Factors of Relapse Behavior on Workers at “X” Hospital Medan

Miskah Afriani, Wahyuni and Milna Chairunnisa

Psychology Study Program of Institut Kesehatan Helvetia Medan

Keywords: Thought Associated with Relapse, Anxiety, Subjective Happiness, Nicotine Dependency, Smoking Relapse

Behaviour

Abstract: Background: Smokers tried to quit for the previous 12 months, and most fail to stop and relapse after

cessation of assistance or without assistance. Objective: The aim of this study is to examine factors thought

associated, anxiety, subjective happiness, and factor of nicotine dependency on smoking relapse behaviour

for workers in "X" Hospital Medan.This study uses an explanatory research approach. Method: The research

subjects were employees in Hospital X Medan who returned to smoking after having stopped with duration a

month to 6 month as many as 38 people who fit the inclusion criteria and were used as research samples. Data

analysis uses multiple logistic regression analysis. Result: The results of this study is thought about relapse,

subjective happiness and nicotine dependency factor affect tosmoking relapse behaviour in workers in

Hospital "X" Medan with a value of p <0.05. Conclussion: Suggestions in research, treatment needs to be

done through cognitive and affective approaches to smokers so that they can avoid relapse of smoking and

efforts to eliminate the carbon monoxide content in the body through a pharmacological approach.

1 INTRODUCTION

Cigarettes contain nicotine which is an addictive

chemical, when inhaled there is the release of another

chemical called dopamine which results in

individuals feeling better. Unfortunately, after

dopamine is gone, these symptoms will return, where

smokers want to continue smoking. Smokers also

become physically dependent on nicotine, where

smokers will continue to smoke to get the same effect.

(Kesehatan et al., 2010)

Cigarettes are addictive and dangerous a person

who smokes 10 cigarettes per day has an average life

expectancy of 5 years shorter and is 20 times more

likely to develop lung cancer than a non-smoker.

According to WHO, the tobacco epidemic is one of

the biggest public health threats facing the world,

there are more than 7 million people per year die.

More than 6 million of these deaths are active

smokers, and around 890,000 are passive smokers,

people who do not smoke but are exposed to cigarette

smoke (Organization WH., 2017).

Indonesia is the third country with the largest

number of smokers in the world after China and India.

Increased cigarette consumption has an impact on the

higher rates of cigarette disease and increased

mortality. In 2030 it is estimated that the death rate

from smoking will reach 10 million and 70% of them

come from developing countries. If this continues,

650 million people will be killed by cigarettes, of

which half the productive age will lose their

life.(Hartono, 2018)

Cigarettes have a negative impact on the health of

various diseases that can occur due to smoking are

lung cancer, hypertension, coronary heart disease,

bronchitis and other diseases (Kesehatan, 2012).

Because of the dangers of the effects of smoking, the

government is trying to stop smoking. one of them is

the inclusion of health hazard warnings on each front

and back side of cigarette packs which contain images

of physical conditions due to smoking, the application

of Non-Smoking Areas including the provision that

places for smoking in public places must be open

spaces that are directly related to outside air,

prohibited promotional advertisements and

sponsorship, controlling advertising of tobacco

products and broadcasting in the media.

Government efforts have been optimal to stop

smoking for smokers, but quitting smoking is not an

easy thing, many smokers after quitting smoking

again and is called relapse. Relapse means a smoker

returns to smoking regularly again after stopping.

Most people who stop returning relapse, the rate of

relapse usually occurs in the first week and 3 months

Afriani, M., Wahyuni, . and Chairunnisa, M.

Factors of Relapse Behavior on Workers at “X” Hospital Medan.

DOI: 10.5220/0009437500550060

In Proceedings of the 1st International Conference on Psychology (ICPsy 2019), pages 55-60

ISBN: 978-989-758-448-0

and also can relapse 1 year after stopping

(Yong et al.,

2018; Hughes et al., 2008).

Based on research, In 45 million Americans

smoke, 70% smokers say they want to quit, some very

addicted smokers make a serious effort to stop but are

only able to stop for several hours, other smokers can

stop within a month and every year only 3% of

smokers are successful in quitting smoking. In other

research, smokers tried to quit for the previous 12

months, and most fail to stop and relapse after

cessation of assistance or without assistance. The risk

of relapse is difficult to completely disappear and

remains at 10% every year even after 30 years of

abstinence

(Benowitz, 2010; García-Rodríguez et al.,

2013).

Factors of the effects of relapse were smoking due

to a positive influence (36.6%) and negative effects

(34.3%), lack of control (10.1%), smoking habits

factors (6.7%), desire to smoke (6.3%), and social

pressure (5.9%). Unemployment and having a mental

disorder in the past increase the likelihood of relapse

in a situation that has a negative impact. Being single

and quitting smoking to save money is associated

with an increased likelihood of relapse in positive

influence situations

(Piñeiro et al., 2017).

Another

factor is There was a significant interaction between

number of friends who smoked and duration of

abstinence, suggesting that a higher proportion of

friends who smoke was only associated with an

increased risk of relapse after approximately a month

post quitting. Self-efficacy also a strong predictor

(Herd et al., 2009).

Lunden, Pittman, Prashad,

Malhotra, &Sheffer, (2019) found other factors of

relapse, 67% of respondents were engaged in routine

activities when respondens initiated relapse, 26%

were as a coping with new or different situations

(Lunden et al., 2018).

The difficulty of quitting smoking is because

when smokers stop smoking for only one hour,

smokers will experience feelings of anxiety, feel very

difficult to hold back, irritable, easily discouraged,

and depressed. Smokers also experience sleep

disorders, frequent waking at night, hunger, increased

body weight, decreased ability to remember simple

work, and encourage the emergence of compulsive

behavior (Liem, 2010).

Based on the results of a preliminary survey in

Indonesia, several workplaces were still seen by

working smoking while working in a room that

should not have been done. One of them is in the

hospital health service. Coworkers are seen working

while smoking in a closed room and the condition of

the room using air condition. As many as 70% of

them claimed to have stopped smoking especially

during working hours and tried not to smoke, but

because the smoking cessation behavior made them

feel uncomfortable, there was a desire to continue

smoking especially when they saw friends smoking

so that they eventually returned to smoking. In

addition, 30% of workers feel more like working with

smoking because smoking makes the body feel better

and feels calmer. The number of cigarettes consumed

in 80% of the workers surveyed spends up to 10

cigarettes per day, 20% of other workers spend up to

20 cigarettes per day. Although they have the

intention and effort to quit smoking, they have not

succeeded because of the above factors and even who

can't afford to stop smoking at all. If viewed from

previous research and from the survey results it can

be concluded that there are several factors that can

affect the relapse behaviour of smoking habits,

positive factors as a form of pleasure and negative

thinking factors. Thus, in this study we would like to

examine further about factors related to relapse,

anxiety, subjective happiness factor, and factor of

nicotine dependence on smoking.

2 LITERATURE REVIEW

Definition of relapse: relapse is return to the initial

behavior during the behavior change process

(Bandura, 1995).

Relapse as a learning experience to focus coping

skills, to know identify the prevent future. And the

others defitions is subject who reported resuming

smoking (even apuff) after obtaing 24 hours of

abstinence (Borland et al., 2006).

Factors of relapse (Greenhalgh et al., 2016):

1. Physiological factors (e.g. level of nicotine

dependence, withdrawal symptoms)

2. Behavioural factors ( e.g slips-ups,pattern of

smoking)

3. Environmental Factors (e.g living or working with

smokers, having smoking friends, home or

workplace subject to smoke, free policies or

seeing tobacco product displayed)

4. Psychological or emotional/affective factors (e.g

stress, depressions, happiness, anxiety,psychiatric

disorders)

5. Cognitive factors (e.g knowledge, self-exempting

belief, perceived disadvantages, motivation, self

efficacy)

6. Barriers to acces to intervention (e.g affordable

quitting medication.treatment programme)

7. Social Contact or life circumtances that may reult

in the smoker giving quitting a low priority.

ICPsy 2019 - International Conference on Psychology

3 RESEARCH METHOD

3.1 Sample

Sample is representatives population based cross

sectional study in which participants in this workers

who smokers in workplace. Sample is 38 person with

accidental sampling who was found smoking in the

working roomwhen the research was conducted.

3.2 Data Collection

Data collection is done with primary data in the form

of a questionnaire. Questionnaire subjective

happiness using the Oxford Happiness Questionnaire,

An anxiety questionnaire uses the scale of the State-

Trait Anxiety Inventory (S-AI) Form Y by Spielberg,

the cigarette dependency questionnaire uses the

Fagerstrom scale form. Data analysis used logistic

regression analysis.

4 RESULT

Table 1: Charateristic and Odd Ratio (OR) with 95% Confidence Interval (CI)

Charateristic Total B P (value) 95% CI

Time of relapse

< 1month 12 (31.6%)

> 1 month 26 (68.4%)

NRT Use

Exist 0

Does not exist 38 (100%)

Age group

18-24 0

25-34 9 (23.7%)

35-44 20 (52.6)

45-54 9 (23.7%)

>55

Education

High school and below 0

College/university and above 38 (100%)

Variabel

Nicotine dependency

10.195 0.006 1.769-58.750

High Dependency 6 (15.8%)

Middle Dependency 20 (52.6%)

Low Dependency 12 (31.6%)

Subjective happiness

.83 .024 .010-.717

Heavy Happiness

5 (13.25)

iddle Happiness

24 (63,2%)

ow happiness

9 (23.7%)

Anxiety

High Anxiety

iddle Anxiety

29 (76.3%)

ow Anxiety

9 (23.7%)

Thought associated with Relapse

.020

0.007

.001-.336

Positive Thought 12 (31.6%)

egative Though

26 (68.4%)

Factors of Relapse Behavior on Workers at “X” Hospital Medan

Based on the results of the study it was found that

68.4% of respondents relapse smoking after more

than one month of quitting smoking, and amounting

to 31.6% of relapse only less than 1 month after

quitting smoking. Smoking dependents were larger in

the middle dependency category (52.6%), smokers

with heavy dependence were 15.8% and smokers

were mildly dependent 31.6%. Of the 38 respondents,

most felt low of happiness, which was 23.7%, and

respondents who had positive thoughts about

smoking were 31.6% and those who had negative

thoughts were 68.4%. Positive thinking that smokers

know the dangers and effects of smoking but have not

been able to stop smoking, while respondents think

negatively about smoking such as feeling smoking is

fun, smoking can solve problems and smoking can

increase morale.

From the results of the regression analysis it was

found that the subjective of happiness, nicotine

dependency and thought of smoking variables had an

influence on the relapse behaviour, while the most

influential variable in this study was the nicotine

dependency variable (p-value 0.006). Smokers who

have a high dependency tend to have a greater chance

of relapse by 10,195 in smokers who have low

nicotine dependence.

5 DISCUSSION

Smoking is a habit that is difficult to stop because of

the presence of addictive substances in cigarettes that

make smokers become dependent and difficult to

stop. This study was conducted to see the effect of the

concepts of thought, anxiety, happiness and the level

of nicotine dependence in relapse behaviouron

workers at the X Hospital services in Kota Medan.

From the results of the study it was found that the

most influential factor on the behaviour of relapse

was the factor of nicotine dependence. Other

influential factors are happiness and thought.

5.1 Nicotine Dependence

Nicotine addiction is a condition when a person

experiences dependence on nicotine substances found

in tobacco products. The condition of nicotine

addiction usually makes it difficult for smokers to

escape the effects of nicotine. This is in line with the

research of Febriyantoro (2016) which states that the

initial response of unpleasant cigarettes will shift into

obsessive activities which if stopped will cause

imbalances in the body because initially smokers will

feel bitter and cough and nauseous and will

eventually get used to it. To reduce this, smokers must

continue to smoke and become dependent

When someone wants to quit smoking they will

experience withdrawal symptoms known as things

that have negative effects on the body such as

depressed mood, insomnia, anxiety, difficulty

concentrating, restlessness and cigarette craving.

These symptoms can cause clinical, cognitive and

social distress disorders. And this is the main cause of

relapse of smokers to consume cigarettes (Caponnetto

et al., 2012). According to Fagerstrom, many

cigarette addicts show difficulties in quitting smoking

permanently, even though smoking activities are very

dangerous, smokers should be able to quit smoking

easily, especially when smokers think of hazard risks

in terms of health and health costs (Hearterton et al.,

1991).

Based on the results of the study, nicotine

dependence is the most influential factor in relapse

behavior where a smoker who experiences a high

dependency tends to relapse as much as 10,950 times

greater than smokers who have a low dependency.

According to the results of the study, smokers became

dependent and could not stop smoking, especially at

work because if they do not smoke, they find it

difficult to concentrate, easily hungry, as a way to

deal with drowsiness in working hours and because

they see other co-workers smoking. Previously, the

smokers who had been studied had already stopped

either because of health conditions or because of the

age with various periods of stopping, namely 2 days

to the longest, namely 6 months. But it can't stop

completely because of these factors. There were

respondents who stated that after previously stopping.

Other respondents are currently smoking more

numbers after trying to quit smoking. He can spend

up to 22 cigarettes per day which previously had a

maximum of only 10 cigarettes per day. And other

respondents stated that relapses smoke even if only a

few cigarettes a day, but every day he feels obliged to

consume cigarettes. Other respondents stated that the

first activity after waking up in the morning was to

take a shower while smoking and admit that it was

already addicted to cigarettes.

Other smoking dependency behaviors appear to

violate existing rules, namely those listed in Law No.

36 of 2009 concerning Health which also includes

Non-Smoking Area Regulations where one of the

areas including Non-Smoking is a Health Service

Facility and Workplace.

The hospital studied,

smokers were seen smoking inside the room while

working with rooms using AC, this is a sign of

dependency where it is not able to resist not smoking

ICPsy 2019 - International Conference on Psychology

in the workplace, especially working in a health

service place.

5.2 Happiness

This study states that there is an influence of

happiness factors on relapse behavior. This is in line

with the Stickle research study, et.al. (Stickley et al.,

2015) this study examined the relationship between

smoking status and happiness in nine FSU countries.

We found that ex-smokers and never smokers were

significantly happier than current smokers. Within the

individual countries ex- smokers were happier than

current smokers in all countries except Kyrgyzstan,

with higher nicotine dependencies compared to

smokers who had low levels of nicotine

dependencies. Other studies have suggested that

Happiness was significantly moderated between

dependence and abstinence-induced increases in

composite withdrawal (β = 7.17, p <.001), such that

predictive power of dependence on withdrawal

increased proportionately weaker levels of SH

increased (Liautaud et al., 2017).

One of the neurotransmitters in the brain is

Dopamine, which functions to improve mood and

activate feelings of pleasure. This is the reason why

people smoke again. When quitting smoking,

smokers will easily feel anxious and more irritable if

their body does not get nicotine intake as their

defence, smokers must return to smoke.

When a person smokes, it will quickly go to brain,

nicotine then increases brain activity in the prefrontal

lobe, cortex, thalamus and visual system, resulting in

the release of dopamine which will trigger a pleasant

sensation in the brain. Thus, smoking is used as an

outlet when facing unpleasant problems, even though

it is only a tentative feeling that is only felt throughout

nicotine work alone (Nabila et al., 2017). The results

of this study found that the tendency of higher relapse

occurred at 0.83 times compared to smokers who feel

more happy. Respondents in this study stated that

relapse occurs because self-defence to mask

unpleasant feelings becomes a pleasant feeling as an

effect of nicotine work. As respondents felt that by

returning to smoking the feeling of being passionate

about work, feeling stressed could be lighter when

smoking, and respondents also felt more relaxed,

feeling they did not need to think hard because they

would enjoy taking smoking. Smokers should realize

that the emergence of happy feelings is only an

immediate effect as a result of smoking, the feeling of

pleasure they feel is not because they are positively

happy, but only a temporary feeling that actually

harms them.

5.3 Thought

According to the results of a previous study

conducted by Febriyantoro (Febriyantoro et al.,

2018), one of the causes of smoking dependence is

the assessment of cigarette advertisements where

men's perceptions of smokers look macho and can be

through whatever obstacles occur in their lives. Some

irrational thoughts on smokers are (Kesehatan et al.,

2010) as an escape to create calm when facing severe

problems, (Organization WH., 2017) facilitating

concentration, (Hartono, 2018) preferring smoking

rather than consuming alcohol. According to the

Lundenet et al. study in 2019, 26% of respondents

said that smoking was to get pleasure where when he

woke up in the morning, the first thing he thought

about was cigarettes. He imagined the cigarette in his

mouth and wanted to immediately smoke as soon as

he woke up in the morning. 19% of respondents

reported that smokers did not want to stop smoking

because when he thought not to smoke, it tormented

him so that he did not want to stop smoking. Based

on the results of this study, smokers who have

negative thoughts about smoking have an opportunity

to relapse than those who have a positive judgment

from several recipes. in this study the respondents

knew of the negative effects of smoking only the

respondents ignored what they knew, because the

thing they prioritized was they thought that cigarettes

were good and they were still healthy by smoking

because smoking can increase their enthusiasm.

humans tend to do what they think, this is seen by

respondents who have stated that cigarettes are fun

and delicious, so it will be difficult to avoid cigarettes

and it will continue and continue smoking. they

should think more about the dangers and negative

effects of smoking so that they can slowly leave their

habit of not smoking anymore.

5.4 Strengths and Limitations

A major strengths of this study is we included some

indicator (happiness, anxiety, thought o relapse,

nicotine dependency) in the analysis, as far as, we

know that have not been examined in Sumatera Utara

before. From the result, have a insight could be

improvement of smoking cessation or relapse

prevention treatment. A limitation of this study is the

data the collect at one moment (accidental sampling)

so, the sample cannot be generalized. The second

limitation is the data not bioche could be

improvement of smoking cessation or relapse

prevention treatment. A limitation of this study is the

data the collect at one moment (accidental sampling)

Factors of Relapse Behavior on Workers at “X” Hospital Medan

so, the sample cannot be generalized. The second

limitation is the data not biochechemically validated.

In this report related chemically validated. In this

report related chemically validated. In this report

related to social-desirabilty bias, we sholud be

minimized.

5.5 Implication

This study emphasizes the importance of control

nicotine dependency, so it is recommended for

smokers, when they want to stop smoking it is better

to do therapy related to nicotine replacement therapy

so that smokers who have stopped can be consistent

and not have relapse.

6 CONCLUSIONS

Based on the results of the research conducted, it was

found that there are factors that influence the behavior

of relapse in smokers, namely nicotine dependence,

pleasure and thought factors. Whereas those that have

no effect are intelligence. The most dominant factor

influencing is the factor of nicotine dependence

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