Background
Chronic Obstructive Pulmonary Disease (COPD) is currently one of the most widespread lung diseases and is a growing cause of suffering and mortality worldwide. It is predicted to become the third leading cause of death in the near future[
1]. In northern Sweden, the prevalence of COPD was 14% among people over 45 years of age[
2]. Both the prevalence and the incidence increased with age[
2,
3]. The health economic costs were ten times higher in severe compared to mild COPD, and the authors suggested that early diagnosis is necessary to avoid disease progression and reduce costs for the society[
4].
Smoking is the most important risk factor for developing COPD, and about 50% of smokers develop the disease[
5]. When diagnosed with COPD, many stop smoking, while some continue to smoke. It is important for smokers with COPD to succeed in smoking cessation before their respiratory health is irreversibly damaged[
6]. It has been shown that smoking cessation, even intermittent cessation, reduced the excess lung function decline due to tobacco smoke[
7‐
9], and decreased the risk of exacerbations[
10].
COPD is an underdiagnosed disease[
3], and obtaining the COPD diagnosis seems important because it has been shown that smoking cessation was more common among those with a diagnosis[
11]. Further, studies have shown that long-term behavioural support increased quit rates[
12], and that smoking cessation may be more effective when counselling and pharmacological treatments were combined[
13]. However, smoking cessation can be difficult to achieve, especially among those with higher nicotine dependence[
14,
15]. Even after receiving smoking cessation support, COPD patients may not be able to quit smoking[
16]. In order to understand why individuals diagnosed with COPD continue to smoke, qualitative studies are required, but very few have been published. One available study showed that having respiratory symptoms was not reason enough to quit, as many of the smokers felt alienated and unworthy of smoking cessation support as they regarded their disease as self-inflicted[
17]. The aim of the present study was to describe the difficulties experienced by individuals diagnosed with moderate COPD who are unable to stop smoking.
Discussion
Smoking cessation is the most important intervention to reduce the risk for cardiovascular and respiratory diseases[
6], especially COPD. While most individuals understand the benefits of smoking cessation and many who are diagnosed with COPD quit smoking, some continue to smoke. In order to understand why individuals diagnosed with COPD continue to smoke, qualitative studies are required. The purpose of the present study was to describe the difficulties of smoking cessation experienced by individuals diagnosed with moderate COPD who had been unable to stop smoking. We have shown that the participants had a long habit of smoking; they had begun smoking when they were between 12 and 13 years old. The participants’ lives were governed by a lifelong smoking habit that was difficult to break although they had knowledge about the harmful effects of smoking. The participants described incidents in their lives as reasons for never finding the time to focus on smoking cessation. Motivation and support are needed after the smoker has made the decision to quit. Those participants who hesitated to make the decision also felt critical of the information and support that were provided. Support should be given after the individual has made his or her own decision. The person’s autonomy must be ensured, and respect for his or her sovereignty must be given.
Because nicotine dependence is a strong addiction and smoking is related to a feeling of pleasure, smoking often becomes a lifelong habit. It has been reported that already at a young age, 14–17 years, smokers experience a strong urge to smoke[
21]. Similar to the experiences described by the participants in the present study, smoking initiation at a young age has been shown to be related to a lifelong dependence on nicotine[
22]. The feeling of pleasure whenever they smoked was described as a positive experience in their lives. This finding is supported by other studies that have shown that smokers often smoked after a meal, when they had coffee, during a break, while drinking alcohol, and when socializing with other people such as co-workers[
23]. Besides the feeling of pleasure, another factor that made the participants want to smoke more was stress and pressure at work, which is in accordance with a study by Kouvonen et al.[
24].
The participants in the present study had plans to quit smoking, but these had not been actualized. Other stressful situations in life, such as having ill relatives, occasions of death in the family, or depression, were some of the reasons that led to difficulties in finding the right time to quit smoking. As in other studies[
25], weight gain was another reason to start smoking again after cessation for some of the participants. This was not a surprising result since most smokers know that nicotine dependence is a strong addiction and that smoking cessation entails substantial behavior modification that requires a huge effort. Therefore, the decision to quit smoking is postponed. Both the reasons for not quitting, and the reasons leading up to the decision to quit smoking, vary among individuals. Health care professionals should be aware of and take these individualities, as well as the smokers’ motivation to quit, into account in providing smoking cessation support[
26]. Further, it is important to understand that smoking cessation is not a single problem to be solved; support regarding other circumstances in the smoker’s life, such as weight gain, stress, and depression, should also be included in order to achieve successful smoking cessation. It has been shown that persons with COPD are more likely to develop depression and anxiety[
27,
28]. Several of our participants described that they began to smoke again after smoking cessation because of depression, which is in accordance with other studies[
29,
30].
The participants were aware of the consequences of continued smoking. Some wished to continually receive information about their decreasing lung function or even get a verdict on whether they would die if they continued to smoke. While some studies have shown that worries about future health problems motivated smokers to achieve smoking cessation[
31,
32], another study showed that having unpleasant respiratory symptoms were not enough[
17]. The chart by Fletcher et al.[
8] can be used to make decreases in lung function apparent and thereby motivate smokers to quit at an earlier age. However, some smokers find the available smoking cessation support and information insignificant. One study showed that half of the smokers quit spontaneously without any support or planning[
33]. All the participants in the present study had been informed about the available support from the health care system, but not all had used it. In another study, smokers described that they were not interested in joining support groups because they expected these to be ineffective[
34]. This is in contrast to the finding in the present study that while the participants did not want support before they have made the decision to quit, they wanted support after they have decided to quit. The participants in the present study described that friends and relatives expressed their wish for them to stop smoking, but this had the opposite result. It is thus important that smokers maintain their autonomy; no one can make the decision to quit smoking for them. May et al. reported that in the long term, personal factors, such as self-confidence and nicotine dependence, play a stronger role in successful smoking cessation than social support[
35]. The important issue for successful smoking cessation seems to be the understanding of individual differences. Health professionals involved in smoking cessation support should recognize the individual smoker in his or her full life situation and adapt the support thereafter.
The strength of this study design is the possibility to give a further understanding of why individuals with COPD continue to smoke, which would not be possible in a quantitative study. One limitation of the study could be the sample size as more participants might have yielded a different result. However, there are no rules for sample size in qualitative research, but six to eight participants can be sufficient when the sample are a homogenous group[
36]. In the present study, the participants were selected homogenously based on age, COPD diagnosis and severity, respiratory symptoms and smoking status. Further, the sample should be based on informational needs and data saturation[
37]. The interviews in the present study provided rich and deep content, and although the small sample size does not allow generalization, the results can be transferred to other settings and be useful for health care personnel involved in smoking cessation work. The interviews were performed at a health care center, which might have made the participants feel uncomfortable. However, the participants were asked if they wanted to be interviewed at home, but none wanted to.
In conclusion, the participants’ lives were governed by a lifelong smoking habit that was difficult to break although they had knowledge about the harmful effects of smoking. Plans to quit were never actualized despite being diagnosed with COPD. The smokers described incidents in their lives as reasons for never finding the time to focus on smoking cessation. In order to help smokers with COPD to quit smoking, health professionals involved in smoking cessation support should recognize individual smokers in their full life situation and adapt the support thereafter. To achieve a successful lasting smoking cessation it might be more effective to first ensure that the smoker has the right internal motivation to make the decision to quit, then assist with smoking cessation.
Competing interest
None of the authors have any conflict of interest to disclose.
Authors’ contributions
BME designed the study, collected and analyzed data, and drafted the manuscript. SN designed the study, analyzed data and helped to draft the manuscript. LH drafted the manuscript. IL designed the study and helped to draft the manuscript. All authors approved the final manuscript.