Identifying and Overcoming the Barriers to Smoking Cessation in Rheumatoid Arthritis

Abstract

The association between smoking and rheumatoid arthritis (RA) is well established. The risk of developing RA is higher among smokers. Smoking may also affect the severity of disease and reduce the efficacy of medications. People with RA who smoke have an increased risk of comorbid disease from pulmonary disease and osteoporosis, and premature death from heart disease. The combination of negative health effects associated with smoking in people with RA make a compelling case for smoking cessation. Smokers with RA may have specific medical and psychosocial issues that are not being met by generic smoking cessation programmes. However, there has been little research that has addressed RA-related barriers to smoking cessation and to date there has been only one arthritis smoking cessation intervention published. This suggests a gap in research and identifies the need for further research on smoking cessation in RA. The aim of this thesis was to identify barriers to smoking cessation in RA and develop an intervention to aid smokers with RA to overcome these barriers. By qualitatively investigating disease-related issues that make smoking cessation difficult for people with RA, five barriers to smoking cessation were identified: 1) people with RA felt isolated and unsupported when attempting smoking cessation; 2) people with RA were often unaware of the detrimental effects of smoking on RA and hence did not perceive this as a reason to quit; 3) smoking was used as a distraction from the pain associated with RA; 4) people with RA found it difficult to exercise and hence saw themselves as unable to use exercise as an alternative distraction from smoking, and 5) smoking was used as a coping mechanism for the frustrations of living with RA. A twelve week smoking cessation intervention, addressing these five barriers, was developed in association with Arthritis New Zealand and delivered by Arthritis Educators. The efficacy of the tailored intervention was assessed in a pilot randomised controlled trial. There was no significant difference in smoking abstinence rates at six months, although quit rates for both intervention (26%) and control groups (21%) were high compared to similar intensity smoking cessation programmes in the general population and the published arthritis smoking cessation study. The key support and advice from the Arthritis Educators were the most valued intervention components, followed by the specific smoking cessation components. There were common factors in the study that equally facilitated or impeded smoking cessation for all participants, including nicotine replacement therapy (NRT) as a shared treatment and the stress resulting from the Canterbury earthquakes. In addition, control group participants had independently developed their own strategies to control their smoking. The implications of this study are that although physical limitations and disease-associated factors adversely affect smoking cessation in RA, the lack of added benefit of a tailored smoking cessation intervention suggests a combination of brief advice and NRT is currently the best practice for supporting people with RA who wish to quit smoking.