Evaluación de un programa de intervención breve motivacional para fumadores: resultados de un estudio piloto / Evaluation of a brief motivational intervention program for smokers: results of a pilot study

ABSTRACT

Tobacco consumption is a world-wide public health problem that has been associated with different types of cancer, cardiovascular and respiratory diseases, alterations in the reproductive system, dental problems and some eye diseases. In Mexico the National Survey of Addictions (2002) reported that 26.4% of the urban population between 12 and 65 years and 14.3% of the rural population are smokers. The Secretary of Health indicated that more than 53000 people died from diseases related to tobacco consumption. The consumption of tobacco stands among the ten first causes of morbidity and mortality in Mexico. In this sense, smoking is considered as one of the main public health problems in Mexico. Several organisms and institutions have undertaken actions in an attempt to solve it, such as the development of educative programs directed to the general population and programs to help smokers to quit this habit. Some of the main strategies to reduce cigarette consumption include nicotine replacement therapy, therapy not based on nicotine (antidepressants, some opiate antagonists and anxiolytic drugs), psychological programs, and the combination of some of them. Regarding psychological treatments, behavioral and cognitive behavioral techniques for smoking cessation hold empirical evidence about their efficacy for reducing the abuse of substances. In Mexico, psychological, nicotinic and non-nicotinic treatments to stop smoking are used. Nevertheless, the methodological and theoretical grounds of the psychological interventions are not well-established and there are no specific data about the changes in the consumption pattern after the application of the interventions and whether the effects of the treatment stay through the time. Specifically, the information about the efficacy of the brief interventions on smokers in the Mexican population is scarce. Although different studies have demonstrated that the brief motivational interventions are more effective to reduce the abuse of different substances than intensive interventions or no interventions at all, the techniques are not widely used in the treatment of tobacco consumption in Mexican population. With this evidence, the National Autonomous University of Mexico (UNAM) developed the Brief Motivational Intervention Program to treat smokers. The Brief Motivational Intervention is based in the Social Cognitive Theory, the Prevention of Relapses Model, in techniques of motivational interview and self-control techniques. Therefore, the goal of the present research is to evaluate a brief motivational intervention program for smokers. In order to achieve this aim, 10 individuals between 19 and 55 years old participated in the program; five individuals showed low nicotine dependence and five severe nicotine dependence according to the Questionnaire of Fagerström Tolerance. There was a public invitation and the participants consent to participate voluntarily in the <> belonging to the Psychology Department, UNAM. The motivational brief intervention program for smokers consists of six sessions an admission session, an evaluation session and four treatment sessions of one hour each. All of them were carried out individually based on the following theoretical and methodological components social cognitive theory, techniques of motivational interview, techniques of self control and prevention of relapses model. The program was evaluated doing a comparison of the consumption pattern during and after the application of the brief intervention, and contrasting the level of self-efficacy before and after the application of the brief intervention. An analysis of variance (ANOVA) of repeated measures showed significant changes in the pattern of consumption (F [2, 18] =53.10,p<0.001), a Bonferroni post hoc test for binary comparisons indicated that the differences were between the baseline and treatment (p<0.001) and baseline and follow-up (p= 0.001). In relation to significant differences in the self-efficacy level, a Wilcoxon test showed differences in the following situations disagreeable emotions (Z= 2.203, p<0.05), physical discomfort (Z = 2.492, p<0.05), conflict with others (Z= 2.556, p< 0.05) and pleasant moments with others (Z = 2.670, p<0.05). In all the cases, the level of self-efficacy reported in the second application increased as compared to the first. Results found in this research agree with those collected in other countries using brief intervention therapy, but specifically with the ones employed in Mexico with drinkers, users of cocaine and adolescents initiating drug consumption. This program makes special emphasis in the strengthening of self-efficacy and in the prevention of relapses model that maintains the change of the consumption behavior of the user during and after the intervention. However, users learn mainly to conceptualize a relapse as a part of the process to quit smoking and not as a failure or an addictive behavior that they will never be able to change. Carroll indicates that the essential principles of the cognitive behavioral programs for the treatment of addictive behaviors are that they allow for individualized programs and that the goals of the treatment reflect a collaborative process between the user and the therapist. These principles allow the user to stay in the program and motivate him/her to maintain a change in the addictive behavior. The brief intervention for smokers in this study has not only shown excellent effects in users with low dependency, but also with users with severe dependency to nicotine (according to the Questionnaire of Fagerström Tolerance). Even though they did not stop smoking completely, they diminished the consumption pattern and increased the number of days of abstinence. The previous finding is congruent with the assumptions of the harm reduction, which is considered as an alternative associated to a decrement on the real and the potential damage with the use of the drug, more than to trying to stop it. It is important to do a follow-up that shows a long-term maintenance of the behavior for at least 12 months after the treatment. Some biological markers (carbon monoxide in the expired air, levels of cotinine in tinkles or shapes) are also needed that will represent an objective measure that helps to increase the motivation with respect to the initial consumption during and after the intervention and also to verify the pattern of consumption reported by the users. This treatment for smokers it is an effective alternative for its adoption in institutions of health and must be a part of the preventive policies for the treatment of smokers in a national scope because it has an impact in the pattern of cigarette consumption and the associated organic damages.

RESUMEN

El consumo de tabaco es un problema de salud pública en el mundo y se le ha asociado con diferentes tipos de cáncer, enfermedades cardiovasculares, enfermedades respiratorias, alteraciones en el sistema reproductivo, problemas dentales, úlcera péptica y algunas enfermedades de los ojos. De acuerdo con la Encuesta Nacional de Adicciones de 2002, en México fuman 26.4% de las personas entre 12 y 65 años de la población urbana y 14.3% de la población rural. En este sentido, la Secretaría de Salud señala que en México fallecen anualmente más de 53 mil personas por enfermedades relacionadas con el consumo de tabaco, lo que lo ubica entre los diez primeros lugares de morbilidad y mortalidad. Entre los tratamientos propuestos para dejar de fumar se identifican las terapias sustitutivas con nicotina, las terapias farmacológicas, los tratamientos psicológicos y combinaciones de ellos. En relación con los tratamientos psicológicos, existe evidencia empírica que muestra la efectividad de las técnicas conductuales y cognitivo-conductuales para dejar de fumar. En México, se emplean tratamientos psicológicos y farmacológicos (nicotínicos y no nicotínicos) en personas que desean dejar de fumar. Sin embargo, en dichas intervenciones no se reportan datos específicos de los cambios en el patrón de consumo después de la aplicación de dichas intervenciones y si éste se mantiene a lo largo del tiempo. Asimismo, se sabe específicamente poco de la efectividad de las intervenciones breves dirigidas a fumadores en la población mexicana. Por lo tanto, en la presente investigación se evalúa un programa de intervención breve motivacional para fumadores que incide en el patrón de consumo de cigarros, en la percepción de la autoeficacia de los usuarios al finalizar la aplicación del programa y en el seguimiento a los seis meses. Para cumplir con el propósito se aplicó el programa de intervención breve motivacional a 10 personas de entre 19 y 55 años de edad que deseaban dejar de fumar. La evaluación del programa se realizó a partir de la comparación del patrón de consumo antes, durante y después de la aplicación de la intervención breve, así como del nivel de autoeficacia antes y después de la aplicación de la intervención breve. Un análisis de varianza (ANOVA) de medidas repetidas mostró cambios significativos en el patrón de consumo entre la línea base, intervención y seguimiento (F[2,18]=53.10, p<0.001). Posteriormente se realizaron comparaciones binarias con el ajuste de Bonferroni, lo cual indicó que las diferencias se ubicaron sólo entre la línea base con respecto al tratamiento (p<0.001) y la línea base con respecto al seguimiento (p<=0.001). En relación con el nivel de autoeficacia se encontraron diferencias significativas antes y después de aplicar la prueba Wilcoxon, y así se obtuvieron diferencias significativas en las siguientes situaciones emociones desagradables (Z= 2.203, p< 0.05), malestar físico (Z = 2.492, p<0.05), conflictos con otros (Z= 2.556, p<0.05) y momentos agradables con otros (Z= 2.670, p<0.05), en las que incrementó el nivel de autoeficacia reportada en la segunda aplicación con respecto a la primera. Los resultados obtenidos en esta investigación concuerdan con los observados en la aplicación de intervenciones breves en otros países, pero específicamente con los obtenidos en México con bebedores problema, usuarios de cocaína y adolescentes que se inician en el consumo de drogas. El programa de intervención breve motivacional enfatiza el fortalecimiento de la autoeficacia y el modelo de prevención de recaídas, que mantiene el cambio de la conducta de consumo del usuario durante y después de la intervención. El usuario aprende a conceptualizar la recaída como parte de un proceso de cambio y no como un fracaso o un comportamiento adictivo que nunca podrá cambiar. Por lo anterior, el tratamiento para fumadores es una alternativa efectiva para su adopción en instituciones de salud y debe formar parte de las políticas preventivas para el tratamiento de fumadores en el ámbito nacional, ya que tiene un impacto específico en el patrón de consumo de cigarrillos y, en esa medida, en los daños orgánicos asociados a su consumo.