The Relationship Between Smoking Cessation and Time Perspective in Patients With Coronary Artery Disease

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Introduction
Coronary artery disease (CAD) is the most widespread type of cardiovascular disease (CVD) and every year, many people die due to this disease or suffer from other types of disabilities. No accurate information has so far been reported regarding the prevalence of CVDs in Iran. However, based on some data, about 40% of deaths in Iran are somehow related to CVDs. In recent years, the prevalence of CVDs has increased by 20-40%. Researches indicate that psychological factors play an important role in the occurrence of CVDs, as well as the tendency toward unhealthy behaviors that are considered risk factors for CVDs (1). Among the psychological factors, time perspective is one of the highly important factors that predicts high-risk behaviors such as smoking (2,3).
Time perspective is a basic cognitive process by which people perceive, interpret, and interact with their social world. It describes the effect of paying attention to the past, present, and future on human behavior because people unconsciously apply it when making judgments and decisions and doing actions regarding their shortand long-term goals. In other words, the general tendency to consider the future consequences of one's current behavior has been described as an individual difference variable called time perspective (4)(5)(6). Smoking is considered an unhealthy behavior and one of the risk factors for CVDs, and time perspective is one of the most important psychological factors in predicting unhealthy behaviors, including smoking (2,7). Time perspective plays a fundamental role in shaping perception, forming expectations, biasing attention, providing interpretations, and determining and achieving social goals, motivation, and a sense of control (8). People with a more balanced time perspective experience have more hope in life than those with a more unbalanced time perspective. According to Zimbardo and Boyd's theory (9), the ideal Tob Health. Vol 2, No 1, 2023 2 http://thj.hums.ac.ir http state of a person's time perspective includes high scores in the dimensions of the positive past and hedonistic present, while low scores in the dimensions of the fatalistic present and the negative past. This perspective of time is the most essential factor in psychological health and successful social functioning (4).
Smoking plays a role in CAD and thus it is essential to reduce its risk after quitting smoking because this may be an issue where culture has an impact (10). To the best of our knowledge, no study has been performed in our culture in this field. Accordingly, the current study aimed to examine the relationship between smoking cessation and time perspective.

Participants and Design
This cross-sectional study was conducted on 170 patients who were admitted to Shahid Mohammadi Hospital with a diagnosis of CAD in 2020 using convenience sampling. Patients were included in the study based on the inclusion and exclusion criteria, and their inclusion criteria were as follows: • People who have been hospitalized with the diagnosis of the acute coronary syndrome; • People who were current smokers or former smokers and attempted to quit in the last year, and it has been at least three months since they quit; • Willingness to participate in research; • Completion of the questionnaires completely. On the other hand, the exclusion criteria were: • Patients who had other cardiac diagnoses, including valvular disease or other disorders during hospitalization; • Patients who did not agree to enter the study.
After approving the research and receiving the code of ethics from the Ethics Committee of the Hormozgan University of Medical Sciences, the purpose of the research was explained to hospitalized patients. Then, the details of each participant were recorded by the main colleague. The questionnaire was provided to the patient and was filled by him personally or by his companion in case of illiteracy. In the study, the Zimbardo Time Perspective Inventory questionnaire was used to evaluate their time perspective.
This questionnaire has six scales, including past positive (indicating strong and happy feelings about the past), past negative (indicating pessimism about the past), and hedonistic present (showing the desire to be satisfied and enjoy the present experiences). The other scales were present fatalistic (life is destined), future positive (using regular schedules to get things done on time), and the transcendental future (believing in the souls) (11). The items of the questionnaire were scored on a 5-point Likert-type scale, ranging from "Very incorrect" (1 score), "Incorrect" (2), "Indifferent" (3), "Correct" (4) to "Very correct" (5).
Each questionnaire provides 6 scores out of 6 examined components. Accordingly, the study subjects were divided into two groups of smokers (currently smoking) and quitters (at least 3 months have passed since the last use). Then, the scores of the two groups were compared to find out the difference in the time perspective of users and quitters. The reliability and validity of this questionnaire were determined in a study by Zimbardo and Boyed with a test-retest method (9).

Statistical Analysis
The data were entered into SPSS software (version 22) for analysis, and chi-square test was used to analyze qualitative findings. Further, an independent t test and Mann-Whitney test were employed to compare quantitative data, and a P value less than or equal to 0.05 was considered statistically significant.

Results
Out of 170 patients participating in the study, 151 (88.8%) were men and 19 (11.2%) were women. The average age of the patients was 52.66 ± 14.28 years. In addition, 105 (61.8%) and 65 (38.2%) people lived in the village and city, respectively. Further, 140 people (82.4%) were smokers and 30 people (17.6%) had quit smoking ( Table 1). The patients' information was collected using a checklist prepared by the researcher, including demographic information and Zimbardo's time perspective questionnaire.
The information was evaluated by the Mann-Whitney test due to the non-normality of the distribution of Zimbardo questionnaire scores. Based on the data in Table 2, the patients who had quit smoking received higher scores in past-positive and future perspectives (P < 0.05).

Discussion
In this cross-sectional descriptive study, the relationship between smoking cessation and time perspective was investigated in patients with coronary arteries admitted to Shahid Mohammadi Hospital in 2020. Based on the results of the Zimbardo Time Perspective Inventory questionnaire, the patients who had quit smoking received higher scores in past positive and future perspectives (P < 0.05).
In the study of Keough et al (12), it was concluded that people who had a present perspective had more tendency in using alcohol, cigarettes, and tobacco, which was not significant compared to the results of our study regarding the relationship between present perspective and smoking cessation. In the above-mentioned study, it was also revealed that the ones who had a vision of the future had an inverse relationship with drug use, which is consistent with our study results.  (2), it was found that the tendency of high school teenage girls to abuse drugs had a positive and significant relationship with negative past-oriented, present-oriented hedonistic, and appreciative-oriented time perspective; however, it had a negative and significant relationship with futureoriented time perspective. The patients who quit smoking in our study also had high scores in future perspectives.
Hall et al (13) reported that the future time perspective has a significant relationship with smoking cessation in men (P < 0.05), and the hedonistic present, fatalistic present, and the future have a significant relationship with smoking cessation in women (P < 0.05). It seems that the score of hedonistic present and fatalistic time perspective was significantly lower in women who had quit smoking, while the score of future time view was significantly higher in them. It was further demonstrated that the future perspective has a significant relationship with smoking cessation in women (P < 0.05).
The results of another study by Kim et al (11) revealed that once the present-hedonistic and future-negative from among the six-time perspectives increased, while the ability to delay gratification decreased, which is in line with the results of our study. On the other hand, once the future-positive time perspective increased, the ability to delay gratification represented an increase. These findings suggest that problems involved with the delay of gratification (e.g., smoking, addiction, and binge eating behavior) are more likely to occur in people who have high present-hedonistic and future-negative time perspectives because these time perspectives lead to a lower perceived possibility of getting a future.
In contrast with our results, the findings of Griva et al (8) showed that smoking is not associated with any of the time perspective dimensions, probably suggesting that when people smoke, they do it regardless of whether they have a tendency to focus on their past or contemplate about their future.
Guthrie et al (7) also found no associations with current smoking; they believe it may also be that smoking is such a strong addiction that it quickly becomes automatic and divorced from outcome expectancies.
In their study, Beenstock et al (14) found that future orientation may influence motivation to engage in a quit attempt. Their result confirms our findings and indicates that future orientation may influence longer-term success in a quit attempt that has already been successful in the short-term smoking cessation trial.
One of the limitations of our study was the low sample size in the smoking cessation group (n = 21), which may have influenced the significance of some results. More accurate results could be obtained if there was another group of people who had no smoking history. In addition, it is suggested that this study be performed on a wider level for better planning to quit smoking in patients with CAD and to reduce the financial and psychological burden for patients.

Conclusion
Most studies suggested that the future time perspective is a strong predictive factor for quitting drugs, which was also proven in our study. Further, other studies stated that obtaining a higher score in the hedonistic present time perspective reduces the chance of quitting, while