Changes in the profiles of smokers seeking cessation treatment and in its effectiveness in Galicia (Spain) 2001–10

Elisardo Becoa 0 Ana Lpez-Durn 0 Elena Fernndez del Ro 0 1 rsula Martnez 0 0 Smoking Cessation Unit, Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Santiago de Compostela , Santiago de Compostela , Spain 1 Department of Psychology and Sociology, University of Zaragoza , Zaragoza , Spain Background: In recent years, the prevalence of daily smokers has decreased in all developed countries due to a great variety of factors. Despite this decrease, the effectiveness of clinical treatments has decreased and several studies report a change in smokers' characteristics. The purpose of the present study is to analyze the changes in the characteristics of Spanish smokers who seek smoking cessation treatment between 2001 and 2010 and the changes in the effectiveness of such treatment. Methods: The sample was made up of 870 smokers who sought psychological treatment for giving up smoking at the Smoking Cessation Unit in the Faculty of Psychology of the University of Santiago de Compostela (Spain) during the period 2001 to 2010. Results: Smokers in the 2006-2010 group, compared to those in the 2001-2005 group, were older, smoked fewer cigarettes per day and of a brand with fewer mg/nicotine, had been smoking longer, were less motivated to give up smoking, and had more antecedents of depression. Quit rates were validated by testing smokers' carbon monoxide (CO) levels. Percentages of abstinence were higher in the 2001-2005 group than in the 2006-2010 group (58.7% vs. 52.15 at the end of treatment, p = 0.05); 30.8% vs. 24.2% at 6 months follow-up, p = 0.031; 27.5% vs. 22% at 12 months follow-up, p = 0.059). Although abstinence decreased more than 5% in the 2006-2010 group there were no differences between the two groups in nicotine dependence. Those participants who did not assist to the follow-up were considered smokers at pretreatment level. Conclusions: In Spain there has been a qualitative change in the profile of the smokers seeking smoking cessation treatment. Treatment effectiveness has decreased, and the variables predicting intervention outcome have changed. - Background In recent years, the prevalence of daily smokers has decreased in all developed countries [1,2]. In Spain, according to the Spanish National Health Survey (Encuesta Nacional de Salud), 31.7% of people of 18 years or older smoked every day in the year 2001, whilst this percentage had fallen to 23.9% in 2012. However, the percentage of occasional smokers has remained stable in the last decade [3]. More specifically, according to a study conducted in Galicia, Spain, in 2005 [4], 25% of the population between 16 and 74 smoked daily, with a slightly higher prevalence of smoking in men than in women. This significant decrease in the number of smokers may be due to a range of factors. Irvin, Hendricks and Brandon [5] consider that the main factors contributing to a 25% fall in smoking in the USA between 1983 and 1998 were: increased concern about the negative health consequences of smoking, the growth in limitations on smoking in public places, and increased availability of treatments for giving up smoking. In the same line, Lando [6] suggests that smoking cessation is more frequent in those contexts in which there are strong restrictions on this activity, such as those in which the price of cigarettes has increased significantly, or where smoking has come to be considered non-normative (through specific legislation). With the aim of reducing the prevalence of smoking in Spain, two legislative measures have been implemented relatively recently (Ley 28/2005 and Ley 42/2010). Until that moment, despite of the fact that many studies conducted worldwide had demonstrated the risks that smoke exposure had in health, smoking was allowed in working and leisure places in Spain. Moreover, legislation had focused only on the incorporation of health warnings in tobacco related products. The entry in 2006 of the Ley 28/2005 and in 2011 the Ley 48/2010 about health measures against tobacco were based on various regulatory aspects and on the promotion of programs and services for tobacco treatment and prevention [7]. These laws introduced the ban of tobacco advertising and promotion, the reduction of tobacco retail outlets and smoking bans in enclosed public spaces and workplaces. After the introduction of these laws a positive impact in Spanish people health was noted, as it significantly diminished smoking prevalence in adolescents; the number of cigarettes smoked was decreased in people who continued smoking; and the morbidity for acute myocardial infarction reduced, an important indicator of the mortality attributable to tobacco [8,9]. Catalina et al. [10] consider these measures to have contributed significantly to the reduction in the number of smokers and the prevalence of smoking. However, according to Nebot and Fernndez [11] this decrease in the number of smokers and even in the number of cigarettes smoked per day in those who continue smoking are due to the falling trend in relation to this habit observed before the introduction of this legislation. In this vein, recent reviews [12] conclude that specific legal prohibition with regard to smoking in public places would have a greater effect on passive than on active smoking, even though we cannot rule out the influence of these types of measures in the reduction of smoking among the general population. In other countries, where this type of legislative measure has been applied for longer, there has been a more detailed study of the changes in smokers characteristics and in the effectiveness of smoking cessation treatments. Thus, for example, Fagerstrm et al. [13] and Fagerstrm and Furberg [14] analyzed the relationship between the prevalence of smoking and nicotine dependence in a range of countries. They concluded that as the number of smokers decrease, the level of nicotine dependence among those who continue to smoke increases (the so-called hardening hypothesis). This concept of hardening is associated with a decrease in the number of attempts to give up and with smokers reduced capacity or maintaining abstinence (due to their greater dependence). This results in a need to use different strategies in relation to the problem [15]. In this same way, Irvin and Brandon [16] point out that as tobacco use decreases in the general population, those who continue smoking are more difficult to treat, and this is reflected in a reduction in effectiveness of clinical treatments in recent years. Furthermore, these researchers report a change in smokers characteristics, greater use of other substances, higher levels of psychopathology, lower educational levels, lower social status and greater nicotine dependence. The relation between the presence of psychopathology and the effectiveness of smoking cessation treatment has been widely studied. Piper et al. [17] and Schroeder and Morris [18], for example, conclude that people (...truncated)