than in the cornparison

PUP-

5 . Four and eight weeks following incarceration, wddence in ability to quit wili be

higher in prisoners given the supportive-educative smoking cessation intervention

than in the comparison group.

6 . Four and eight weeks foiiowing incarceration, self-reported health will be rated

higher in prisoners given the supportive-educative smoking cessation intervention

than in the cornparison group.

7. Four and eight weeks following incarceration, quit attempts wiil be greater for

prisoners given the supportive-educative smoking cessation intervention than in the

comparison group.

Summary

This chapter described the research design, selection of subjects, data coUection,

the intervention or inde pendent variable, and instrumentation with s c o ~ g techniques. It

concluded with the operationally stated hypothesis for statistical testing.

CHAPTER IV

THE RESULTS

One hundred abjects who met the inclusion d e r i a volunteered to participate in

the study at T i e 1. To avoid possible interaction among abjects and contamination of

results, intervention and comparison subjects were housed on separate ranges. Data

âom 16 subjects were dropped fiom the analysis because they were unwilling or unable to

complete the questionnaires at T h e 2 and T i e 3 . At the conclusion of the study there

were 54 complete data sets.

Data Analysis

The data were analysed using the Statistical Packages for the Social Sciences

(SPSS) for windows software prograa Responses were fkst examined in tems of

descriptive statistics for frequency diaributions and measures of centrai tendency. Scores

on the questionnaires of the intervention and comparison groups were wnsidered interval

data. Thus it was assumed that the use of parametic statisticai methods was justined

(Armstrong, 198 1; Burns & Grove, 1997). As this was a paired samples-two group

design, t tests for independent samples were first computed to compare the Merences

between means. Paired sample 1 tests were then computed to examine the probabiiity that

paired prisoners among groups had similar smoking outcomes over t h e . Bonferroni's

procedure' was used in order to control for the escaiation of significance when tests are

performed on different aspects of the same data. Because there were 42 tests performed

'In these analyses tests of the means were performed on seven different questions at three times in two groups 2(7x3)=42. For an alpha of .05/42, r-001.

35

on the data, the Bonferroni adjustment provideci an alpha of <.O01 to decrease the nsk of

Type 1 error (Winer, Brown, & Michels, 1991). Sackett, Haynes, and Tugwell(1985)

suggest it is criticai to apply the stringent Bonferroni correction when evaluating the

resuits of clinicai trial research. It could be argued that the use of this wnservative factor

excessively reduces the power of a test, thereby increasing the rïsk of a Type II error

(Shott, 1996). However when deciding to apply the Bonferroni correction in this study,

the relative risk associated with Type 1 error was weighed in favor of that associated with

Type II error.

Sub-iect Demoara~hics Data at Tirne 1

Masures of centraiity, eequency, and variability were used to summarize the

sample characteristics. Demographics of the sarnple at T h e 1 are presented in Table 1.

Subjects ranged in age from 19 to 62 with a mean of 34, a median of 32 and a standard

deviation of 9.5. The years of education in the study sample ranged nom less then Grade

5 education to greater than post-secondary education. Seventeen percent (n=14) of the

sample had less then Grade 8 education. Fi-nine percent (n=49) of the sample indicated

they had not finished high school. Twenty-five percent (n=21) of the sarnple indicated that

they had quivalent to a post-secondaq education or greater. Forty-one percent (n=34)

of the entire sample indicated they were trying to quit smoking on the fkst questionnaire.

Niety-six percent (n=81) indicated other subjects on their range smoked. One

abject reported that he was the ody one who smoked on his range. Seventy-five percent

(n=63) of the sample indicated their c d mate smoked, thus only 25% (n=2 1) indicated

they had a non-smoker as a ceii mate. The reasons for smoking were exarnined initidy

36

and 36% (n=30) of the sample indicated they smoked because it was a habit. Nrneteen

percent (n=16) indicated they smoked because they were addicteci. Eleven percent (n=9)

indicated they smoked because they were bored, and another 11% (n=9) because they

were in jd. Ten percent (n=8) indicated they smoked because they were stressecl, and

another 10% were not sure why they smoked (n=8). Other reasons for smoking are listed

in Table 1. Several prisoners provided more than one answer. Twenty-nine percent

(n=24) indicated that they used other forms of tobacco while they were on the Street such

as snuE (n=4), pipe (n=1 O), and cigan (n= 10). The subjects were asked what proportion

of their familylfiiends were smokers. Sixteen percent (n=13) indicated few were smokers,

19% (n=16) indicated some, 56% percent (n=47) indicated most, and 10% percent (n=8)

indicated that they aii were smokers.

Scales

The SSA (Stage of Smoking Change Algorithm) is the scale that indicates where in

the quitting process the subject is at the time of asking. The Tirne 1 data is in Table 1, and

the rneasures of central tendency are in Table 2. The sale ranges nom precontemplation

(not intending to quit in the next six months) to the maintenance stage where the subject

has quit for at least six months. At the begiming of the study, 16% (n= 13) indicated they

were not intending to quit in the next six months. Thirty-eight percent (n=32) indicated

they had not quit but were contemplahg quitting in the next six months. Forty-six

percent (n=39) indicated they had not quit but were planning to quit in 30 days and had

tried quitting for at least 24 hours in the past year. There were no participants in the

action phase or maintenance phase.

Table 1

Freauency Sample Characteristics of ail Subiects at Time 1 (N=84')

Variables Frequency Percentage

Years of Education < grade 5 to < grade 8 > grade 8 to < grade 12 > post-secondary education

Trying to Quit @ present Yes no

Do others on your range smoke? Yes no

Does your ceil mate smoke? Yes no

Are others helping you to quit smoking? Y= no

Reasons for smoking? habit 30 36 addicted 16 19 boredom 9 11 only smoke while I'm in jail 9 11 stress 8 9.5 no reason given 8 9.5 1 don't feel like quitting 6 7.1 1 never thought about it 5 6.0 depressed with the situation 1 1.2

(Table continues)

Variables Frequency Percentage

Other types of tobacco use Yes no

Which proportion of your fdylfr iends are smokers?

few some most al1

Stages of smoking change Algorithm pre-contemplation contemplation preparation action maintenance

Life Skills Student Questiomaire above average knowledge 8- 10 correct moderate knowledge 4-7 correct poor knowledge 1-3 correct

Fagerstrom Tolerance Questionnaire mildly addicted 9- 1 1 moderately addicted 12- 1 5 severely addicted 1 6- 1 8

Amount of cigarettes smoked per day less than 1 Oldzy 10 to 19/day 20 to 29/day 30 to 39lday 40 to 49/day 50 to 59lday >6O/day

Confidence in quitting 1-3 not confident 4-6 moderately confident 7- 10 very confident

(Table continues)

Variables Frequency Percentage

Self reported heahh of subjects exceiient health above average average health below average poor heaith

Quit attemp t s O 1-5 6-13

Table 2

Measures of Central Tendency for all Sub-iects at T i e 1 N=84)

Variable Range Mean Standard Deviation

Cigarettes per day 2-75 23.9

Confidence 1-10 4.8

Health 1-5 2.8

Quit Attempts 0-13 3 .29 Note.

Trying = trying to quit presently Range = do others on your range smoke? Smokers = proportion of fdlyfi iends who are smokers SSA = Stage o f Smoking Change Algorithm LSSQ = Life Skiiis Student Questionnaire F'ïQ = Fagerstrom Tolerance Questionnaire

The LSSQ (Life Skills Student Questionnaire) is the scale that tests how

knowledgeable a person is about the effects of smoking. Subjects were asked to check the

best answer to 10 tme and fdse questions. At T h e 1, the mean correct responses of the

sample was 5.19 with a standard deviation of 1.39 (Table 2). The first scoring of the test

indicated that 50.0% (n-42) of the sample had poor knowledge (only 1 to 3 correct).

Forty-six percent (n=39) were a little more knowledgeable (between 4 and 7 correct

answers) and only 4% percent (n=3) had two or less wrong answers.

The FTQ (Fagerstrom Tolerance ~uestiomaire) is a measure of addiction that

categorizes subjects fiom mildly, to severely addicted. Scores can range from 8 meaning

low dependence on nicotine to 18 rneaning highly addicted. The mean of the entire

sarnple was 14.4 with a standard deviation of 2-24. Eightysne percent (n=68) of the

subjects indicated that they were so dependent that they smoked their first cigarette within

30 minutes after waking up in the moming. Seventy-four percent (n=62) indicated they

found that the hardest cigarette to give up was the first one they had within 30 minutes

after awakening in the moming. Forty-three percent (n=36) indicated they found it

ditncult to refiain from smoking in places where it is forbidden, i.e., case management

office, church, etc. Fifty-three percent (n=44) of subjects indicated that they were so

dependent that they would stil smoke even if they were too sick to get out of bed al1 day.

Ninety-three percent (n=78) indicated they always inhaleci. Oniy 4% (n=3) stated they

never inhaled, and another 4% (n=3) indicated they inhaied sometimes.

The amount of cigarettes smoked per day at T h e 1 ranged from 2 to 75, with a

mean of 23 -9, a median of 23, and a standard deviation of 1 1.82. With regard to

42

confidence in quitting this was measured using a iikert d e fkorn 1 to 10, 1 being not at

aii confident to 10 being completely confident. Forty percent (n=33) ranked themselves

below three as not being very confident, 3 1% (n=26) rated themselves midway on the

scale, and 30% (n=25) rated themselves kom 7-10 on the continuum of being very

confident they could quit smoking.

The abjects were asked to rate their health using a scale from excellent to poor.

At Time 1, 1 1% (n=9) indicated they had excellent health, 30% (n-25) hdicated they had

above average health, 33% (n=28) indicated they had average hedth, 20% (n=17)

indicated below average, and 6% (n=5) indicated poor health.

The number of recalled quit attempts varied fiom 1 to 13. Only 23% of the sample

(n=20) indicated they had never tned to quit smoking. SEay-four percent ( r i 4 1)

indicated they had tried to quit fiom 1-5 times Ui the past. Sixteen percent (n=13)

indicated they tried to quit 6 to 13 ùmes in the past.

Difference Between the Cornparison and Intervention gr ou^ at Time 1

The mean age of the cornparison and intervention group was 34. A t test for

independent sarnples was conducted to determine if there were significant Merences

between the two groups on age, other demographics, and scale results at Time 1 before

the intervention was conducted (Table 3). The means for the classification and response

variables were similar indicating that the groups were f&ly hornogeneous (Table 3).

Table 3

t tests toExam fferences between C-on & Interventipn Subiects on

Selected Studv Variables at Time 1 M=841

Variable Cornparison Intervention Test Statistic

Age Mean

Education Mean

SSA

LSSQ

FTQ

Cigarettes smokedlday

Confidence

Health

Quit attempts

Note. NS = non-significant SSA = Stage of Smoking Change Algorithm LS SQ = Life S kills Student Questionnaire FTQ = Fagerstrom Tolerance Questionnaire

Research Ouestion 1

1s there a ciifference in stage of smoking change between the comparison group of

prisoners and those prisoners who are @en the supportive-educative smoke cessation

intervention 4 and 8 weeks foiiowing incarceration? To address this first question, 1 tests

for independent samples were done at T i e 1,2, and 3 to determine if there were

signifiant changes in sample means over tirne (Table 4). Paired sample f tests were then

computed to determine if the change was attributed to the effect of treatment (Table 5) .

The SSA was treated as an interval scale measure because it was assumed there were

equal numerical distances between stages of change on the scde and the categones were

muhiaily exclusive (Myers & Well, 199 1). The level of si@cance was set a t p . 0 0 1.

The ciifference between the means of the SSA for the cornparison group and

intervention group at Time 1 was not signifiant, Table 4 (pl -000). At Time 2 there was

a significant dflerence as the mean of the intervention subjects indicated they were more

prepared to quit or contemplating quitting (Table 4, p--000). At Time 3, signifiant

differences between the means of the two groups continued (Table 4, p.000).

Paired sample 1 tests computed between T i e 1 and Time 2 showed that although both

groups had an increase in theu stage of smoking change, neither change was significant

(Table 5, r.006). Paired samples also were compareci at Tirne 2 and Time 3 intervention

and comparison groups were not significantly different (Table 5). Paired sample tests

also were computed between Tirne 1 and Tirne 3 and the impact of the intervention on the

treatment group was not significant (1,41) F=3.30,~.004. Thus although the means of

the two groups were significantly dif5erent at Time 2 and Time 3 the paired sample test

Table 4

t Sarn~les at Time 1.2 and 3 t tests for hde~enden

T h e 1 T h e 2 Time 3

Mean SD Mean SD Mean SD

SS A

LSSQ

FTQ

comparison intervention P

comparison intervention C)

comparison intervention P

Amount Smoked comparison intervention B

Confidence comparison intervention C)

Health comparison intervention P

(Table continues) Note.

*p<.OO 1 significant SSA=Stage of Smoking Change Algorithm FTQ=Fagerstrom Tolerance Questionnaire LS SQ=Life Skills Student Questionnaire

Time 2

Meau SD

Quit attempts cornparison 1.2 1 intemention 1.26 P .6 14

Note. *p<.00 1 significant SSA=Stage of Smoking Change Algorithm FTQ=Fagerstrom Tolerance Questionnaire LS SQ=Life Skills Student Questionnaire

Table 5

Ouestion 1 : 1s the Stane of Smoking Change Sidcantlv D i e n t &er F i e Education Sessions?

Paired Sample t tests

SSA comparison and intervention groups at Tme 1 and Time 2

Comparison group Intervention group Entire sarnple

Test Statistic F(1,41) = -3.522, p=.001NS F(1,41) = 2.874, ~=.006NS F(1,83) = -. 109, r . 9 13 NS

SSA comparison and intervention groups at Time 2 and Tirne 3

Comparison group Intervention group Entire sarnple

Test Statistic F(1,41) = -077, r . 0 7 7 NS F(1,41) = -374, r.710 NS F(1.83) = 1.562, p1.122 NS

SSA comparison and intervention groups at Time 1 and T i e 3

Comparison group Intervention group Entire sarnple

Test Statistic F(l.4 1) = - 1.649, r. 107 NS F(1,4 1) = 3.3032, g=.OMNS F(1,83) = 1.2 1 1, r.229 NS

- - -- -. -

~ o t e . NS=non-significant. Bonferroni's procedure was used in order to control for escalation of significance. SSA=Stage of Smoking Change Algorithm

48

statistic did not support the impact of the intervention. The hypothesis that stage of

smoking change would change after five educative sessions was not supported.

Research Ouestion 2

1s there any différence in knowledge about smoking 4 and 8 weeks followùig

incarceration between the cornparison goup of prismers and those who are &en the

supportive-educative smoke cessation intervention? The Life Skills Student Questionnaire

was treated as an intervai-sale measure. At T i e 1, the mean knowledge scores between

intervention and comparison groups were not significantiy dBerent (Table 4). At Time 2

and Thne 3 the increased mean scores of knowledge in the treatrnent group went nom

5.14 at The 1, to 6.88 at T h e 2, to 8.26 at Tirne 3. The wmparison group's mean

knowledge stayed at 5 -24 at Tirne 1 and Tirne 2, and increased slightly to 5.3 1 at Time 3

(Table 4).

Paired sample tests were computed behveen Thne 1 aud T h e 2 (Table 6).

Results indicate the intervention may have impacted sipificantiy on knowledge from Tirne

2 to Time 3, F(1,41)=-8.820, r.000 (Table 6). This effect dso lasted between Time 1

and Time 3. Thus the hypothesis that there wodd be a sigdcant change in knowledge

about smoking between the intervention and the comparison group over time is accepted.

Research Ouestion 3

1s there any dEerence in Ievel of nicotine addiction 4 and 8 weeks following

incarceration between the comparison group of prisonen and those who are given the

supportive-educative smoke cessation intervention? The Fagerstrom Tolerance

Questionnaire was considered an interval-scale measure. Independent t tests were

Table 6

Ouestion 2: 1s Knowledae Simificantlv Mirent d e r Five Education Sessions?

Paired Samole t tests

Knowledge about smoking cornparison and intervention groups at Tiie 1 and Time 2

Comparison group Intervention group Entire sample

Test Statistic F(1,4 1) = .000, p=1 .O00 NS F(1,41) = -10.188, ~.000* F(1,83) = -4.612, g=.OOO*

Knowledge about smoking comparison and intervention groups at Time 2 and Time 3

Comparison group Intervention group Entire sample

Test Statistic F(1,41) = -.621, ~ S 3 8 NS F(1,41) = -8.280, r-OOO* F(1,83) = -6.692, r.OOO*

Knowledge of smoking comparison and intervention groups at Tirne 1 and Tirne 3

Test Statistic Cornparison group F(1,4 1) = -2.63, p.794 NS Intervention group F(1.41) = -15.005, ~.000* Entire sample F(1,83) = -6.692, ~ . 0 0 0 *

Note. *~<.00 1 simcant LSSQ=Life Skius Student Questionnaire

50

calcuiated to determine ifthere were differences in FTQ means between each group over

t h e (Table 4). The mean tolerance to nicotine at Times 1,2 and 3 for both groups was

not significantly difEerent.

The paired sample t tests also supported that the educational intervention had no

signifiant impact on level of addiction of either group (Table 7). The treatment group's

addiction did not change significantly between tirne 2 and t h e 3 p-.010, or between Time

1 and Time 3, p=.010 (Table 7). The hypothesis that level of nicotion addiction would be

decreased in prisoners given the supportive-ducative smoking cessation is rejected.

Research Ouestion 4

1s there any ciifference in the amount smoked 4 and 8 weeks following

incarceration between the cornparison group of prisoners and those who are given the

supportive-educative smoke cessation intervention? At Time 1 there was no difference

between the groups in amount smoked (Table 4). At Tirne 2 at test for independent

samples also indicated that there was no significant dserence between the means

(p=.O 10). At T i e 3 however thme was a significant Merence between the means of the

2 groups (gc.001). The mean number of cigareîtes smoked by the intervention group

dropped h m 22.83 at Time 1, to 19.52 at Time 2, and to 13.8 1 at T ï e 3.

Paired sample f tests were then computed for the data (Table 8). Between T h e 1

and Time 2 the fewer number of cigarettes smoked among the intervention group was not

significant, F(1,4 1)=2.746, r.009. From T h e 2 to Time 3, there was a significant

decrease in amount smoked in the intervention group F(1,4 l)=4.189, r. 000). Sirnilarly

the intervention may have had a continuing effect on amount smoked between Time 1 and

Table 7

Ouestion 3 : 1s Level of Nicotine Addiction Sianificantlv Merent after Five Education Sessions?

Paired Sam~le t tests

FTQ of cornparison and intervention groups at Tirne 1 and Time 2

Comparison group Intervention group Entire sample

Test Statistic F(l,4l) = 9.223, r.825 NS F(1,41) = .734, r.467 NS F(1,83) = .376, r.708 NS

FTQ of comparison and intervention groups at Time 2 and T h e 3

Comparison group Intervention group Entire sample

Test Statistic F(1,41) = .662, g=.512 NS F(1,41) = 2.720, r.01 O NS F(1,83) = 2.398, r.019 NS

FTQ of comparison and intervention groups at Time 1 and T i e 3

Comparison group Intervention group Entire sampie

Test Statistic F(1,41) = 1.202, p.236 NS F(1,41) = 2.720, r . 0 10 NS F(1,83) = 2.133, p=-036 NS

-

Note.

NS=non-significant FTQ=Fagerstrom Tolerance Questionnaire

Table 8

Ouestion 4: 1s the Amount Smoked Sigdicantl~ Different after Five Education Sessions?

Paired Sarn~le t tests

Cigarettes smoked comparison and intervention groups at Time 1 and Thne 2

Comparison group Intervention group Entire sample

Test Statistic F(l,4l) = 0.223, r . 8 2 5 NS F(1,41) = 2.746, r.009 NS F(1,83) = 1.774, p=.080 NS

Cigarettes smoked comparison and intervention groups at T h e 2 and Time 3

Comparison group Intervention group Entire sarnple

Test Statistic F(1,4 1) = œ.788, r . 4 9 6 NS F(l.4 1) = 4.189, r . 0 0 0 * F(l,83) = 2.668, r.009 NS

Cigarettes smoked cornparison and intervention groups at Time 1 and Time 3

Cornpanson group Intervention group Entire sample

Test Statistic F(1,41) = -1.053, r . 2 9 8 NS F(1,4 1) = 4.189, p . 0 0 0 * F(1,83) = 3.510, p . 0 0 1 *

- - -- .-

Note. *ec. O0 1 =si@cant NS-aon-sigiuficant

53

Time 3, F(l,4 l)=4.189, p-.O00 (Table 8). T'us the hypothesis that amount smoked

would be less among prisoners given the supportive-educative intervention is accepted.

Research Ouestion 5

1s there a dflerence in confidence about quitting 4 and 8 weeks following

incarceration between the comparison group of prisoners and those who are given the

supportive-edocative smoke cessation intervention? The confidence in ability to quit

smoking between groups at T i e 1 and T h e 2 was not signrficant (Table 4). At Time 3

there was a statistically sigdicant difference between their rneans e .000 ) .

Paired sample tests were then computed for the data (Table 9). Between T i e 1

and Time 2 there was no statisticdy significant ciifference in confidence in either the

comparison or the intervention group. Between Time 2 and Tme 3 there was also no

significant difTerence. Similarly between Tirne 1 and Time 3 there was no statisticaily

significant ciifference in confidence about quitting in either group (Table 9). Thus even

though the intervention group's mean confidence about quitting increased at Time 3,

paired sample tests fded to show significant difference in either group. Therefore the

hypothesis that subjects' confidence would change d e r being given the smoking-

educative sessions is rejected.

Research Ouestion 6

1s there a ciifference in self-reported health 4 and 8 weeks following incarceration

between the comparison group of prisoners and those who are given the supportive-

educative smoke cessation intervention? Subjects' perceived level of health means did not

d8er significantly across time (Table 4). Paired sarnple 1 tests supporteci that there were

Table 9

Ouestion 5: 1s the Level of Confidence Sianificantiy Merent d e r Five Education Sessions?

Paired Sam~Ie t tests

Confidence comparison and intervention groups at Time 1 and T ï e 2

Comparison group Intervention group Entire sample

Test Statistic F(1,4 1) = - 1 -022, r . 3 13 NS F(1.41) = - 1.390, r . 3 7 7 NS F(1,83) = -1 .Mg, r.2 15 NS

Confidence comparison and intervention groups at Time 2 and Time 3

Cornpaison group Intervention group Entire sample

Test Statistic F(1,41) = 1.532, p . 3 13 NS F(1,41) = -1.390, r.172 NS F(1,83) = -.390, r.698 NS

Confidence comparison and intervention groups at Tirne 1 and Tirne 3

Test Statistic Cornparison group F(1,41) = -489, r . 3 13 NS Intervention group F(1,41) = -2.3 11, r.026 NS Entire sample F(1,83) = - 1.796, r.076 NS

Note. NS=non-signifiant

55

no significant Merences in either group ova 4 and 8 weeks (Table 10). Therefore, the

hypothesis that there would be changes in seKreported hedth given the supportive

educative sessions is rejected.

Research Ouestion 7

1s there any difference in number of quit attempts 4 and 8 weeks foUowhg

incarceration between the cornparison group of prisoners and those who are given the

supportive-educative intervention? Independent f tests on this data at T h e 1, Time 2, and

Time 3 indicated their were no significant merences between group means over time

(Table 4). This was supported when paired sample f tests were wmputed for number of

quit attempts at Times 1,2, and 3. There were no signifiant dserences, in either group

Time 1, to Time 2, to Tirne 3 indicating that the education intervention did not impact on

number of quit attempts over time (Table 11). Thus the hypothesis that there would be

significant daerences between groups in quit attempts following the supportive-educative

sessions is rejected.

Sumrnary

This chapter reported on the descriptive and Serentüil statisticd tests and fhdings

related to the data analysis. Paired f tests indicated that there was a significant increase in

knowledge regardhg the effects of tobacco and the amount smoked foliowing the

intervention. Although the 1 tests for means of independent samples showed signiticant

dserences between groups at Time 2 and Tirne 3 for stage of change, the paired sample

test failed to support the hypothesis that this might be due to the intervention. f tests for

independent sample means for confidence about quitting were sisnificantly ditferent

Table IO

Ouestion 6: 1s the Level of SeKReported Heaith Sidcantlv DEerent aRer Five Education Sessions?

Health comparison and intervention groups at Tirne 1 and T h e 2

Comparison group Intervention group Entire sample

Test Statistic F(1,41) = -1.355, F. 183 NS F(1,41) = ,000, pl .O00 NS F(l, 83) = -.49 1, r.625 NS

Heaith comparison and intervention groups at Time 2 and T i e 3

Comparison group Intervention group Entire sample

Test Statistic F(1,41) = 1.432, r.160 NS F(1,41) = -813, r . 4 2 1 NS F(1.83) = .155, p=.877 NS

Hedth cornparison and intervention groups at Tirne 1 and T h e 3

Test Statistic Cornparison group F(1,4 1) = -3 74, pz.7 10 NS Intervention group F(1.41) = ,339, p.736 NS Entire sample F(1,83) = -155, r.877 NS

Note.

Table 11

Question 7: Is the Number of Quit Attempts Sianificantl~ DBerent after Five Education Sessions? - -

Paired Sample t test

Quit atternpts cornpaison and intervention at T h e 1 and Time 2

Comparison group Intervention group Entire sample

Test Statistic F(1,41) = .1.138, r.262 NS F(1,4 1) = 2.460, r . 0 18 NS F(1,83) = .466, r.642 NS

Quit attempts comparison and intervention at Time 2 and T h e 3

Comparison group Intervention group Entire sample

Test Statistic F(1,41) = -529, p.262 NS F(1.41) = -.628, r.534 NS F(1,83) = 9.506, r.614 NS

Quit attempts comparison and intervention at Time 1 and T i e 3

Comparison group Intervention group Entire sample

Test Statistic F(1,41) = 336, r.408 NS F(1,41) = 1.638, r.534 NS F(1,83) = -691, r.491 NS

Note. NS-on-signincant

between groups at T h e 3 but the paûed sample g test did not support this research

hypothesis either. Furthemore, the intervention did not significantly change nicotine

addiction, self-reported health, and number of quit attempts. The foliowing chapter

speculates on the essence of these redts among a prison population.

CHAPTERV

DISCUSSION

The purpose of this quasi-expentnental study was to determine if ducative-

supportive smoke cessation sessions would make a difference among 84 subjects who

were divided into comparison and intervention groups. Spdcal ly , the study was

undertaken to determine whether an intemention of five smoke cessation classes, each of

approximently 60 minutes in duration, provided for prisoners over a four week period

would change smoking outcornes. This was a pilot project, the evaluation of which may

provide the building blocks for other smoking cessation classes with prisoners. It is the

goal of CSC to have institutions smoke fiee by the year 1998 which is in hamiony with the

Federal Government's wish to reduce smoking in the general population by the year 2000.

Subject Demographics

The demographic characteristics of the smoking prisoners were examined to

determine if the two groups were homogeneous. M e r the researcher explained the study

and requested volunteer smokers, about haif of each orientation class aayed behind to

participate by filhg out the questionnaires and consent forms at Tirne 1. It was not

known how rnany of the non volunteen were smokers and ifso why they declined to

participate. At the tirne of volunteering, subjects did not know what group they would be

placed in. It was refieshing to note that both the intervention and the comparison groups

had remarkably similar means for demographic characteristics so that one cm assume

these were two similar groups of smokers at the beginning of the study.

Sucty percent (N=50) of the sample indicated they were trying to quit at Time 1

60

which is higher than the general population of smokers. This may have been why they

volunteered for the study. Those who might not have been interesteci in quithg may not

have volunteered for the study to begin with. Everyone but one penon indicated that

other individuals on their range smoked. The one individuai d o indicated he was not

aware of anyone else smoking may have been on the special needs section of a range and

may not have left his celi often enough to be aware that othen were smokers. When

incarcerated in this prison reception environment, subjects were locked up 23 hours per

day until they were M y assessed and penitentiary placed. A few were lucky to get a job

which enabled them to get out of their celis during the day or evening to work. The

remainder had access to the small yard for one hour of exercise. Seventy-five percent

responded that their cell partner smoked indicating it was very difficult to get a celi

partner who did not smoke. When asked ifthey had anyone who was helping them to quit

smoking, only 26% (N=22) indicated someone was helping them to quit. But it was not

clear who that someone was, perhaps a cell mate who was also taking the sarne sessions,

or someone on the outside.

The subjects were asked to state and came up with eight reasons for smoking

(Table 1). Eight of the subjects provided no reason while another eight subjects provided

two reasons. Habit was the most fiequent response 36%, followed by addicted 19%, then

bord, 1 1%, and only while I'm Li jail, 11%. Subjects' other reasons for smoking included

stress, 1 don't feel like quitting, 1 never thought about it, and I'm depressed with the

situation. This could be interpreted to mean that many of these subjects were indicating

that smoking was in response to their appraisal of their recent incarceration.

61

Subjects were not asked whether they were currently using ilIicit drugs or dmhol

in the institution, or whether they had anoîher addiction on the outside. The issues of co-

addiction could be examine- in fiiture research. Fifty-six percent indicated that moa of

their family/fnends were smokers and 9.5% said dl were smokers which is consistent with

the literature on smoking. Only 15.5% indicated that few of their farnily/fnends were

smokers. If one lives in a rnileu where others around one are smoken, it is very diffidt

to get the support and empathy required in the quit process. Questions can be raiseci

about the subjects who were smoking out of boredom or ody while in jd. Were these

people with an extenial locus of control believing their response to events was detennined

by outside forces rather than being in thek control? Wojcik (1 988) suggested that

individuals with an extemal locus of control tended to blame their smoking on reasons

such as addiction, boredom, being stresseci out, and feeling depressed with the situation

Zamble (1 992) indicated that at the beginnùig of their sentences, prisoners reported

boredom was a major reaction to incarceration because they were lonely, depressed, had

guilt feelings, and had a lot of tirne on their hands.

Over 55% of study subjects indicated very high tolerance to nicotine, 73%

reported smoking 20 or more cigarettes per day and only 23% indicated they had never

tned to quit. Katz and Singh (1986) suggested that smokers with strong beliefs that

nicotine was addictive were the moa troubled by withdrawal symptoms, and made more

attempts at quithg before quitting successfùily. Secondary analysis of the data might

determine if addiction is a predictor of quit attempts in this population. This study was

accomplished over a reiatively short t h e penod of eight weeks which may not have been

62

long enough either to change a person's perception of their nicotine addiction or to

change their number of quit attempts. Another longmiciinal saidy rnight show different

resuits.

Research Questions

Was there a ciifference in stage of smoking change 4 and 8 weeks following

incarceration between the cornparison group of prisoners and those who were given the

supportive-educative intervention? In the beginning a large portion of the sample

indicated that they were at the preparation stage of quithg which may aiso have been a

reflection of why they volunteered for the study.

tests for independent samples at T i e 2 and The 3 indicated the intervention

group m e . had moved sigdicantiy M e r towards the action phase of change.

However when a paired sample test was computed to d e t e d e the variability within

samples between Time 2 and Time 3, both groups were not statistidiy different on their

stage of change. The educational intervention may have been having an impact on their

stages of smoking change but not at the p<.001 significance level that was determined by

the Bonferroni adjustment. It usualiy takes a long time to help participants move through

the stages of change and there rnay be rebound effects where smokers report quitting,

fdure, then resume smoking (DiClemente et ai., 199 1). Stage of smoking change was

discussed during the intervention sessions. Therefore, results may indicate that the

prisoners in the intervention group were particularly receptive to this change theory, but

given the shon duration of the intervention, and the limited range between 4

(contemplation) 3 (preparation) and 2 (action), the algorithm was not sufitient to

63

distinguish between contemplation, preparation, and action stages of the two groups.

The second question looked at knowledge regarding the effects of smoking after

five supportive-educative sessions. At T h e 1 both comparison and intervention groups

were not very knowledgeable about what cigarettes did to their bodies answering a mean

of 5 out of 10 questions correctly. The intervention group's mean was seven questions

comect at Tirne 2, and eight questions correct at The 3. The cornparison group's means

stayed the sarne with five questions correct at all three testings. Paired sample f teas

demonstrated the sigmfïcance of this knowledge change between groups. It would appear

that the intervention group was partiailarly receptive to the intemention messages. This

rnay well have been reinforcd by the selection of materials that they could retum to their

cells with and peruse over their rnany hours of inactivity. The intervention group may

have been receptive to principles of adult leaming incorporateci in the sessions which

encouraged participants to make personal meaning of the messages. The use of videos

and role playing may ais0 have been helpful for those with poorer iiteracy skiiis.

In much of the literature even though smokers have a good knowledge base about

the effécts of smoking, they d l 1 continue to smoke. People continue to smoke when they

have been diagnosed with heart disease, had bypass surgery and during pregnancy. When

comparing groups, even though the intervention group's knowledge about smoking

improved significantly they did not move significantly dong the stage of smoking change

vis avis the comparison group. Bull, Pederson, and Ashley (1 994) found that smokers

who had less knowledge regarding the effects of tobacco, dso tended to be more resistant

to change. Findings fiom this study would indicate that it may be possible to plant the

64

germinal seed that helps prisoners to want to change, but more t h e is needed to help

move them dong the continuum.

Zamble and P o r p o ~ o (1990) found that prisoners were more receptive to change

and most motivated to do something positive during the beginning of th& sentences.

Their subjects were receptive to change at the beginning of their sentence because many

had guilt feelings about being in jail and wanted to do something good for thernselves and

their families. This rnay have been reflected in the m e n t study. Assessrnent and waiang

for placement may be the ideal t h e to introduce educative-supportive sessions for

prisoners if CSC facilities wish to move to more smoke fiee environrnents.

The third question asked whether there were any dserences in nicotine addiction

d e r the smoking cessation classes. There were no sigdcant Merences between groups

over tirne. The FTQ is a self-report tool and the questions rnay have been difncult for

these prisoners to respond to. The participants only had so much money to spend and it

was cheaper for them to buy bales of tobacco and roll their own cigarettes than to buy

Player's Light, the only light cigarette for sale. Upon arrivai, the prisoners received a

canteen fund loan of $30.00 and had to buy their tobacco, hygiene products and tylenol

f?om this fùnd before money was transferred into their pison account. AU prisoners were

put on Level2 pay which limited the arnount of money they could spend unless they had

farnily who could deposit additional money in their amunts for them. Almost ali of the

prisoners reporied smoking the heavier nicotine brand because it was cheaper and they

were able to get more cigarettes from a bale. Many prisoners reported that they would

stiU smoke even if they were so il they could not get out of bed ail day. The prisoners in

65

this rmximum security sethg spent an average of 23 hours per day in their ceils udess

they were able to get a job. They were required to double bunk unless they were mentaiiy

challenged or had protective aistody concems that delimiteci their ability to &are a ceil.

The celi diameter was very smaii so most spent their entire thne lying or sitting on their

beds.

Aithough the issue of CO-addictions was not tested for among this sample, it would

be interesting to know in fùture studies if the newly incarcerated pnsoners are trying to

give up an addiction to alcohol andior dmgs at the same &ne as they are being

encourageci to give up smoking. Previous studies were not found that tested the FTQ

with a prison population. In fbture, biochemical measures of addiction such as cotinine

analysis might be helpfùl to validate its authenticity.

Was there any ciifference in amount smoked after the education sessions? At Time

1 the whole sample ranged fiom smoking less than 10 cigarettes per day to over 60 per

day (Table 1). The mean for the entire sample was 24 cigarettes per day. Paired t tests

indicated that between Time 1 and Time 2 the effect of the intervention was not

sigrilficant. But between Time 2 and 3, and T h e 1 and 3 the intervention may have

impacted significantly on the amount pnsoners on average were able to cut down, ~=.000.

The intervention group reported moving fiom smoking an average of 22 cigarettes per day

at T h e 1, to 19 cigarettes per day at Time 2, and 13 per &y at Time 3 compareci with

comparison group's mean of 25 cigarettes per day at Tirne 1 and Tirne 2, which increased

at Tirne 3 to 26 per day. Short of answering questionnaires about smoking at weeks 1'4,

and 8 into the study the comparison group had linle to take their minds off an important

66

coping strategy in their lives.. .smoking, even though many had expresseci an interest in

receiving help to cut d o m at Time 1. Whereas the intervention group subjects were

provided with encouragement and strategies which may men have had a spiii-over effect

among ceil mates and other prisonen on the range to which they were assigned.

These results are encouraging in that by providing prisoners with cognitive

information, behavioural techniques and support, it may be possible to change cigarette

consurnption and maintain it over tirne. The a h of the National Strategy for Health

Promotion (1992) was that by "1996 the smoking Canadian population would decrease

their tobacco use to 13.5 cigarettes per day" (p. 6). This National Strategy also

emphasized the need for more health professionals to be involved in smoke cessation

programs. Although somewhat coincidentai that the prisoners in this intenrention group

cut d o m to 13 cigarettes per day, there is an apparent need for testing among other

prison populations and it is not known if this sample was responding to the halo effect.

Research Question 5 focused on confidence regarding quitting smoking before and

after the education sessions. The participants rated themselves 6om 1 (not at ali

confident) to 10 (completely confident) they could quit smoking. Paired tests to

determine whether the intervention impacted on confidence at Time 2 and Time 3 showed

no signifiant dflerences. The prisoners in this sarnple rnay have experienced a lot of

stress, for many it was the fit time in jail, they were not sure what to expea and they

may have been very susceptible to what other prisoners told them. The intervention goup

subjects were able to cut down on their cigarette consumption and group means indicated

they felt more confident that they could quit. Garcia, Sc- and Doefler (1990) found

67

that individuals who used various strategies to help them feel cordident had higher quit

rates. Although a lot of factors in prison are out of a smoker's control smoking cessation

nirricula that build on promoting seff-esteem rnay be of value in confidence building.

Research Question 6 examineci whether the cornparison and intervention groups

rated their health Meren* f ier the five educative sessions. The prisoners rated their

health f?om 1 indicating they had excellent health to 5 indicating they had poor health. The

intent of this question was to see whether there was a role for CSC nurses to delve fùrther

into newly incarcerated prisoners' health concems. Future anaiysis might determine

whether those who are concerneci about their health are more willing to entertain receiving

help with quitting as the Literature would suggest.

Change in self-rated health was not significant over the . The intervention group

rated their heaith 2.64 at Tme 1 and 2.60 at Time 3 wmpared with the cornparison group

2.98 and 3 .O0 out of a possible 5. This result is not surpnsing given this prison

environment. The maximum time fiom the beginning of the study to the end was eight

weeks from recruitment to four weeks post-intervention. This may be too soon to see a

sigmfïcant difference in self-rated health. The intervention group did decrease their -

smoking signiIicantly but did not change their health rating. An important dimension to

reducing nicotine is the withdrawal that a person goes through which includes initability,

restlessness, drowsiness, difficulty concentrating, impaireci task performance, anxiety,

hunger, and decreased circulation of neurotransmitters (Benowitq 1992). As mentioned,

the majonty of the sample had to be locked up 23 hours a day with a one hour allotment

for exercise. If this study could be replicated in another environment with less stringent

68

security where prisoners are Eeer to roam within the grounds of the institution, more

encouragement to replace smoking with exercise could be part of the smoking cessation

cunicuIum. With better fticiiities for exercise rnight corne better ratings of health over

tune.

Question 7 measured quit attempts between the cornparison and intervention

groups given five education sessions. Paired sample 1 tests on the data indicated that there

were no significant ciifferences in quit attempts of cornparison or intervention groups over

tirne. Most smokers quit many times before becoming successful and many rebound

before they are able to quit for good. At four weeks, and then again at eight weeks there

was one person who had abstained fkom cigarettes for at least seven days prior to being

tested. Twenty-five subjects in the intervention group were smoking 10 or less cigarettes

per day and reported being on their way to quitting at Tirne 3. It would have been

interesting to test this group further dong in time to determine how many had quit, cut

down, or who were back smoking heaviiy. In a review of 10 prospective self-quitting

studies, Cohen et al. (1989) reported a median sixmonth abstinent rate of 13.2%.

Sumrnary

In sumrnary, two groups of prisoners volunteered to take part in a smoking

cessation study. Paired sample 1 tests showed that after the intervention there was a

significant dserence in the intervention group's knowledge and amount smoked.

Although the SSA means indicated movement for the intervention group, many of subjects

in the two groups were already in the contemplation and preparation stage of change.

Similarly, although the intervention group's confidence mean was higher at the end of the

69

midy this was not significant on the paired sarnple t tests. Thus stage of smoking change,

addiction to nicotine, self reporteci level of heaith, confidence about changing smoking

habits, and number of quit attempts were not si@cantly different immediately foiiowing

and four weeks after the intervention.

CHAPTERVI

SUMhfARY, RECOMMENDATIONS AND CONCLUSIONS

summary

The educative-supportive smoking cessation intervention may have intluenced the

means of two groups of prisonen in the Stage of Smoking Change Algonthm immediately

after and four weeks post intervention. Paireci sample f tests did not, however, show

signifiant dierences in groups' contemplation, preparation and action phases of change

nom Time 1 to T i e 2 and Time 1 to Time 3. This supportive nursing intervention was

designed to be consistent with the remmendations of other studies. Rather than focus

on quitting, the intervention was based on change theory, and stress reduction through

collaborative goal sethg to guide smokers on their way to contemplathg quitting,

preparing to quit and taking action. This intervention did support a signincant

improvement in knowledge about smoking which lasted over four weeks. Reported

number of cigarettes smoked also declined signiticantly. The corollary, level of addiction,

also declined to a srnail but not significant degree for the intervention group. Although 1

tests for independent samples showed the means of the intervention group feeling more

confident they could quit, their paired sample t tests were not signincant. Prisoners' self-

reported health, and number of quit attempts were not significantly changed after the

intervention. In sum, the hypothesis for the research questions 1,4,5,6, and 7 were

rejected.

Signincance of Research

Smoking is a critical hedth care issue that costs the govemment in sccess of 45

billion dollars a year in illness care. The mean age for starting smoking is 15 years and

tobacco related diseases wiil kill30,OOO Canadiam before they reach the age of 70 (Health

and Weifàre Canada, 1989). The majority o f Canadians who smoke will go on to smoke

for 40 more years ifthey do not participate in smoke cessation programs that work

(National Clearinghouse on Tobacco and Health, 1993). It is imperative that nurses in

CSC be active and involved in hami reduction and health education Nurses need to target

rnembers of the prison smoking population so the Federal mandate that alI CSC

institutions in Canada be smoke fke by April 1, 1998 becornes reality.

Limitations of the Shidy

There are a number of aspects of this study design that may have duenceci the

results. Due to the quick turn around of prisoners at this f i tut ion, it was only possible

to test them &er the Mh class and again four weeks later. The study was based on

prisoner acwunts and not ventied through any other means. The prisonen in this study

were newly incarcerated and yet to be penitentiary placed and most had to spend up to 23

hours per day, double bunked in their ceiis. In sample selection there was no

diferentiation made about offenders who had a job and were able to work and be out of

their celis during the day. This may have influenceci their perception of hedth and general

well-being because they did not have the opportunity to exercise fieely or control their

diet and Mestyle. This study used only newly incarcerated males who were iikely

expenencing additionai stress as a resuit of being incarcerated. Repeat versus first time

72

offenders, and type and length of sentence were variables that were not controlled for in

this study. Protective custody and administrative segregated prisoners could not be

inciuded because of their lack of institutional fieedom. Little is known about the reliability

and validity of the scales so further testing is warrantecl. One item rneasure of a variable

lacks range and reliability.

Social desirability may have idluenceci the intervention respondents' answers to

questions since they were in the classroom with the researcher who provided the

intervention. The FTQ, and the LSSQ had not previously been tested with a prisoner

population. Further reliability and validity checks on the instments appear warranted

and caution needs to be taken when interpreting one-item measures. At the outset three-

quarters of the sample were sharing a ceIl with a smoker which made it harder for them to

quit. There was no provision to be placed with a non-smoker as at this institution there

were not yet in place non-smoking ranges.

Nursing Implications

This study has implications for the role of the nurse in the CSC. Health teaching is

a mandate for nursing. Nurses because of their biopsychosocial expertise and fkequent,

continuing contact with the prisoners, have the unique opportunity of providing prisoners

with knowledge about their health. Nurses can serve as role models for promoting healthy

behaviour. The information that prisoners receive may empower them to bring about

changes in their lives which may in tum influence their families. Many prisoners are

vulnerable to iilness and need to leam about illness-prevention. By leamhg more about

smoking and the dangers to their health they may be moved steps beyond

73

precontemplation. Beyond smoking, CSC nurses need to help prisoners understand the

benefits of exercise, nutrition, stress management, and h m reduction masures related to

Mestyle practices.

Future Duections for Nursing

Until this time there were no studies on smoking cessation in CSC. This shidy

needs to be replicated in penitentiaries with dinerent levels of Secunty. W~th the movement

towards releasing prisoners at the earliest point in their sentence, nursing mua target

individuals who need health Uiformation and provide them with this at the begirIiing of

their sentence. W~th health promotion the cost savings are huge (Pender, 1996).

in the course of her daiiy work, other prisoners approached the researcher about

doing something positive for themselves and their families. Some indicated that they did

not want to smoke in fiont of their children when they were released, and felt it was a

good time to contemplate cutting down on their smoking. Where programs are available,

this pnsoner population has the t h e on their hands to go to programs. The intervention

group seemed to respond weil to psychosocial support in the classroom and the

educational materials. Thus early intervention during incarceration may be the best tirne to

introduce change because new prisoners are reflecting, may feel remorsefil and want to

start their life over again.

Recommendations

In the ideal situation there should be non-smoking ranges for prisoners who are a

non-smokers or who want to quit. In at least two Federal institutions efforts are being

made to place non-smoking prisoners with ceil mates who do not smoke. A M e r

74

consideration might be to place prisoners who are in the action phase with voiunteer sr-

smokers or non-smokers to get the encouragement and social support they need. It rnay

be tirne, to introduce into CSC nicotine replacement which is therapeutically tailored to

help the severely addicted prisoner who wants to quit. If CSC hold to their mandate to

rnake institutions smokefiee, it is t h e for nuning and medical advisors to develop

guidelines about which pnsoners are candidates for nicotine replacement. A protowl will

have to be developed for the CSC nursing staff.

This study needs to be replicated with other male and femde prison populations.

Post tests should occur over longer periods of the. Qualitative data also needs to be

gathered from prisoners so they c m report what works best for them and this cm be built

into future nursing interventions. Secondary analysis of the data f?om this study, using

rnultivariate statistics, might show significant predictors of smoking outcornes in this

prison sample.

King's theory of goal attainment (1986) is a usefùl paradigm because it elaborates

on the importance of mutual goal setting between the nurse and client (Kameoka, 1995).

Her insistance on collaboration is key to her conceptual model and can be useftl in

smoking cessation prograrns for pnsoners. Lazarus and Folkman's theory of stress and

coping (1984) describes cognitive and behavioural buffers that one uses to cope with

stress. Coping rnechansirns are different for each pnsoner and past experiences with

prison life and inmate culture may influence their response to incarceration. Prochaska

and Di Clemente's stages of change transtheoretical model (1983) was helpfùl for the

intervestigator and the intervention group to see how they must pus through the Werent

75

stages as they becorne more cornmitteci to quitting smoking. When shared with pisoners

this mode1 can explain the eqerientiai and behaviourai changes taking place and how they

think about their smoking.

76

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Socio-Demographic Questionnaire

Age? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

How many cigarettes a day do you smoke? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Whydoyousmoke? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

..... Does your cell mate smoke? Yes .--.. No

..... ..... Do other offenders on your range smoke? Yes No

..... ..... Are other people helping you to quit smoking? Yes No

How would you describe your health? No limitatioIIS/exceilent (.-..) Above average (....) Average (....) Some limitations/below average (. .. .) Several health problemdpoor (.. . .)

Have you ever îried to quit smoking? Yes .... No ..... ..... times

Do you use any other forms of tobacco wMe on the street? Yes ..... No ..-..

If yes, what kind? C hewing to bacco SnuE Pipe Cigars

..... Are you trying to stop smoking now? Yes ..... No

Ifnot, why not? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 1. Please circle the number of years of formai education you have had?

Less than 5, 5 , 6, 7, 8, 9, 10, 11, 12, 13, 14,

15, 16, 17, 18, 19, 20, more than 20

12. How confident are you that you can quit smoking? (circle one #) Not at aU Completdy 1 2 3 4 5 6 7 8 9 10

13. What proportion of your famiIy/fEends are srnokers? (Circle one #)

,.... a few ..... some ..... most ..... all

Stage of Smoking Change Aigorithm

Question: Have you quit smoking cigarettes? Check one. Score

O Yes, 1 have for more than 6 months (defines maintetaance). I

O Yes, 1 have, but for less than 6 months (defines action).

0 No, but 1 intend to in the next 30 days and have aied for at least 3 24 houn in the past year (defines prepatioo).

O No, but 1 intend to in the next 6 months (defines contemplation). 4

O No, and 1 do not intend to in the next 6 months (defines precontempIation) .

Life Skills Student Questionnaire (Botvin, G.J., Resnick, N., Filazzola, AD., & Botvin, E.M., 1984)

Most people my age smoke cigarettes.

Fewer than halfof the aduhs in this CO- smoke cigarettes

Fewer people smoke now than five years ago

Cigarette smoking is becoming less socidy acceptable than it once was

Cigarettes smoke contains a poisonous gas d e d carbon monoxide

Smoking a cigarette causes your heart to beat slower

Smoking a cigarene wiil d e a person more physically relaxed

Smoking a cigarette increases a person's blood level of carbon monoxide within a few minutes

Regular smokers have higher levels of carbon monoxide in theû blood and lungs than non-smokers

Smoking a cigarette decreases your hand steadiness almost

True

True*

True*

Tme*

True*

True

True

True*

True*

True*

False *

False

False

False

FaIse

False*

False*

False

False

False immediately

* l for each correct answer.

Fagerstrom Tolerance Questionnaire for Smokers

1. How won afier you wake up do you smoke your fïrst cigarette? Score

. . . . . d e r 30 minutes

. . . . . within 3 0 minutes

2. Do you find it difEicuit to refrain fiom smoking in a place where it is forbidden, e.g., in church, library, case management office?

..... no

..... yes

3 . Which cigardte wodd you hate most to give up?

. . . . . any other

. . . . . first thing in the moniing

4. How many cigarettes per day do you smoke?

. . . . . 1 5 or less

..... 16-25

... . . 26 or more

5. Do you smoke more fkquently during the fùst hours after awakening than during the rest of the day?

..... no

..... yes

6. Do you smoke ifyou are so iil that you are in bed most of the day?

..... no

..... yes

7. What is the brand of cigarettes that you smoke?

iight brand any other brand

Score 8. Do you inhale?

Information and Consent Forms

1 am a nurse studying for my Mastas who is mterested in your howledge about smoking and tobacco addiction 1 would Iike you to consider participating in rny study, though your decision is entirely voluntaxy. In addition to filling out q u c s t i ~ , half of you wili be asked to take part in 5 c lasmm sessions in the school over the nad 4 w d s . Each session wiil tdce approximentiy 1 hour. I wiU be leading the disaission about Me style and health issues, apeçiaiiy smoking. Those invoIved in these classroom sessions wiU discuss and participate in exercises which may help reduce stress. Those of you in the other half WU receive an information package about smoking and an opportunity to discuss this with me a f k the 8th week.

To se whether the 5 discussion sessions make a Merence, a i i of you wiii be asked to fïii out short questionuaires that date tc your cigareüe smoking and health. Ifyou agree, 1 will give you these questionnaies at 3 different times during your stay at this institution That wiii be now, in 4 weeks, and 8 weeks. Each time they wiii take appmximeny 30 minutes to complete.

Your participation wiU not affect your sentence laigth, placement, programs, or eligibility for parole. You have the right to withdraw your participation at any t he . Yom identity will be kept strictIy conMcntial and your name will not be associated with any of the questionnaires. Your sulswers wili be grouped with those of other volunteer smokm. The questionnaires wdi be identifid oniy with a code number. Your si@ consent will be locked in a nle cabinet in Millhaven and wiii not be associated with your m e r s on the questionnaires.

CONSENT

The purpose of this study has been described to my satisfaction and 1 a p to complete the questionnaires to the best otmy ability. By signing below, 1 am indicating that 1 have read and understood the information fom conceniing this study. If1 have am/ concems about this study now or in the future, 1 can contact the principal investigator Carey Varga at Milihaven institution at (6 13) 35 1-8388, rny thesis advisor Edith CosteIio at (613) 545-2668, or Dean Baumgart at (613) 545- 2668. My supervisor Dennis Comigan at Millhavm may also be contactcd at (6 13) 35 1-8388.

1 have read the idonnation fom and voluntarily consent to participate in the shidy.

Participant's Signature Witness Date

1 have explaincd this çtudy to the above participant and have sought his understanding for idonneci consent.

Investigator 's Signature Date

Educationd Component for the Intervention Group

RECRUITMENT OF VOLUNTEERS

* Study will be explained to participants. * Volunteers will sign idonnation and consent foms

SESSION 1

Go ai: To introduce the goals of the program and to bdd a supportive classroom setting.

* Introduction and purpose of program explaùied to participants. lnfom them that the program is designed to help people like them to lem about themselves and to promote cutting dom and eliminating tobacco. Teli them that they will leam about many different issues concemhg tobacco and practice important Life sMs. An effort wiil be made to develop opporhinities to lem and practice important life skiils and to mate an atmosphere where participants feel that they can discuss topics openly and honestiy.

Activities:

* Explain to group that you hope they wiU develop an atmosphere in which people act toward one another in supportive ways.

* Develop and post niles for establishing a cornfortable and supportive environment. * Explain that one of the goals of the program is skills training. Some of the skills they

will leam and practice include: a) decision making, b) communicating, c) building self-esteem, d) resisting peer pressure, e) setting goals.

* Introduction to knowledge component of smoking. * Give statistics on smoking and hedth, including the nsks of smoking for both men,

women, and children. * Discuss second hand smoke. * The benefits of quitting smoking wili be dixusseci. * Video fiom the Canadian Lung Association on Smoke Cessation. * Introduction on goal setting. AU participants will be asked to fili out an index card with

their personal goal for each week and the program. Card to be given to principal investigator .

* Relaxation techniques are explained to the participants and they will be asked to practice one technique for next week.

SESSION 2

Goal: To help participants leam about the types of s a s they need to deal with cutting d o m and quiniog smoking.

Activities:

* Review of what was learned fkom session 1. Explain throughout the study they will be leamhg about and practisiog the s m s and ideas discussed in the sessions.

* Principal investigator wiU present a discussion on prison üfe and the effects of stress and anxiety. Participants wili be asked to relate their on smoking habits with stress and being newly inmcerated. They d also relate this to other substance abuse areas such as drinking and dmg use when under stress.

* Relaxation techniques will be discussed and they will be asked to practice a technique for next week.

* Building seKesteem and communication sWs will be discussed. * Goals will further explained and each participant wilI write down their personal goal for

next week on a index card to be given to the principal investigator.

SESSION 3

Goal: to help participants think about the types of skilis they will need to deal with the challenges they are facing now and in the fiture.

Activities:

* Review of relaxation techniques, stress, and anxiety. * Knowledge on smoking and other substance abuse wiil be further discussed by the

researcher. * Video fiom the Lung Association will be used to explain substance abuse, peer pressure,

and resisting peer pressure. * Skilis-based prognims will be practised by the participants to include: Practice

interacting with others, and encourage ways to interact with others. * Participants d l agah be asked tu write down a goal for next week.

SESSION 4

Goal: Building Self-Esteem

Activities:

* Review of what was learned fkom last week. * Teii participants that today's class will explore the concept of self-esteem, and discover

ways to make them feel better about thernselves and help others to feel better. They will spend tirne thllikllig about who they are, what îhey are good at, and how they are seen by others. Al1 of these things affect uieir feelings about themselves and whether they feel confidant (Rhodes & Jacob, 1988).

* Ask the participants to form pairs and take tums asking and a n s w e ~ g the following questions: 1) Name 2 things you do well. 2) Descrifie a success in your life.

* Decision making d l be discussed and the ways that our values affkct the decisions that we d e .

* Ask the participants to write dom one example of a srnall decision and a difficult decision.

* Ask them to share some examples of their diEicult decisions (decisions about smoking and quitting) .

* Introduce the Ttop and Think Model" (Rhodes, & Jacob, 1988, p.62). 1) STOP: Identify the problem. 2) THINK: Select the goal 3) CONSEQUENCE: Think about the pros and cons. 4) DECISION: Decide what to do. 5) EVALUATE OUTCOME

*participants will be asked to fili out a goal on a index card to be collecteci by the principal investigator.

SESSION 5

Goal: To introduce role playing

Activities:

* Review of what was learned fiom Iast week. * Role playing wiil be discussed.

Role Playing Scenarios

Scenario 1)

Scenario 2)

Scenario 3)

Mchael is asked by his ceil partner if he should start smoking. Role play what you should tel him about smoking and stress.

Your daughter asks you about smoking because her fiends are pressuring her into starting smoking. Role play what you should tell your daughter.

You have quit smoking for one week and your ceIl partner finds you very irritable and he tells you "have a cigarette ço you can fit in to prison life' Role play what your response would be to your cefi partner.

Thank al participants for participating in the program.

* AU participants will flll out the questionnaires.

4 WEEKS P O S T / D J T E R ~ O N

* AU participants in the study wili fiii out the questionnaires.

Appendix G

Letter of Support

r CATHY GAINOR A T0 1 RESEARCH

1 EGIONAL HEADQUARTERS

MEMORANDUM NOTE DE SERVICE

slJSEIz7 ET RESEARCH PROPOSAL

I am a Mastas of Nursiilg Science studm at Queen's University and am submitting my research proposai to Queen's University Ethcs Department on June 24, i 996. 1 am going to conduct a quasi study to eacarMne knowiedge and stage of smoking change foilowiq a smokmg cessation htewention m Millhaven Institution. I wish to start reçniitmg participants for my r d study in September 1996 and have my daîa collected by November 19%. 1 am piamhg to have my thesis writrai and defmded by April 1997 to g d u a t e in the Spring c o n d o n . 1 then wish to go on and get a PHD in Nursing to be able to conduct research in Correctionai SeMces of Canada Piease see attache- description of proposal.

If you have any questions please feel fiee to call me a Miilhaven Iastiaiaon 3 5 1-8388 or by teamluiks. My hornephonemmiberis 384-1519.

Carey Varga RN., B.A, BMc

1 4

July

Correctional Service Senrice correctionnel Canada Canada

Ontario Region Région de I'Ontario

16, 1996

Ms. Carey Varga 734 Cedarwood Drive Kingston, Ontario K7P IV4

Dear Ms. Varga:

Your proposal to conduct a quasi .experimental study to examine knowledge and stage of smoking change following a smoking intervention in a federal correctional setting has been approved by the Regional Research Committee and Supported by the Warden at Millhaven Institution.

I would like to advise your however, that approval of this proposal, is conditional upon your agreement to abide by the conditions outlined in your agreement.

Also, to provide CSC with a copy of your findings and a brief summary that can be shared with managers and staff of the Region.

I wish you success

Yours, Sincerely,

in your project.

> ,l,, &D';~.Lv~/-, L i n e r A 1

/

Chair, Regional Research Cornmittee, CSC (Ontario Region), 440 King St. W., KINGSTON, Ontario K7L 4Y8

cc: Warden Millhaven Inst.

Government Gouvernement *I of Canada du Canada

1 MiUhaven Institution

FR- ~l ~tevenson DE Warden

1 Milihaven Instituton

C y CA-4" MEMORANDUM NOTE DE SERVICE

_I 1 July 16 1996 1 -WECr

J~~ Smoke Cessation Studv

This is to inform you that Carey Varga will be conducting a smoking cessation intervention study with newly adrnitted offenders in MAU. ïhere will be 100 participants in the study with 50 in the control and 50 in the intervention group. She will be conducting 5 classroom sessions with the intervention group divided into small groups. This study will take place in the programs area of the school from July 22 1996 to the

rL middle of September 1996.

Thank you for you cooperation.

Sincerelv

Al Stevenson

Canada

Appendix H Histogram of Age Frequencies

I Frequency