Smoking as an occupation: functions and meanings attributed by people undergoing smoking cessation treatment

Abstract

Objective

This study sought to understand the occupations of people undergoing smoking cessation treatment. The motivations for this research emerged during a resident professional practice in a Tobacco Control Program. A theoretical perspective on the functions and meanings of occupations in the context of Occupational Science was used to understand the occupations of the participants of this program.

Method

This is a qualitative study carried out with four people undergoing smoking cessation treatment from September to October 2020. Data were analyzed by Content Analysis.

Results

It was possible to identify and discuss smoking as an occupation and the meanings that have led the participants to smoke and stop smoking. These meanings are related to culture, psycho-emotional context and factors, illness, and self-perception of health. In addition, the participants identified the treatment space as a support for the moment of occupational transition.

Conclusion

Smoking is an occupation that needs to be considered during smoking cessation treatment, as how the occupational transition is addressed can interfere with treatment adherence.

Keywords:
Tobacco Use Disorder; Activities of Daily Living; Occupational Therapy; Primary Health Care

Resumo

Objetivo

Este estudo buscou compreender as ocupações de pessoas em tratamento para deixar de fumar. As motivações para tal pesquisa surgiram durante a prática como profissional residente em um Programa de Controle do Tabagismo. A fim de compreender as ocupações das pessoas participantes desse programa, utilizou-se uma perspectiva teórica sobre os sentidos e significados ocupacionais desenvolvida no contexto da Ciência Ocupacional.

Método

Trata-se de uma pesquisa qualitativa realizada em setembro e outubro de 2020 com quatro participantes que estavam em tratamento do tabagismo. Os dados foram analisados a partir da Análise de Conteúdo.

Resultados

Foi possível identificar e discutir sobre fumar como ocupação e os sentidos que levaram os participantes a fumar e deixar de fumar. Esses sentidos estão relacionados à cultura, contexto e fatores psicoemocionais, adoecimento e autopercepção de saúde. Além disso, os participantes identificaram o espaço de tratamento como um suporte para o momento de transição ocupacional.

Conclusão

Fumar é uma ocupação que precisa ser considerada no tratamento do tabagismo, pois a maneira como se lida com a transição ocupacional pode interferir na adesão ao tratamento.

Palavras-chave:
Tabagismo; Atividades Cotidianas; Terapia Ocupacional; Atenção Primária à Saúde

Introduction

Tobacco is a plant extracted from a substance called nicotine (Centro Brasileiro de Informações sobre Drogas Psicotrópicas, 2012). According to the Ministry of Health (MH) (Brasil, 2015), tobacco can be consumed in several ways, classified as smoked tobacco and non-smoked tobacco. Smoked tobacco is consumed by burning it (generating “smoke”). The most common in this category is industrialized cigarettes, as well as pipes, cigars, straw cigarettes, and hookah. Non-smoked tobacco, in turn, is any way of consumption in which there is no burning (chewed, inhaled, or under the skin) (Brasil, 2015).

Smoking is considered by the World Health Organization (Organização Mundial da Saúde, 2019) as the leading cause of preventable death in the world. In Brazil, according to the José Alencar Gomes da Silva National Cancer Institute (Instituto Nacional do Câncer, 2020), smoking and passive exposure to tobacco are responsible for 428 daily deaths in the country and approximately 156,000 deaths annually, in addition, to be responsible for the development of 50 diseases on average. According to INCA (Instituto Nacional do Câncer, 2020), cardiovascular diseases and cancer, which have smoking as the main risk factor, were the first and second causes of death attributable to tobacco in the country.

The Unified Health System (SUS- Sistema Único de Saúde) implemented the Tobacco Control Program (PCT- Programa de Controle do Tabagismo) to reduce these impacts, which offers treatment for people who declare the desire to stop smoking. These people are assisted individually or in groups using Cognitive-Behavioral Approach techniques and, when necessary, drug support for the cessation of tobacco use (Instituto Nacional do Câncer, 2019).

The PCT runs on Primary Health Care (PHC) devices; however, the minimum approach regarding smoking can and should be taken by all health professionals, regardless of the level of complexity in which they work. Thus, in the context of PHC, care for tobacco-dependent people takes the form of a detailed assessment, which should identify the level of dependence and the existence of the user's desire to quit. Those who do not express a desire to quit smoking should be counseled about the consequences of maintaining the habit, and those people who wish to quit smoking are treated individually or in groups (Brasil, 2015).

Smoking has a very close relationship with people's daily lives, and there may be occupations that are triggers for the desire to smoke or even that are only performed when they are smoking (Helbig & McKay, 2003; Luck & Beagan, 2014).

For Lanas & Salas (2019), occupations are activities that people perform daily, in which people attribute value based on sensory, affective, motor, cognitive, social, and spiritual experiences (Helbig & McKay, 2003; Kiepek & Magalhães, 2011; Luck & Beagan, 2014).

Some people smoke while drinking coffee, before going out, and after lunch, among other situations. In this scenario, considering that the PCT is a welcoming and caring space for the person who uses tobacco and that after the experience of acting as a resident professional in a PCT, problems and questions arose that instigated this study. We can highlight the occupational changes of these people and how these influenced the course of treatment and their lives.

In this context, occupation, according to the International Society for Occupational Science (International Society of Occupational Science, 2016), refers to all activities that people perform in their daily lives for themselves, that is, as individuals, in family or community, to occupy time, as well as to bring meaning and purpose to life. For the American Occupational Therapy Association (American Occupational Therapy Association, 2020), occupations occur over time in different contexts, having goals, meanings, and usefulness for people. The occupations involve several daily tasks, which also promote different experiences during their execution. Thus, considering the importance of occupations for human beings and to better understand them, the perspectives developed within the scope of Occupational Science stand out as a reference, which is considered a basic science dedicated to the study of human beings as occupational beings that also considers the relationship with social, economic, cultural and political conditions (Yerxa, 1993; Magalhães, 2013), and aims to build scientific bases and foundations of occupation as a manifestation of human doing in all areas (Ramírez & Schliebener, 2009).

Occupational Science allows us to understand the relationships that permeate occupational choices, as well as the influence of context and how this interferes positively or negatively with health (Kiepek & Magalhães, 2011). One of the occupational perspectives developed within the scope of Occupational Science seeks to analyze how each individual engages in occupations and understand how occupations provide meaning and identity to human existence (Costa et al., 2017). Thus, Occupational Science is important for Occupational Therapy since occupations are the domain of the profession such science allows understanding the occupations in their nature, their relationship with health and well-being, and factors that can influence and modify occupations (American Occupational Therapy Association, 2020; World Federation of Occupational Therapists, 2012).

Among the studies of Occupational Science, there is the perspective of sense and significance. Meaning is understood as the reasons, and purposes for a person or group to engage in an occupation (Sy et al., 2019). By meaning, we understand the subjective motivations that people find for certain choices that influence their experiences (Sy et al., 2019).

We believe that the person undergoing treatment to stop smoking goes through several changes and new situations, from visits to the health unit, and probable abstinence crises, to the adaptation of activities. All these possible events provoked a question: how are the occupations of users of a PCT presented? In this sense, this study aims to understand how the occupations of users of a PCT are presented.

Methods

Research type

This is qualitative research that responds to very particular questions and analyzes subjective data, that is, data that cannot be quantified or considered as variables - they are deep processes that seek to understand realities, attitudes, and meanings (Minayo & Minayo, 2001). For Minayo (2017), qualitative research deals with phenomena, and seeks uniqueness and meanings, paying attention to social and cultural issues that are expressed through values, beliefs, behaviors, and relationships; therefore, this type of research is complex and necessary.

Research location

The research was carried out at the PCT of the Municipal Health Unit in the neighborhood of Marambaia, Belém, Pará (PCT/UMS-Marambaia) in September and October 2020. At the time of data collection for this research, UMS-Marambaia completed six years of execution of the PCT, being one of the pioneers in the implementation of this tobacco control service.

PCT/UMS-Marambaia assists users individually or in groups. Group consultations take place once a week and are conducted by two higher-level professionals: a nurse and an occupational therapist. The group meeting lasts from 40 minutes to 1 hour. The group approach to smoking cessation is structured into four sessions lasting 90 minutes each. The sessions address what cigarettes are and the substances contained in them, the interference of smoking on health, methods to quit smoking, self-perception of dependence, the abstinence syndrome and its relationship with mood, and the benefits of stopping smoking (Instituto Nacional do Câncer, 2014). After the four group sessions, follow-up is recommended through spaced meetings to maintain cessation and prevent relapses (Brasil, 2015).

Research participants

Four PCT/UMS-Marambaia users participated in the research. The inclusion criteria were being an active user, that is, being in treatment, participating in PCT/UMS-Marambaia sessions; being over 18 years old; understanding and signing the Informed Consent Form (ICF). Exclusion criteria: users not participating in the PCT/UMS-Marambaia; under 18 years old; users with mental disorders diagnosed and identified in the medical records.

Data collection and analysis procedures

The data collection procedures started with the ambience phase, in which the project was presented to the professional coordinator of the PCT/UMS-Marambaia, who also had the objective of knowing the environment, opening hours, and the development of activities. After this phase, the users were searched through a verbal invitation at the end of the treatment sessions and presentation of the research and the ICF. After the consent and acceptance of the users to participate in the research, the search for the evaluations of the medical records was carried out after authorization through the Consent Form for Data Use.

The medical records of the research participants were searched to obtain data from the Smokers' Ambulatory Record, which contains the user's data, 23 items about their clinical history, consisting of closed questions about the use of medications, diagnoses, allergies, weight, height, dental prosthesis, heart and lung problems, psychological and/or psychiatric treatments, pregnancy, and breastfeeding, and nine items about their smoking history, consisting of closed or multiple-choice questions about the age they started smoking, everyday situations related to cigarettes, reasons for smoking if they have ever managed to quit smoking and self-perception of health.

In addition, the Fagerström Test scores were obtained, which is a brief application instrument, performed directly with the smoker. This test consists of six closed questions (1. How long after waking up do you smoke your first cigarette?; 2. Do you find it difficult not to smoke in forbidden places like churches, libraries, cinemas, etc.?; 3. Which cigarette of the day brings more satisfaction?; 4. How many cigarettes do you smoke per day?; 5. Do you smoke more often in the morning?; 6. Do you smoke even when you are sick and need to stay in bed most of the time?). The alternatives range from two to four options. For each answer alternative, there is a score whose value is found next to the answer option. The sum of the points of the answer alternatives chosen by the smoker classifies the individual in five categories that correspond to his degree of nicotine dependence: 0-2 - very low; 3-4 - down; 5 - average; 6-7 - high; 8-10 - very high (Hallal & Campos, 2016).

Subsequently, an open interview was conducted with questions regarding occupation: 1. What reasons led you to start smoking?; 2. How did you find out about the program?; 3. How long have you been in treatment?; 4. Tell us about your current occupations; 5. What is the meaning of these occupations?; 6. Are there meanings in the occupations you perform? if yes, which ones?; 7. How has this treatment been for you?; 8. For you, what does it mean to participate in this program?; 9. How do you evaluate this moment of participation in the research?

The qualitative analysis of the data was developed from the answers to the questions, which were recorded in audio, transcribed in full, carried out individually by the researcher, and validated by another researcher. The texts, when necessary, went through linguistic corrections, however, without eliminating the spontaneous character of the reports. We sought to ensure the fidelity of the recorded reports and the inclusion of all relevant material. The Content Analysis method proposed by Bardin (Bardin, 2011) was adopted. According to Bardin, this method is composed of a set of communication analysis techniques that follow these organization criteria: pre-analysis, material exploration, and treatment of results. Therefore, there was a range of possibilities in several fields, considering that it is a method in constant improvement and that it applies to discourse - a vast field that cuts across relationships (Bardin, 2011).

Ethical issues

The participants of this research were interviewed respecting the Norms for Research Involving Human Beings (Res. CNS 466/12 and Res. CNS 510/16) of the National Health Council (CNS). All agreed to participate in all stages of the research and were allowed audio recordings after signing the ICF. This study was approved by the Ethics Committee for Research involving Human Beings of the Center for Biological and Health Sciences at the State University of Pará (CCBS/UEPA) under opinion number 4,058,982.

Results and Discussion

This study the participation of four PCT users: three women and one man. The average age of participants was 55.2 years old. Regarding their marital status, there were two divorced, one widowed, and one married. Three started smoking before the age of 20, and two were still underage when they had active contact with cigarettes. Regarding cessation, participants U1, U2, and U3 were able to stop smoking before the end of the treatment, while participant U4 relapsed (Table 1).

Table 1
Sociodemographic data of participants, information on occupations and reasons related to smoking, reasons for quitting smoking, and degree of dependence according to the Fagerstöm Test, Belém, PA - 2020.

Identification	Age	Age that started smoking	Gender	Marital status	Everyday situations related to cigarettes	Reasons to smoke	Reason for thinking about quitting smoking	Result of the Fagerström Test (Degree of Dependence)
U1	42	28	F	Married	After meals; with alcoholic beverages; with coffe; anxiety; sadness; happiness	Smoking is a great pleasure; smoking is very tasty; the cigarette calms down	For the well-being of the family; because you find smoking antisocial; because the children ask; because you are worried about your health in the future; because you spend a lot of money on cigarettes; because you do not like to be dependent; smoking is a bad example for children.	1= Very low
U2	63	13	F	Widow	After meals; with alcoholic beverages; with coffee; anxiety; sadness; happiness; go to the bathroom	The cigarette calms down	Because you are worried about your health in the future; because it is affecting your health.	8 = Very high
U3	59	15	M	Divorced	After meals; with alcoholic beverages; with coffee; anxiety; sadness; happiness	Smoking is a great pleasure; the cigarette calms down	Because it is affecting the health; for the welfare of the family; because you are worried about your health in the future; because you spend a lot of money on cigarettes; because you do not like to be dependent.	3 = Low
U4	57	19	F	Divorced	When talking on the phone; after meals; with alcoholic beverages; with coffee; anxiety; sadness; happiness; going to the bathroom	Smoking is a great pleasure; smoking is very tasty; the cigarette calms down	Because it is affecting health; other people are pushing; because you are worried about your health in the future; because you do not like to be dependent; smoking is a bad example for children	8 = Very high

• Source: Field research.

Regarding data from the smoking history, which is part of the initial interview with the user, in the item “everyday situations related to cigarettes”, the participants chose: when talking on the phone; after meals; with alcoholic beverages; with coffee; anxiety; sadness; happiness; go to the bathroom. The “reasons for smoking” were: smoking is a great pleasure; smoking is very tasty; the cigarette calms down. When asked about the “reasons for thinking about quitting smoking”, the participants marked the items: for the well-being of the family; because you find smoking antisocial; because the children ask; because you are worried about your health in the future; because you spend a lot of money on cigarettes; because you do not like to be dependent; smoking is a bad example for children; because it is affecting health (Table 1).

Participants' scores on the degree of nicotine dependence range from “low” (1) to “very high” (8). Based on this assessment, it is possible, in addition to knowing the level of dependence, to reflect on the strategies that can be used by professionals to cope with cessation, as well as to sensitize the user about their dependent condition. Table 1 shows the sociodemographic data of the participants, such as age, age at which they started smoking, gender, marital status, everyday situations related to cigarettes, reasons for smoking, the reason for thinking about quitting smoking, the result of the Fagerström Test (Table 1).

Between smoking and quitting smoking: occupational meanings of people in smoking care and attention program

Through content analysis, we identified the meanings added by people undergoing treatment for smoking, meanings linked to smoking and quitting, and the implications for occupations. Occupational sense is understood as the objective arising from the dynamic interaction between the person and the activity (Jáuregui & Lucero, 2013). Relating this to cigarette use, we believe that the person who smokes seeks this occupation for some reason: relief, desire to belong, or reproduction of behaviors. There may be several senses linked by a person to “what” they smoke for. From the analysis, the following meanings led the participants to start smoking: smoking was beautiful (U3 and U4); it calmed down in cases of stress, anxiety, and depression (U1 and U4); the cigarette was part of the family context (U2, U3, and U4).

Regarding the meaning linked to beauty, in the 20th century, tobacco use spread around the world with the help of advertising and marketing, becoming a symbol of sophistication, high purchasing power, and elegance (Centro Brasileiro de Informações sobre Drogas Psicotrópicas, 2012; Darsie et al., 2017). Participants U3 and U4 expressed how they perceived cigarettes when they started smoking:

I started because, [...], I don't know, [...], I saw other people smoking, then I thought it was beautiful and I also started to try it (U3).

At first, I even thought the cigarette in the mouth was beautiful (U4).

We understand that context influences occupations. Context is understood as the environmental and personal factors of each person. Therefore, relationships, knowledge, and culture, among others, influence engagement in occupations (American Occupational Therapy Association, 2020). In this sense, in a social context in which it was common to use cigarettes, new people started this practice influenced by the environment in which they lived.

On the other hand, we believe that the investment in campaigns and advertisements regarding the harmful effects of cigarette use has influenced a new context, in which cigarettes have become harmful to health, life-threatening, and even cease to be beautiful and become something most people want to distance themselves from. This change in context can be observed in the data that show the reduction in the number of smokers in the country. In 2008, the Brazilian Institute of Geography and Statistics (IBGE- Instituto Brasileiro de Geografia e Estatística) carried out the Special Survey on Smoking, which detected that in the population over 18 years old, 18.5% were smokers. Whereas in the National Health Survey carried out in 2013, this percentage was reduced to 14.7% (Instituto Brasileiro de Geografia e Estatística, 2009).

Regarding the new context related to smoking, that is, the view of smoking as a threat to health, Darsie et al. (2017) discuss the scenario created by health advertisements, which use images of tobacco products as the cause of impotence, aggravated diseases and organ damage behind cigarette packages and on campaign posters. This view, while contributing to reducing the number of smokers, has the idea that smokers are sick, impotent, and without a quality of life, which can contribute to the decision to quit smoking.

Another motivation for starting or continuing to smoke was associated with emotional factors. For the participants of this research, the cigarette calmed them down in moments of stress, anxiety, and depression. Even though she was abstaining, participant U1 reported how psycho-emotional states can bring back memories of when she smoked:

I, in my moments, even have some stressful thoughts inside me, in the case of my day-to-day routine, if I have a lot of problems, [...], then I have the thought of lighting a cigarette, [...], I think this is psychological dependence, right? (U1).

Participant U4 reported that she started smoking because of her emotional state, finding relief from the feelings of that context in the effects of cigarettes:

It was at the time I separated from the father of my children - a couple that I have. I was married, I got married very young. Then, there was a betrayal with my cousin inside my house, so I got very depressed, [...], then, I had some colleagues who smoked, I took a cigarette from one, I took a little, [...], on the other hand, [...], when I saw it, I was already smoking a cigarette, when I saw it, I was already buying a cigarette, so I got addicted [...] (U4).

Time passed, I smoked one here, another there, sometimes I bought a package and it lasted a week. Like, I bought it when I was very distressed, or very thoughtful. Then I smoked to relax, I thought (U4).

Regarding factors related to mental health, Jesus et al. (2016) present the impacts of smoking on daily life and state that cigarettes are considered, for those who smoke, support for coping with the stress resulting from daily activities, including family life. The 15 study participants by Jesus et al. (2016) were undergoing treatment in a PCT and reported the influence of cigarettes in stressful and conflicting situations. Such everyday situations had repercussions on the success or failure of the attempt to quit smoking, revealing the intensity of the relationship between smoking and the individual's daily life. Participant U1, even though she is abstinent, still remembers the cigarette as a means of going through the moment of stress.

In the case of people who are abstaining, mental health problems represent a risk factor for relapse. In this sense, it is of great value that the treatment for smoking cessation is carried out in partnership with the target health care, preferably with a multidisciplinary team, respecting the singularities and needs of the case (Oliveira & Furegato, 2017).

Oliveira & Furegato (2017) interviewed 96 people in psychological distress about the best time to quit smoking. Some reported that it is more viable when the clinical condition is stabilized, while others said that it only depends on the person. However, Oliveira & Furegato (2017) also state that the smoking cessation process in people with psycho-emotional symptoms or psychological distress should include comprehensive care, treating, and meeting all demands.

On the motivations for starting to use cigarettes, there is the relationship with the family context. In this sense, three of the four participants had smoking parents, which aroused their interest and curiosity since childhood. Participant U2's report shows that tobacco use had been in the family for more than two generations:

The reason is that I was curious, right? When I was 13, I started smoking and never stopped. I saw my mother smoking, [...], my father, [...], then, blowing that smoke, [...], then, I started to catch myself too. I smoked first, hiding from them, until I turned 20, [...], that's when I started smoking near my mother (U2).

I started with the one of doing it on the 'little paper' [...], my mother's porronca’. Really bad tobacco. Then, I smoked my grandmother's pipe too. Hidden. Everything hidden. When they leave home (U2).

Participants U3 and U4 also had parents who smoked:

I 'was' more or less 15 years old [...], 14 to 15 years old. My parents smoked. My mother still smokes [...] (U3).

[...] my mother came to attend here (Tobacco Control Program), you know? But then, she soon got sick, went to Barros Barreto, it got really bad, and then she ended up quitting (referring to cigarettes) because she had spent almost two months hospitalized due to pneumonia (U4).

In this context, knowing that culture is linked to the production of meanings, desires, and ways of relating to the world and that it directly impacts human occupation (Silvestrini et al., 2019), perhaps, there is a culture of tobacco, since people, families, and groups add meanings to smoking, build knowledge and experiences from this occupation.

According to Silva et al. (2017), culture occurs in everyday life and is permeated by interaction with others. In the case of smoking, people smoke in their daily lives and for some of them, smoking in the company of others is satisfactory (Luck & Beagan, 2014). Luck & Beagan (2014) state that smoking is an occupation in which people allocate time and is the center for organizing routines. This occupation is valued, significant, and associated with positive and negative factors, factors that are attributed by smokers. Thus, the idea of ​​studying the abusive use of substances and interventions beyond the perception of harm reduction is still encouraged, going to analysis based on occupations. Leppard et al. (2018) performed a systematic review of the literature regarding interventions used to address substance use by women in North America and concluded that interventions and studies are largely focused on the harm reduction philosophy, calling attention to the development of interventions that address occupations.

Smoking in family contexts can be configured as a co-occupation. According to Fraga et al. (2019), co-occupation is a term used to describe the implicit involvement of two or more people in an occupation. Pierce (2009) also states that co-occupation is a movement between individuals that shapes the occupations of both. In the case of smoking and based on the reports of the participants in this research, there is an interest, involvement, and engagement in smoking based on the interaction with smoking parents, for example.

A study carried out with 58 smoking parents showed a lack of knowledge about the repercussions of cigarette use on their children's lives: 52% of the participants did not consider that their children were passive smokers who could have respiratory damage, which suggests that these parents did not realize that smoking influenced their children (Ribeiro et al., 2015).

In this study, the participants attributed the meaning of quitting smoking to the repercussions on health, the illness of family members, and family encouragement. These meanings could also be analyzed in the smoking history assessment questionnaire; however, the evaluation instrument is a closed questionnaire, while the participants freely presented the whys in the open interview.

In health-related motivations, it is known that some people were motivated to quit smoking based on guidance about its harm, others from the illness of a close person, and still others from the illness (Brasil, 2015).

In this scenario, some of the participants in this research reported their motivations based on the health-disease process. Participant U2 reported that he arrived at the treatment referred by a physician due to the diagnosis of a smoking-related disease.

I already had a health problem. Because as I started to feel sick, with shortness of breath, then I told the Doctor and he told me to smear the lung four times, then, it was a stain. Then he said it was all the cigarettes. He said: You have to stop smoking immediately. Then, I said, Doctor, I can't. He said: But you have to make an effort to do it (U2).

So much so that I came here and enrolled, then I came the first week, the second week, the third week I dropped out all at once (U2).

From this report, we could reflect on how much a health problem can be the central motivation for quitting smoking, which may lead to thinking about the relationship between smoking cessation and the desire to live:

Participant U4 also starts treatment to stop smoking based on a medical diagnosis and an affective request from a grandson:

[...] my doctor who referred me (U4).

[...] because I can no longer manage to clean the house, I depend on others to do it, and, [...], to wear shorts, pants, [...], all that makes me work because I get tired, I have to use an inhaler, you know? (U4).

[...] my grandchildren ask me, my children, [...]. My grandson told me: grandma, on my birthday I want a present from you. I asked what it is. He said: I want you to stop smoking (U4).

[...] because of my health, because of everything, because I know that everything is because of cigarettes. This sucks (U4).

Participant U1 found the motivation to stop smoking in the illness of her sisters; in addition, she perceived age as a relevant factor for quitting smoking:

[...] a sister who died of cancer. She smoked a lot. And, another sister who found out that she has breast CA also because of cigarettes, she's already had chemo, she's had radiotherapy and now she's fine and I also thought that because of my age, I'm 45, and I thought that was enough and for one health issue (U1).

Corrêa & Echer (2015) point out that concern for health and family is a reason to stop or want to stop smoking. They also state that for patients already diagnosed with diseases related to smoking and in the hospital, cessation is closely related to the restriction of the environment. That is, hospitalized people commonly stop smoking because smoking is prohibited in the hospital environment and their hospitalizations are prolonged.

In this sense, some illness processes may be related to cigarette use, given that some people who smoke have already had to stop their daily occupations due to health problems triggered by smoking. Azevedo et al. (2009) indicate that, in a sample of 171 people, 12.3% had already needed to be away from work due to diseases related to tobacco consumption.

In that same study, Azevedo et al. (2009) report that 51% of the sample (171 people) sought the service spontaneously; another factor identified was that 61.7% of the participants smoked for at least 30 years, long enough for a person to possibly present clinical complications. Such results were also found in three of the four users interviewed, and only participant U1 had smoked for less than 20 years. Participants U2, U3, and U4 had been smoking for 50, 44, and 38 years, respectively, when they sought care.

Lima et al. (2017) analyzed the quality of life of smokers who did not have diagnosed clinical diseases and found that the longer the time of tobacco use, the lower the quality of life. After evaluating 48 individuals, these authors identified that there is a loss of vitality and functional capacity and an increase in pain.

In this context, according to Vieira et al. (2017), pain is a factor that directly interferes with individuals' occupations, limiting them in their daily activities and being able to influence their social relationships and general health. Because of the pain, people may stop doing meaningful activities for fear that it will increase or return.

Such studies contributed that, regardless of a diagnosis, smoking will always cause damage to people's health, and these damages can be, as observed in this research, motivation to start quitting.

However, smoking cessation increases people's life expectancy. Quitting smoking before 50 years old reduces the risk of smoking-related death by up to 50% after 16 years of abstinence, while after 10 years without smoking, there is a 30 to 50% reduction in the risk of death from lung cancer. Regarding cardiovascular diseases, the risk drops by half after 1 year of cessation (Brasil, 2015). Kaiser et al. (2017) corroborate these data by stating that treatments for smoking cessation are successful and contribute to the improvement of cancer patients and their general health status.

Zampier et al. (2017), in a phenomenological study conducted with people abstaining from cigarettes, point out that people who stop smoking keep quitting. They perceive health-related gains, such as improved taste and appetite, sociability - especially regarding the conquest of permanence in social environments because they no longer need to be away to smoke, and the performance of activities.

In this scenario of harm vs. benefits of cigarettes, participant U2 contributes through the report on the existence of benefits with cessation and better quality of life. This participant, who arrived at the PCT with many respiratory complaints and in the performance of daily occupations, also reported how he feels after cessation:

I wake up early, make my coffee, take my medication, I have to take it at 7 am. Then, later I take my shower and take care of the rest of the things. I go to the market sometimes, when I'm not cooking, [...], washing clothes, or sweeping the house. After I stopped smoking, I get less tired (U2).

Between smoking and quitting smoking: occupational meanings of people in smoking care and attention program

As for the meaning, the users interviewed found in the treatment an option and support for the occupational transition, understood as the process of quitting smoking. Ceasing the use of cigarettes represented more days of life and health for the participants of this research.

From the perspective of Occupational Science, meaning is understood as a subjective dimension that arises from the direct interaction with the occupation. Therefore, the dynamic interaction between the person and the environment generates a unique value for what has been performed (Carrasco & Olivares, 2008; Jáuregui & Lucero, 2013). Lanas & Salas (2019) understand the meaning as the subjective effects of occupational experiences, effects that influence experiences.

In this research, we identified the meanings of the process of smoking and quitting. This is a unique process and requires all possible care from the professionals involved in the cases.

From the report of participant U4 when questioned about the meaning of undergoing smoking treatment, we infer that quitting smoking finds meaning in living and in the hope of contemplating future generations:

Everything, [...], Everything, [...], is my hope of living longer. To see my great-grandchildren grow up [...]. So, the program for me is a better life expectancy, to be able to live longer, to see my little great-grandchildren that I love them - I don't know if I'll be able to see them grow up (U4).

The concern with health and the fear of not living with the family is also present in the study by Lucena et al. (2019), who consider that fear of health problems and complications have become factors that drive smoking cessation. Also, other factors identified were related to family support and the bond with the health professional.

For participant U2, being involved in participating in smoking treatment was satisfactory:

I liked coming here. So much so that I started asking her (Nurse) to go with the doctor... a doctor there I was coming too. That's when I started doing the other exams around here, everything and it was like this... I got everything on the right days. Something on a Tuesday at two o'clock in the afternoon, that's when I came... For me, it was a good thing (U2).

For this participant, the smoking treatment aroused interest in taking care of his health: in addition to the sessions, the user started to use other services available at the Health Unit. Lucena et al. (2019) state that when people undergoing treatment for smoking understand the benefits of quitting, they value health, and this becomes a facilitating factor for maintaining the cessation of smoking.

Zampier et al. (2017) also highlight that the cardiorespiratory and sensory benefits (taste and smell) and better performance in daily activities were an incentive for participants to continue abstaining from tobacco.

Smoking has a very close relationship with people's routines. This is because cigarettes are used throughout the day and some people only perform certain activities after smoking a cigarette, while others need to leave certain environments to smoke. For Jesus et al. (2016), in addition to the persistence of the habit, its cessation led to numerous occupational changes, as activities had to be interspersed with periodic visits to the Health Unit, following guidelines, and changing routines during treatment.

Lucena et al. (2019) discuss the ambiguous relationship existing in the process of quitting smoking. These authors point out that the understanding of the positive aspects of tobacco cessation arises over time and, during this journey, people encounter difficulties related to psychological dependence, weight gain, and the development of activities that were previously performed together with the act of smoking.

Suazo & Julio (2018) point out that changes in the occupational structure require a careful and thorough organization, in which the needs, demands, and interests listed by the person must be considered and prioritized. Such considerations point to possible opposing feelings during treatment, which may or may not be favorable to their adherence. As they understand the importance of quitting smoking, participants may also experience feelings of sadness, absence, and stress resulting from the repercussions of stopping smoking, configuring it as an occupational ambivalence (Hoppes, 2005).

Therefore, we can say that, from the beginning of the choice to smoke, there are linked senses and meanings that permeate from social constructions to the illness process and the development of occupational competence to face abstention. Faced with this process, we found that smoking and quitting smoking is unique, that is, each person experiences it in their way, but it can also be built from the relationship with another. People undergoing treatment for smoking showed occupational impacts and gave us subsidies to encourage the importance of studying how occupations were presented in these conducts.

Smoking and quitting are complex process, which requires a sensitive therapeutic look also at the repercussions on occupations. This understanding enables us to say that the occupational dimension needs to be evaluated and monitored during the treatment of smoking, as occupations contemplate people's daily lives, which can be modified through the transition between smoking and quitting. In this case, Occupational Therapy is considered as the profession that can actively participate in the PCT, helping people in their transitions, evaluating, accompanying, and understanding occupations. Once the occupational dimension is considered, there are possibilities of greater success in the treatment of smoking.

Final Considerations

This research revealed the occupations of users of a PCT and helps to reveal singularities regarding the occupational senses and meanings of the participants. It presented the occupations and their relationships with the motivations to keep or stop smoking.

The program chosen for data collection is one of the oldest in the municipality under study and, to the best of our knowledge, this was the first research that analyzed, qualitatively and from an occupational perspective, the people who work tobacco use. This further reinforces the importance of keeping the PCT active, also presents the effectiveness of conduction, and encourages professionals to remain welcoming and interested in the subject.

Within the scope of PHC, this study aggregates knowledge related to smoking beyond the biological dimension but reaches biopsychosocial and occupational results, which need to be included in the care of smokers. Also, it reveals to managers, professionals, and the territory a complex but efficient field in the prevention of injuries and health promotion, especially of chronic non-communicable diseases.

By presenting this work as a product of a residency, the mission is to contribute to the Unified Health System. In this perspective, in addition to scientific production, it contributes to the visualization of the occupational dimension existing in the care processes. We suggest including the assessment of occupations in standardized PCT assessments. This research reveals data that can contribute to SUS, occupational therapy, and multidisciplinary care.

As weaknesses of this study, we point out the collection carried out in only one program and only in the individual modality. We suggest that future studies be carried out with larger samples and consider the experimental possibility of occupations in the treatment of smoking.

• How to cite: Sobrinho Cardoso, J., Folha, O. A. A. C., Omura, K. M., Leite, A. P. S. B., & Corrêa, V. A. C. (2022). Smoking as an occupation: functions and meanings attributed by people undergoing smoking cessation treatment. Cadernos Brasileiros de Terapia Ocupacional, 30, e3332. https://doi.org/10.1590/2526-8910.ctoAO255333322

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Edited by

Section editor

Profa. Dra. Marta Carvalho de Oliveira

Publication Dates

• Publication in this collection
  06 Jan 2023
• Date of issue
  2022

History

• Received
  19 May 2022
• Reviewed
  26 May 2022
• Accepted
  29 July 2022