Abstract
For many people, smoking has been used as a method of ‘self-medication’ for easing feelings of distress. However, research evidence has shown that continuous smoking and the failure to quit actually increases tension and anxiety. Nicotine is a substance that creates an instant sense of relaxation and relief, which enables people to smoke with the expectation that they can curb stress and anxiety. In the general population, the attempts to cut out smoking from daily life has shown to have a favorable impact on both physical and mental well-being, which suggests that in narrow population groups, such as veterans, similar results are expected to be revealed in the proposed qualitative study. In the target population of veterans, smoking has also been used as a form of stress relief, especially when it comes to PTSD.
This study proposal aims to explore the healthcare problem of smoking and stress among veterans. The challenge is extensive, and there is research evidence showing that smoking only exacerbates the symptoms of anxiety among people. The target population of veterans has been chosen for analysis because the individuals experience severe mental health symptoms and seek different methods to relieve them. The study will be of qualitative nature and look at a smaller sample size than in quantitative procedures. While there is bias from self-reported data, the qualitative study can help achieve more profound insight into the problem through the understanding of participants’ behaviors. The expectation of the study is that smoking does not help veterans deal with stress on a long-term basis, which is why behavioral interventions may be carried out to help them quit and achieve physical and mental well-being. The limitations of the proposed research include smaller sample size and the possibility of bias.
Statement of the Problem
Smoking and stress have come hand-in-hand as many people have engaged in smoking as a self-medication method to ease the feeling of pressure. However, research has found that smoking actually increases emotional tension and anxiety (Choi, Ota, & Watanuki, 2015). The effect of nicotine is such that it can provide a sense of relation, which makes people continue smoking in the belief that they can calm themselves down and ease the tension. However, such a feeling does not last a long time as the symptoms of withdrawal take place and increase the craving to continue smoking (Choi et al., 2015). Continuous smoking reduces the symptoms of withdrawal, but it does not alleviate anxiety on a long-term basis and cannot help people get rid of the stress that they experience. Therefore, smoking as a way of stress reduction creates a vicious circle – a person smokes to relieve stress but starts experiencing further strain from the withdrawal.
Significance of the Topic
The topic is significant to explore because of the misconception that smoking can alleviate the emotional burden of stress and anxiety when in reality, it has an exacerbating effect on emotional stress. It is essential to study the healthcare challenge because adults with stress and depression are twice as likely to engage in smoking as adults without depression (Kim et al., 2019). The majority of people begin smoking before experiencing the signs of stress or depression, and it is not clear whether smoking results in a reduced mental health state. It is also most likely that there is a much more complicated relationship between the two.
Because cigarette smoking is a significant health risk, researchers have explored the influence of cessation on stress levels and the changes in stress levels. For example, in the study by Kim et al. (2019), of the subject population that smokes, 78.3% felt stressed. Among research participants that successfully stopped smoking, 73% reported feeling stressed (Kim et al., 2019). In contrast, of those who failed to quit, 83% also reported high-stress levels (Kim et al., 2019). Besides, among people that made no attempts to stop smoking, 81% reported stress (Kim et al., 2019). Overall, individuals who were unsuccessful at stopping smoking experienced more stress compared to those who did not attempt to quit the habit (Kim et al., 2019). This shows that besides the adverse physical health consequences, smoking results in mental health complications that need further addressing.
Target Population
The target population of the proposed study includes veterans who are more likely to suffer from stress and even posttraumatic stress disorder (PTSD). Many people who experience emotional strain report engaging in smoking to manage their moods and deal with anxiety. Among veterans, the stress may be associated with their experiences during deployment or coping with life after the military. Even though smoking may feel like smoking helps relieve the symptoms of stress and alleviate the burden of mental strain, on a long-term basis, it can make stress and PTSD even worse. Therefore, it is essential to explore the issue of tobacco use among veterans who smoke in order to relieve stress. While quitting smoking can be challenging, veterans have experienced significant success in quitting smoking without making their stress and PTSD worse.
Literature Review
Relationship Between Stress and Smoking
The interplay between stress and smoking has been of interest among researchers, with scholarly studies available for review. The objective of the current literature review is to provide a comprehensive overview of the original scientific studies that are relevant to the topic. Considering the fact that the issue is extensive, the research literature ranges in dates of publication and scholarly journals in which it was published. A comprehensive study on perceived stress and smoking was carried out by Stubbs et al. (2017), who gathered data across forty-one countries from Europe, Africa, Asia, and the Americas. Evidence suggests that perceived stress can represent a limitation to smoking cessation even though that little is known about the link between perceived stress and smoking in countries that have different income levels (Stubbs et al., 2017). It was found that the prevalence of smoking was 27.3%, with the highest and lowest prevalence observed in Africa (13.4%) and Asia (32.1%), respectively (Stubbs et al., 2017). Importantly, older individuals were much more less likely to smoke in Europe than in order regions (Stubbs et al., 2017). In the overall sample, a one-unit increase in the perceived stress scale (in the range between 2 and 10) was associated with a 1.05 times higher likelihood of smoking (Stubbs et al., 2017). Overall, the perceived stress is significantly linked with the higher rates of smoking across countries with different levels of income.
A comprehensive study on the influence of smoking cessation attempts on the levels of stress was conducted by Kim et al. (2019), who suggested that even though smoking cessation can benefit both physical and mental health, the process of quitting is difficult and shows its relationship to stress levels. In the study, the researchers analyzed the connection between the attempts to stop smoking and stress levels. The scholars used data from Korean Community Health Survey that included 488,417 participants (Kim et al., 2019). Using the chi-square test and logistic regression, survey data was analyzed. It was found that the prevalence of stress among individuals who were unsuccessful at stopping smoking was 1.11-fold higher compared to those who made no attempts at quitting smoking (Kim et al., 2019).
The prevalence of stress levels in participants who were successful at stopping smoking was 0.87-fold lower compared to those who have not tried to quit smoking (Kim et al., 2019). Notably, the association was stronger in females than in males, which may explain why the two genders had variable success rates of smoking cessation. Such variables as income, the number of individuals in the family, and marital status were stratified to get analyzed (Kim et al., 2019). The results illustrate the trend that people who were unsuccessful at stopping smoking had a higher risk of stress in the majority of the strata, especially when it comes to men. Besides, it is shown that smoking cessation can reduce stress levels when the attempts have been successful (Twyman et al., 2019). However, quitting smoking can be harmful and result in increased stress if attempts fail.
In their study, Lawless et al. (2016) explored the perceived stress and smoking-associated levels and symptomology in both men and women. The research represented a retrospective analysis of 62 smokers who were screened, gave relevant sociodemographic information, and whose smoking behaviors and survey measures were carried completed (Lawless et al., 2016). It was found that males experienced a more significant negative association between the perceived levels of stress and the degree of smoking (measured in the number of cigarettes smoked each day). In females, the trend had the same direction, although the association between stress and smoking was not significant (Lawless et al., 2016). Such findings can be explained by the smoking behavior model that suggests that the acute deprivation of nicotine results in increased levels of stress. This means that those who smoke more cigarettes every day are subjected to fewer instances of nicotine deprivation and thus less stress. The study differs from the findings of Kim et al. (2019) because it does not show that heavy smokers have high rates of perceived stress. The discrepancy between the two articles may be linked to the fact that Lawless et al. (2016) used a smaller sample. Therefore, future research using a larger sample may be needed.
The behavioral and sociological perspectives have also been applied in order to study the connections between stress and smoking. In their study, Jahnel et al. (2019) explored everyday stress as a connective point between disadvantage and smoking. Through the social-ecological perspective, the sample of 194 daily smokers was examined. The participants were not attempting to quit smoking and recorded the information about smoking, including both situational and contextual factors, for three weeks. It was tested whether socioeconomic disadvantage, which was indicated by educational attainment, race, and income, exerts indirect effects on smoking, such as cigarettes smoked every day, via daily stress.
In their study, individuals with lower levels of education were much older compared to higher educated individuals, although no differences were found concerning gender and cigarettes smoked per day. Individuals who are disadvantaged socially in terms of their racial background and education are more likely to experience more daily stress. More everyday stress leads to more cigarettes smoked each day, which results in significant indirect effects of education and racial background of smoking as mediated by stress (Jahnel et al., 2019). While it can only be speculated, individuals with lower levels of educational attainment may be more vulnerable to daily stress because the stressors are much more severe and disruptive of their daily lives through the lack of material and psychological coping skills (Jahnel et al., 2019). For example, people of lower-income are more likely to experience long-term stress in the form of financial strain, which does not always have to result in the daily stress experiences but rather chronic stress. Therefore, the more socially disadvantaged a person is, the more likely are they to experience stress and engage in smoking behaviors.
Stress and Smoking in Veterans
While the studies discussed previously discussed the relationship between stress and smoking without a narrowed target population, it is essential to explore articles that focus on veterans as the target population. In their article, O’Toole et al. (2018) investigated the relationship between combat, posttraumatic stress disorder (PTSD), and smoking trajectory in a group of male Australian army veterans who served in Vietnam. A cohort of male Australian Vietnam veterans, which included 388 individuals, was interviewed using standardized psychiatric diagnostic and health interviews and the assessment of combat exposure. Over time, the smoking trajectory showed a spectrum of outcomes, which included veterans that never smoked, quit early, quit late, and continued smoking. Multivariate statistics were used for assessing the relative contributions of combat trauma exposure and PTSF while also controlling for potential confounders.
The analysis of the trajectory of smoking over time showed that 21.9% of veterans had never smoked, 45.1% had quit smoking by the time of the first wave, 16.2% were current smokers at first wave who had quit by the time of the second wave, 2.8% were late adopters and smoked currently while 13.9% were continuing smokers (O’Toole et al., 2018). Smoking was related to demographics in single-predictor models, as well as with intelligence, exposure to combat, PTSD symptoms, and alcohol disorders. The most significant finding related to the increased smoking levels due to the exposure to military combat and trauma. Smoking is used as a form of stress relief rather than post-stress disorder, which is more pertinent to smoking and the inability to quit.
In their study, Salas et al. (2022) explored increased smoking cessation among veterans with significant decreases in PTSD severity. The research was carried out because it was unknown whether the reduction of PTSD severity was linked to smoking cessation, an inadequate health behavior common in patients diagnosed with the disorder. To identify PTSD patients in need of specialty care, the Veterans Health Affairs medical record data was used (Salas et al., 2022). The scholars intended to find a relationship between clinically meaningful improvements in PTSD symptoms and the cessation of smoking within two years after baseline. On average, there was a clinically significant improvement of PTSD symptoms in 19.8% of participants who successfully quit smoking (Salas et al., 2022). It was found that patients with clinical diagnoses of PTSD had a meaningful improvement in their symptoms when they stopped smoking. Because patients with PTSD are likely to develop adverse physical and mental health conditions, it becomes of great importance to facilitate positive health behaviors.
The research by Peterson, Prochazka, and Battaglia (2015) explored smoking cessation and care management targeting veterans with posttraumatic stress disorder. The rationale for the research was that individuals with PTSD have higher rates of smoking and are less likely to quit because it relieves their symptoms (Pericot-Valverde et al., 2018). The study involved one hundred and twenty participants that were divided into control groups. The participants were engaged in an intervention that involved a telehealth PTSD program, a motivational interviewing-based smoking cessation program through a telehealth device, as well as weekly motivational interviewing counselling phone calls (Peterson et al., 2015). Motivational interviewing was shown to boost readiness for changing behaviors and smoking cessation care when it comes to the incorporation of in-person mental health care. Using the research, it is possible to combine a written smoking cessation curriculum and phone-based motivational interviewing counselling into a well-developed program that coordinates telehealth and self-care models.
Research Methods
The aim of the qualitative research is to gain an in-depth understanding of the real-world challenge that affects the target population of veterans. The significance of the study lies in need to address the health problem of smoking as a behavioral response to the increased stress levels among veterans. Veterans represent a vulnerable patient population that is at a higher risk of receiving medical care of lower quality, which results in worse medical outcomes compared to patients who have not experienced combat. Considering this healthcare limitation and the fact that smoking has an adverse effect on the physical health of individuals, it is essential to explore the relationship between smoking and stress in the veteran population. The purpose of the research is to evaluate the association between smoking and stress among veterans and determine whether such variables as gender and educational background have an influence on the relationship. The rationale for the research is connected to the issue that smoking is mistakenly used as a stress relief method while, in reality, it does not bring the desired results. From the socioeconomic perspective, it is essential to look at characteristic variables such as gender and educational background as possible predictors of increased smoking due to stress.
The study will involve veterans of different backgrounds, experiences, genders, and educational statuses. The research hypothesizes that the socioeconomic status of participants will have an influence on the relationship between stress and smoking, with veterans of lower educational levels and males being more likely to smoke due to stress. The research questions are the following:
- What is the connection between stress and smoking in the target population of veterans?
- Does the socioeconomic status (namely, gender and educational background) influence the likelihood of increased smoking due to stress?
- Does smoking alleviate the symptoms of stress on a long-term basis?
- What interventions can be put in place to improve the well-being of veterans who engage in smoking due to stress?
In contrast to the quantitative design, generalizability is not expected to be accomplished in the study. With the help of semi-structured interviews with focus groups, data will be gathered on participants’ perspectives on stress and smoking, with considerations of the socioeconomic status of respondents. The focus group design was selected because it can enable group discussions between study participants. This way, the veterans included in the study will be encouraged to share their views and experiences, thus facilitating a potential reflection in terms of hearing others. During the focus group interactions, veterans will be asked both open- and closed-ended questions to encourage discussions and interactions between the participants based on the researcher-supplied topic. The main goal of the focus group interviews is to evoke a certain degree of respondents’ feelings, attitudes, feelings, beliefs, reactions, and experiences that are otherwise not available using such methods as solely observations or one-on-one interviews.
The feelings, beliefs, and attitudes, which are expected to get revealed during focus group interactions may be somewhat independent of a group or its social setting. However, they are more likely to get revealed when participants, especially those with traumatic and stressful experiences of trauma, gather together and interact within a focus group that has common definitions. The focus group setting is especially useful in the current study because the experiences of veterans will range from one individual to another even though they share a similar language and culture. The degree of consensus on the given issue will be comprehensively explored during the focus groups. Due to this, it is essential that the interviewer ensures that the participants are open to sharing their specific experiences and opinions about the healthcare challenges of stress and smoking.
The qualitative study will be conducted in a community health center situated locally. Such organizations offer communities support through government-funded programs underpinned by integrated support and care models. The programs at community health centers can involve partnerships between non-governmental organizations specializing in veteran support as well as psychosocial support and other healthcare teams offering clinical care. The services aimed at helping veterans quit smoking varies within and across organizations, with most support provided with the help of outreach.
Because of the narrowly-defined target population of war veterans, the study will use purposive sampling to include as many participants as possible that fit the criteria of eligibility. Participants were eligible to participate in the focus groups if they had a former experience of combat and have engaged in smoking as a method of stress relief, being either ex-smokers or smoking currently. The initial surveys for participants assessed potential participants’ age, gender, socioeconomic status, educational background, and experiences associated with their time serving in the army and engaging in battles. The study subjects will not be reimbursed for participating in the research, with data being collected until the necessary level of information saturation is reached.
Discussions based on semi-structured interviews will be developed in such a way that is clear and understandable to the target population. They will be created by the research team based on the aims of the study. The guides for interview questions will cover such topics as stress developed as a result of trauma from battle (including PTSD), smoking history and current smoking behaviors, educational attainment experiences, as well as previous experiences with interventions aimed at smoking cessation and stress relief.
When it comes to the analysis of data, it will be collected, transcribed, and analyzed once the focus group discussions are fully complete. It is expected to carry out four focus group discussions over the course of two months, twice a month. Notably, the two week gaps between the focus groups are expected to give participants some time to think and reflect on what they and others have said. Besides, such gaps are necessary to ensure that the traumatic experiences of battle are not overwhelming and do not bring up the negative emotions and increase stress and smoking as a way of stress relief.
The transcripts of focus group discussions will be analyzed with the help of thematic analysis. The interviewer will develop summary notes of observations and talks after each focus group. The data will be continuously reviewed and compared for identifying patterns and themes in the data, participant groups and responses to specific questions asked by the interviewer. After all four focus groups are completed, each transcript will be reviewed for noting initial impressions and the understanding of the data. To develop a set of codes for thematic analysis, impressions and initial emerging themes will be discussed. The transcripts will have to be re-read and coded by the data analyst for relevant and meaningful sections and phases of the transcripts represented by themes and comments that several participants repeat in their discussions. Codes will be modified and revised as required in order to best represent the data to then arrange them based on emerging themes. Finally, solid themes will be reviewed and further discussed, with the study authors confirming the accuracy of data interpretation.
An important aspect of qualitative methodology is the reporting of strategies for ensuring the rigor of qualitative work. In the study, the researcher will consider how their experiences, professional background, and prior assumptions could influence data collection and the capacity to facilitate honest and open responses from the interviewed participants. It is important to be sensitive to the different priorities and values that researchers and study participants have. Bias is a common challenge of qualitative studies, but it is crucial to acknowledge the individual experiences and perspectives of participants.
Researchers will summarize, reflect, and give feedback on the information for confirming or clarifying data collected within focus groups. Data will be deliberately collected from sources that are quite different from one another, with varying demographic variables, geographic locations, and experiences, which can increase the transferability of study findings. Research findings’ dependability can be enhanced by involving another researcher in the processes of data collection and coding. The results will be presented in the form of tables summarizing relevant qualitative data for a better breakdown of information and illustration of findings.
In terms of research limitations, there are some challenges to be considered. The method of focus groups is limited by the dependency on the study design itself and can be addressed with the help of diligent planning. The limitations include less control over the produced data, limited leverage over the interactions within focus groups to keep participants focused on the topic, as well as difficulty assuring full anonymity and confidentiality as information is being shared within the veteran focus group. The relatively smaller number of study participants is another limitation in addition to bias stemming from self-reported data.
References
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Jahnel, T., Ferguson, S. G., Shiffman, S., & Schuz, B. (2019). Daily stress as link between disadvantage and smoking: An ecological momentary assessment study. BMC Public Health, 19(1284).
Kim, S-J., Chae, W., Park, W-H., Park, M-H., Park, E-C., & Jang, S-I. (2019). The impact of smoking cessation attempts on stress levels. BMC Public Health, 19(267).
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