The Effect of Sleep Hygiene Training on Treatment Seeking Smokers with Poor Sleep Quality

ABSTRACT

Aim: This study was conducted to investigate the effect of sleep hygiene training on sleep quality among nicotine addicts.

Methods: A prospective observational search was planned between May and November 2017 at a tertiary hospital’s family medicine clinics. Treatment-seeking smokers (N = 100) who had a poor sleep quality aged between 18-67 years were randomized to a sleep hygiene training intervention (n = 50), and control (n = 50) groups. A comparison between the first and final PSQI (Pittsburgh Sleep Quality Index) scores of two groups was analyzed by NCSS 10 (2015. Kaysville, Utah, USA) statistic program at a significance level of p<0.05 value. 

Results: Beginning and final PSQI scores of our study sample (59% male, mean age 35.8± 10.6 years) were 7.08±2.6 and 7.05± 2.5, respectively. No significant change in PSQI score was finally found in control (p=0.317) and intervention (with sleep hygiene training) groups (p=0.083). However, a clinically negative although not statistically significant relationship among daily smoking with first (p=-0.051 r=0.612) and final (p=-0.052 r=0.621) sleep quality score was possible. 

Conclusion: Although there is no significant change in the quality of sleep in the quitting process of smokers with hygiene education in our study, it is thought that there is a result indicating the need for not only sleep hygiene training but holistic behavioral therapy methods. 

Keywords: Fagerstrom, Pittsburgh, Nicotine, Smoking Cessation, Sleep Hygiene

1. Introduction

The first condition of a good and healthy life is to sleep well. Sleep hygiene is indicated for patients who engage in habits, consume substances, and/or set up sleep environments that are not conducive to initiating or maintaining sleep [1]. Good sleep hygiene; can improve one's sleep. If insomnia continues despite sleep hygiene and this period covers 4-6 weeks or more; a physician and institution (Sleep Center) specializing in this subject should be consulted [2].

Smoking has been associated with a group of symptoms that suggest difficulty in falling asleep and sleep division in both sexes. The prevalence of sleep disorders in smokers may be due to the stimulating effect of nicotine or nighttime withdrawals [3]. Sleep disturbance is emerging as a potential neurobiological factor in smoking relapse [4]. Studies suggest that smokers may spend less time in deeper, more restful sleep-states than nonsmokers [5] and a higher baseline sleep efficiency in smokers predicts a higher end of treatment cessation, too [6]. The extent to which unhealthy sleep in smokers may be a viable intervention target for promoting response to smoking cessation treatment is considered. Ultimately, conceptual support for sleep therapy as an adjunctive treatment for smoking cessation might be a useful way [7].

Sleep Hygiene Training which is a method of adjunctive sleep therapies includes lifestyle measures such as diet, exercise, substance use, and advice and measures designed to provide a better sleep on environmental factors such as heat, light, and sound. Applying behavioral therapy in patients receiving smoking cessation has been shown to improve sleep efficiency, quality, prolong sleep time, and reduce symptoms of insomnia [1].

This study aims to evaluate the effect of sleep hygiene education on sleep quality levels in nicotine addicts with poor sleep quality. It is hoped that the findings can be used to develop smoking cessation strategies.

2. Methods 

2.1. Participants and procedures

This search was a prospective observational study based on two steps by randomization. Treatment-seeking smokers aged>18 years old were asked questionary for nicotine dependence and sleep quality from May 2017 to November 2017 at a tertiary hospital’s family medicine clinics for smoking cessation. Participants were classified with assessments of demographic data ( e.g. age, education, marital status...), nicotine dependence characteristics based on FTND (Fagerstrom Test for Nicotine Dependence), and sleep quality based on PSQI (Pitsburg Sleep Quality Index) scales.

100 participants with poor sleep quality (PSQI>5 points) were selected and divided in two (50 for intervention and 50 for control) groups based on a random sampling technique. The intervention group was given sleep hygiene training by a psychotherapy certified healthcare professional and not the control group. Participants received counseling sessions across 12-weeks. According to the results of the second PSQI scores of the two groups, the sleep quality was reevaluated, it was tried to check whether there was an improvement in sleep quality and whether sleepy hygiene education was effective.

2.1.1. Exclusion criteria

Exclusion criteria included the prior diagnosis of sleep disorders, history of restless leg syndrome, obstructive sleep apnea syndrome; medical contraindications or any additional chronic disease (e.g., pregnancy, uncontrolled hypertension, asthma, diabetes mellitus…); a history of current major depression; current use of antipsychotics, stimulants, alcoholism or medications (e.g., MAO inhibitors, tricyclic antidepressants) and history of shift work or distant travel necessity that disrupt sleep patterns.

2.1.2. Compliance with ethical standards

The participants were informed about the search and, the verbal consent of volunteers was obtained. The Taksim Training and Research Hospital Clinical Research Local Ethics Committee reviewed and approved this study on date 05/04/2017 (Approval no:35). All authors read and carried out the principles of the Helsinki Declaration.

2.2. Measurements

2.2.1. Pittsburgh Sleep Quality Index (PSQI):

Turkish validity and reliability of PSQI scale consisting of 24 questions including 19 questions for him/herself and 5 questions for his/her partner were made by Ağargün et al.. Those who score 5-21 points on the scale have poor sleep quality [8].

2.2.2. Fagerstrom Test for Nicotine Dependence (FTND):

Fagerstrom Test for Nicotine Dependence (FTND): FTND is a six-item questionnaire ranging between 0-10 points. Reliability in the Turkish version of FTND (to assess nicotine dependence severity) and factor analysis was done in 2004 by Uysal et al.[9].

2.3. Sleep hygiene training:

It is aimed to inform the environmental and acquired factors that disrupt the sleep structure of the patient, to be aware of their habits, and the conditions for healthy sleep, e.g. (i) avoiding stimulants before bedtime (ii) avoiding excessive physical activity and sports before bedtime (iii) the bedroom should only be used for sleep and sexual life. TV or book should not be read in the bedroom (iv) the bedroom should be at the optimum level in terms of sound, light, and heat (v) alcohol should not be taken before bedtime and (vi) the patient should keep a regular sleep diary… [2, 10].

2.4. Statistical analysis

Analyzes were done using NCSS 10 (2015. Kaysville, Utah, USA) software. Descriptive methods ( e.g. mean, standard deviation, median…) independent samples t-test (normal distribution) and Mann Whitney U test (non-normal distribution) for two-group comparison, Kruskal Wallis one-way analysis of variance for groups with 3 or more categories, Wilcoxon test for comparison of first and last values and chi-square test for nominal variables were used. The limit of significance was taken as p <0.05.

3. Results

3.1. Demographic and clinical 

characteristics

100 patients included in the study, 59% (n=59) were male and 41% (n=41) were female. The average age of patients was 35.78± 10.57 (min=18, max=67) years. 81% of all were married. The mean FTND score and daily time cigarette consumption were 5.88±2.33 points and 22.68±10.41 cigarettes/per day. The median values for the first beginning age and duration of smoking were 17 and 18 years, respectively. As seen in Table 1, the difference for nicotine addiction features was only daily consumption (p=0.018) between control and intervention groups. There was no sociodemographic difference.

Table 1 Evaluation of sociodemographic variables and nicotine addiction features between 

control (without hygiene education) and intervention (with hygiene education ) groups.

3.2. Evaluation of change in sleep 

quality between control and intervention groups based on sleep hygiene 

education presence

Beginning and final PSQI scores of study sample were 7.08±2.6 and 7.05± 2.5, respectively. The control group consisted of the other 50 smokers with poor sleep quality that had no education on sleep hygiene. The beginning sleep characteristics of the two groups are given in Table 2. The intervention and the control groups were different in terms of the first and last PSQI scores. Both first (p=0.032) and final PSQI (p=0.034) scores of the intervention group were higher than that of the control group. Despite the increase of PSQI points in control and decrease of PSQI points in the intervention group that supports the effect of sleep hygiene education, these increase (p=0.317) in control group and decrease (0=083) of PSQI points in intervention group were not statistically significant.

Table 2 Evaluation of PSQI scores for control and intervention groups based on the presence of sleep hygiene education

1Mann Whitney U Test 2Wilcoxon Sign Test *p<0.05 Before education; BE After education; AE

Figure 1 shows that daily smoking of over one packet (≥20 cigarettes per day) had a similar change in PSQI score difference for control (without the hygiene education) and intervention (with the hygiene education) groups.

3. Associations between before 

and after of hygiene training 

situations according to education level.

Graduation rates for primary, secondary, high school and university were 37%, 12%, 21%, and 30%, respectively. Table 3 shows if there was a change in sleep quality by education level in first and final visits. In the control group (without hygiene education) and intervention group (with hygiene education), there was no difference between education levels.

Table 3 Evaluation of PSQI levels before and after of hygiene education situations according to education level.

However, in terms of gender and sleep quality, no statistically significant relationship was found among first and last PSQI values with gender in the control group and last PSQI values of men were found to be statistically significantly lower than women in the intervention group (p: 0.049)

3.5. Correlation between PSQI 

scores and data

There was no relationship between change in PSQI scores of study sample and age (p= 0.958 r=0.005), beginning FTND score (p=0.647 r=0.046), beginning smoking age (p=0.574 r=0.057), daily cigarette consumption (p=0.786 r=0.028). However, a negative correlation that may be clinically significant, although not statistically, had been among daily smoking (cigarette/per day) with first (p=-0.051 r=0.612) and final (p=-0.052 r=0.621) PSQI scores.

4. Discussion

In studies conducted in patients with sleep disorders, sleep disturbance effects on smoking cessation are complicated by the fact that both smoking and nicotine withdrawal also produces sleep disturbance [11]. The evaluation of our study based on the change in PSQI scores from the first visit to the final visit showed that a significant change in sleep quality among smokers is not possible whether with sleep hygiene training or without. It was thought to be related to a difference in daily cigarette consumption between control and intervention groups because features which were listed as age, gender distribution, FTND score mean, duration time of addiction, education level, and beginning PSQI scores were statistically similar between groups.

An association between nicotine dependence severity in young adult smokers and poor sleep quality was indicated in a recent study. Advice from practitioners to cut back on the number of cigarettes smoked per day and treatment of nicotine dependence symptoms may improve sleep quality in young adult smokers [12]. In our study, lower daily smoking was seemed to may be effective in sleep quality.

In a study that was an important resource of similar results to ours, sleep quality of two groups (one given cognitive behavioral therapy including sleep hygiene training and cessation counseling versus the other one given only cessation counseling) has shown no difference in terms of sleep quality. [4]. In a Brazillian school-based sleep hygiene study has suggested sleep hygiene training program was effective in reducing sleep irregularity and latency and advancing nap awaking although no difference was in sleep quality and daytime sleepiness [13]. An Iranian search for elderly women with sleep disorders has obtained a sleep quality improvement in the intervention group based on sleep hygiene training effect [14]. Sleep hygiene education combined with reflexology for patients receiving chemotherapy has increased sleep quality and decreased fatigue after sleep hygiene training and reflexology [15]. In a Japan large-scale study, the intention-to-treat analysis revealed that the intervention group (the group with hygiene training) presented significantly greater prevention of insomnia symptoms and short sleep duration. However, there were no significant differences in odds ratios between the two groups for poor sleep quality [16].

In a past meta-analysis analyzing insomnia and gender differences, the ratio of women/men in insomnia problem was found to be 1.41 / 1, and it was found that this tendency to increase insomnia in elderly women [17]. A recently published meta-analysis reported that after 9 sessions of CBTI, women reported longer sleep onset latency and more general fatigue compared to men. In contrast, men reported higher scores on the PSQI compared to men after treatment [18-20]. In our study, sleep quality was not related to age and no gender difference was detected that might be depending on cessation treatment-seeking participant’s characteristics based on sociocultural differences in our country. At the same time, in the intervention group of our study, the final PSQI values of men were found statistically significantly lower than women as an effect of sleep hygiene training. This result was compatible with the higher prevalence of sleep disorders in women than that of men.

The most important point of our study was that; there was only a smoking cessation treatment group versus a combined therapy group with both cessation treatment and sleep hygiene training. A study has shown that cognitive-behavioral therapy for insomnia (CBTI) and sleep restriction therapy (SRT) effectively treat menopause-related insomnia disorder and were superior to sleep hygiene education (SHE) [21]. So that, we saw that a rich combine behavioral therapy group might be included for future studies.

5. Conclusion

Nowadays, poor sleep quality caused by nicotine or post-cessation withdrawal have been led to a search for adjunctive cessation strategies. Although there is no significant change in the quality of sleep in the quitting process of smokers with hygiene education in our study, it is thought that there is a result indicating the need for not only sleep hygiene training but holistic behavioral therapy methods.

6. Limitations

Daily nicotine level during the 12-week follow-up was a confounding factor in the effectiveness of hygiene training since the smoking or non-smoking status of the participants could not be stabilized and was not equal. Secondly, another confounding factor of the study was smoking cessation treatment’s side effects that would cause sleep disorders during treatment.

Funding: None funding received. 

Conflict of interest: None declared.

Acknowledgments: All authors thanks to participants of this study.

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