Effects of an Anger Management and Stress Control Program on Smoking Cessation: A Randomized Controlled Trial

Bektas Murat Yalcin; Mustafa Unal; Hasan Pirdal; Tevfik Fikret Karahan

doi:10.3122/jabfm.2014.05.140083

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Figure 1.
Flowchart of the study procedure administered to all participants in the study and control groups (a total of 12 groups); a new study and control group were included every month between March 2010 and February 2011.
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Figure 2.
Comparison of estimated marginal means of pretest, post-test, and first and second follow-up tests for Trait Anger Scale of the State and Trait Anger Scale in the control and study groups.
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Figure 3.
Comparison of estimated marginal means of pretest, post-test, and first and second follow-up tests for hopeless subscale of the Stress Coping Styles Inventory in the control and study groups.
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Figure 4.
Comparison of estimated marginal means of pretest, post-test, and first and second follow-up tests for self-confident subscale of the Stress Coping Styles Inventory in the control and study groups.

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Table 1. Clinical and Epidemiological Features of the Two Groups

Variables	Study Group	Control Group	P Value	χ²	t
Sex (n)
Men	87	89	.102	0.686
Women	88	86
Age (years)	35.25 ± 21.25	37.19 ± 51.14	.201		0.807
Marital status			.098	0.143
Single	11 (8)	10 (6)
Married	140 (86)	147 (88)
Widow	6 (4)	3 (2)
Divorced	5 (3)	6 (4)
Education year	9.25 ± 1.8	9.8 ± 1.0	.117		0.568
Fagerstrom nicotine Dependency score	5.84 ± 2.32	5.67 ± 1.78	.157		1.021
Package/year	26.2 ± 2.4	24.1 ± 3.9	0.361		0.972
Mean years of active smoking	16.4 ± 2.7	15.9 ± 1.8	0.512		0.954
Cessation method selected			0.213	0.705
BC only	29 (16.5)	31 (17.7)
BC + NRT	46 (26.2)	42 (24.0)
BC + bupropion	45 (25.7)	45 (25.7)
BC + varinicline	55 (31.4)	57 (32.5)

Data are n (%) or mean ± standard deviation unless otherwise indicated.
BC, behavioral counseling (motivational interview with life style modification); NRT, nicotine replacement therapy.

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Table 2. Mean Pretest, Post-Test, and Follow-up State Trait Anger Inventory (TAS), Self-Confident Approach Subscale (SCS), and Hopeless Subscale (HS) Scores Between the Two Groups

	Pretest		Post-test		First Follow-up		Second Follow-up		P Value^*	F
	Mean ± SD	n	Mean ± SD	n	Mean ± SD	n	Mean ± SD	n	P Value^*	F
TAS
Study	22.48 ± 3.7	175	20.66 ± 4.3	169	19.3 ± 4.0	167	18.40 ± 3.5	163	<.001	25.041
Control	22.13 ± 3.7	175	23.44 ± 3.5	168	22.9 ± 3.5	168	23.2 ± 3.5	166	.234	1.201
P Value^{^†}	.721		<.001		<.001		<.001
t	0.932		6.569		8.851		12.798
SCS
Study	10.43 ± 3.4	175	13.45 ± 3.5	169	13.42 ± 3.6	167	13.37 ± 3.6	163	<.001	13.506
Control	11.17 ± 4.1	175	10.86 ± 3.0	168	10.54 ± 3.3	168	10.49 ± 3.0	166	.130	1.018
P Value^{^†}	.098		<.001		<.001		<.001
t	1.023		6.918		10.151		10.255
HS
Study	11.55 ± 4.6	175	10.27 ± 4.0	169	11.64 ± 4.98	168	10.15 ± 4.1	163	<.01	3.829
Control	11.62 ± 4.5	175	11.35 ± 4.7	168	12.05 ± 5.1	168	11.54 ± 4.2	166	.148	1.616
P Value^{^†}	.121		.03		<.01		.02
t	0.987		2.114		5.564		3.897

↵* The statistical relation within study or control groups' pretest, post-test, first follow-up, and second follow-up of mean TAS, SCS, and HS scores.
↵† The statistical relation between study or control groups' pretest, post-test, first follow-up, and second follow-up of mean TAS, SCS, and HS scores.

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Table 3. Relapse Rates of the Participants in Study and Control Groups According to Cessation Method in the First Week and First, Third, and Sixth Months

Time	Study Group					Control Group
Time	BC	BC + NRT	BC + Bupropion	BC + Varenicline	P Value	BC	BC + NRT	BC + Bupropion	BC + Varenicline	P Value
First week	9 (50)	14 (50)	12 (46.1)	16 (55.1)	.231	17 (65.3)	18 (56.2)	20 (62.5)	19 (51.3)	.125
Second week to first month	6 (33.3)	8 (32)	6 (23)	7 (24.1)	.158	6 (18.7)	7 (21.8)	6 (18.7)	10 (27)	.098
First to third month	2 (11.1)	1 (4)	6 (23)	3 (10.3)	.02	2 (6.2)	4 (12.5)	4 (12.5)	5 (13.5)	.03
Third to sixth month	1 (5.5)	2 (8)	2 (7.6)	3 (10.3)	.568	1 (3.1)	3 (9.3)	2 (6.2)	3 (8.1)	.215
Total relapse rate	18 (62)	25 (53.1)	26 (57.7)	29 (53.7)	.012	26 (83.8)	32 (76.1)	32 (69.5)	37 (66)	.009

BC, behavioral counseling (motivational interview with life style modification); NRT, nicotine replacement therapy.

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Table 4. Logistic Regression Model Investigating the Factors for Quitting Smoking

Factors	B	Standard Error	Wald	P Value	Exp(B)	95% CI for EXP (B)
Participating in the program^*	0.741	0.310	5.701	.001	2.091	1.148–3.851
Pre-TAS	−0.054	0.30	3.154	.076	0.947	0.893–1.006
Post-TAS	−0.135	0.034	12.202	0.001	0.889	0.810–1.049
Pre-SCS	0.010	0.034	0.081	.776	1.010	0.945–1.078
Post-SCS	0.120	0.047	6.407	.01	0.887	0.808–0.973
Pre-HS	0.029	0.026	1.178	.278	1.029	0.997–1.084
Post-HS	−0.091	0.029	4.146	.03	0.989	0.934–1.047

↵* The anger management and stress control program.
Bold values are significant. Wald: 25,682; P significant at .001.
SCS, Self-Confident Subscale of the Styles of Stress Coping Inventory; TAS, Trait Anger Subscale of the Strait and Trait Anger Scale; HS, The Hopeless Subscale of the Styles of Stress Coping Inventory.

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Appendix 1. The Agenda of The Anger Management and Stress Control Program

Main Theme By Session	Time	Content	Techniques and Tools Used
First session	90 minutes	First half (45 minutes): After a warm-up, “Introduction Game” was played; members were introduced to one another and were also told about the aim of the program, the duration and frequency of the sessions, the privacy contract applicable in the group, how the group would work, the rules to be obeyed in the group; and the rules surrounding attendance.	Warm-up surveys
“To form a group”		Second half (45 minutes): Sharing those experiences and situations that most angered members with the group; sharing experiences such as behaving unrestrainedly, psychic attack, displaying subsequent regret for the damage that anger does to relations, taking alcohol, smoking, overeating, or drug use in times of anger, or facing legal problems as a result of anger, and role play. The group participated in the game “The Things That Make Me Angry” Homework: the group members asked to list things that made them angry. The session finished with the “Deadlock Game.”	Warm-up surveys
“To form a group”			Active presentation Handouts Small-group discussion Role plays Workshop
Second session	90 minutes	First half (45 minutes): Identifying clues to anger and its psychic, emotional, and behavioral symptoms, with the aim of controlling anxiety, training in relaxation and breathing correctly, the ability to use relaxation in daily life. The group participated in the “Anger Machine” game.	Warm-up Homework Music listening with breath exercise Active presentation with discussion
“Identify your anger”	90 minutes	Second half (45 minutes): The group discussed the previous session's homework and the ability to perceive negative feelings once they arise and the attribute of awareness. Homework: the group members exchanged the former sessions' homework and propositions on how to avoid them. The group participated in the warming game “Acting a Feeling” (Schilling, 1996). Evaluating the states of being aware or not being aware of the basic feelings experienced in the face of negative events.	Handouts Small-group discussion on topic Role plays Workshop
Third session	90 minutes	First half (45 minutes): To comprehend the “Theory of Election” and attain the ability to use it with the aim of anger control; taking responsibility for behavior displayed at the time of anger and giving examples from personal experience. A group forum took place at which the Election Theory was discussed.	Warm-up Homework Music listening with breath exercise
“Choice is yours”	90 minutes	Second half (45 minutes): The group discussed the previous session's homework and the ability to define a strategy related to managing feelings of anger and the ability to implement that strategy; identifying, exemplifying, practicing and role playing various strategies such as cognitive reconstruction, changing the environment and using humor, communicating effectively, sharing feelings, and perceiving cognitive distortions. Relaxation repetition. Homework: What is your favorite relaxation method?	Active presentation with discussion Handouts Small-group discussion on topic
Fourth session	90 minutes	First half (45 minutes): Expressing anger and negative feelings using “I language”; practice, role play, and relaxation repetition; the role of music to relieve the anger and stress.	Warm-up Homework Music listening with breath exercise
“Express yourself”		Second half (45 minutes): The group discussed the previous session's homework and using the ability to listen effectively by way of eye contact with the person one is angry with; realizing the reactions to poor listening, practice, role play, and relaxation repetition. Homework: create a situation with a friend of yourself which made you angry or stressed.	Active presentation with discussion Handouts Small-group discussion on topic
Fifth session	90 minutes	First half (45 minutes): Giving reactions intended to maintain communication during conflict and in times of anger, understanding other people's feelings by developing empathy. Practicing and role-playing.	Warm-up Homework Music listening with breath exercise
Fifth session		Second half (45 minutes): The former sessions' homework is dispatched to other members and asked to role play with a group member to find an effective solution to the scenario. The group's feelings and experiences were shared, and the program was evaluated with the members. The program came to an end with the game of “Building Ego” and relaxation exercises.	Active presentation with discussion Handouts Small-group discussion on topic
“I am empathetic, you are empathetic”