CHAPTER II THEORETICAL BACKGROUND REVIEW OF RELATED LITERATURE Stress Stress is the mental, physical or emotional strain or tension caused

by different situations and factors. (Butts, DeJoy, Wilson & Vandenberg, 2009) It is defined as the bodys response to physical and mental demands or the interaction between environmental forces and events called stress precipitators, which appear threatening to the persons reaction to the threat. (Rogers, Li & Shani, 1987) Three components affect stress response namely, stressor, stress and strain. A stressor is an event or set of conditions that causes a stress response. Stress is the bodys physiological response to the stressor, and Strain is the bodys longer - term reaction to chronic stress. (PEF Health and Safety Department, 2006) Major causes of stress include threat, fear, uncertainty and cognitive dissonance. (Change Minds, 2008) Stress is simply a fact of nature -- forces from the inside or outside world affecting the individual. The individual responds to stress in ways that affect the individual as well as their environment. Because of the overabundance of stress in our modern lives, we usually think of stress as a negative experience, but from a biological point of view, stress can be a neutral, negative, or positive experience.

In general, stress is related to both external and internal factors. External factors include the physical environment, including job, relationships with others, home, and all the situations, challenges, difficulties, and expectations you're confronted with on a daily basis. Internal factors determine your body's ability to respond to, and deal with, the external stressinducing factors. Internal factors which influence your ability to handle stress include your nutritional status, overall health and fitness levels, emotional well-being, and the amount of sleep and rest you get. Stress has driven evolutionary change (the development and natural selection of species over time). Thus, the species that adapted best to the causes of stress (stressors) have survived and evolved into the plant and animal kingdoms we now observe. (Marks2011)

Major causes of stress are threat in which it is perceived threat that will lead a person to feel stressed. This can include physical threats, social threats, financial threat, and so on. In particular it will be worse when the person feels they have no response that can reduce the threat, as this affects the need for a sense of control. Threat can lead to fear, which again leads to stress. Fear leads to imagined outcomes, which are the real source of stress. Uncertainty when we are not certain, we are unable to predict, and hence feel we are not in control, and hence may feel fear or feel threatened by that which is causing the uncertainty. Cognitive dissonance when there is a gap between what we do and what we think, then we experience cognitive dissonance, which is felt as stress. Stress affects peoples health physically, psychologically, behaviorally and cognitively. Physical symptoms that may occur because of stress include fatigue, headache, stomach problems, muscles aches and pains, chronic mild illness, sleep disturbances and eating

disorders. Psychological and behavioral problems that may develoAp include anxiety, irritability, substance abuse including smoking, feeling powerless and low morale and problems in relationships. Cognitive symptoms include absent-mindedness, failure of attention and memory. (Brynien & Igoe, 2006) If exposure to stressors continues for a longer period of time, chronic health problems can develop including High Blood Pressure, Heart disease, Stroke, Spastic colon, Immune system dysfunction, Diabetes, Asthma,

Musculoskeletal disorders. Serious psychological and behavioral problem may also develop including serious depression, suicidal behavior, domestic violence, alcohol abuse, substance abuse and burnout. (PEF Health and Safety Department, 2006) The stress model, Fagerstrom helps to identify particular job characteristics important for employee well being. (Jonge, Landsbergis & Vegchel, 2005)

Lazaruss Transactional Model Stressors are demands made by the internal or external environment that upset balance, thus affecting physical and psychological well-being and requiring action to restore balance (Lazarus & Cohen, 1977). Beginning in the 1960s and 1970s, stress was considered to be a transactional phenomenon dependant on the meaning of the stimulus to the perceiver (Lazarus, 1966; Antonovsky, 1979).

The Transactional Model of Stress and Coping is a framework for evaluating the processes of coping with stressful events. Stressful experiences are construed as personenvironment transactions. These transactions depend on the impact of the external stressor. This is mediated by firstly the persons appraisal of the stressor and secondly on the social

and cultural resources at his or her disposal (Lazarus & Cohen, 1977; Antonovsky & Kats, 1967; Cohen 1984).

When faced with a stressor, a person evaluates the potential threat (primary appraisal). Primary appraisal is a persons judgment about the significance of an event as stressful, positive, controllable, challenging or irrelevant. Facing a stressor, the second appraisal follows, which is an assessment of peoples coping resources and options (Cohen, 1984). Secondary appraisals address what one can do about the situation. Actual coping efforts aimed at regulation of the problem give rise to outcomes of the coping process.

Richard Lazarus and Susan Folkman suggested in 1984 that stress can be thought of as resulting from an imbalance between demands and resources or as occurring when pressure exceeds one's perceived ability to cope. Stress management was developed and premised on the idea that stress is not a direct response to a stressor but rather one's resources and ability to cope mediate the stress response and are amenable to change, thus allowing stress to be controllable.[3] In order to develop an effective stress management program it is first necessary to identify the factors that are central to a person controlling his/her stress, and to identify the intervention methods which effectively target these factors. Lazarus and Folkman's interpretation of stress focuses on the transaction between people and their external environment (known as the Transactional Model). The model contends that stress may not be a stressor if the person does not perceive the stressor as a threat but rather as positive or even challenging. Also, if the person possesses or can use adequate coping skills, then stress may

not actually be a result or develop because of the stressor. The model proposes that people can be taught to manage their stress and cope with their stressors. They may learn to change their perspective of the stressor and provide them with the ability and confidence to improve their lives and handle all of types of stressors.

(http://www.utwente.nl/cw/theorieenoverzicht/Theory%20clusters/Health%20Communicatio n/transactional_model_of_stress_and_coping.doc/)

Nicotine Dependence Nicotine is a liquid alkaloid found in the family of plants Solanaceae. An alkaloid is an organic compound made out of carbon, hydrogen, nitrogen and sometimes oxygen which have potent effects on the human body health. Nicotine constitutes approximately 0.63.0% of dry weight of tobacco. It is the tobacco plant's natural protection against its prey. In low concentrations, it acts as a stimulant in mammals which is responsible for making it highly addictive. Nicotine binds to cholinergic receptors in the central nervous system. Repeated use of nicotine causes these receptors to rapidly desensitize and increase in number. These nicotine-stimulated neurons then stimulate dopaminergic neurons within nucleus accumbens, a brain structure associated with rewards and reinforcements, which then results to widespread neuronal activation that causes users to experience pleasure, reduced fatigue, increased information-processing ability, reduced anxiety and other reinforcing effects. (Lagrue, Lebargy & Cormier 2001)

Nicotine dependence is an addiction to tobacco products caused by the drug nicotine. It is the inability to stop using the substance even though its causing the user harm. (Baillie, Mattick, Hall, Webster, 1994) It is characterized by both tolerance and withdrawal symptoms in relation with the nicotine use. Nicotine tolerance develops when the frequency and dose of nicotine use are increased. When nicotine concentration in the body increases, desensitized cholinergic receptors on neurons projecting to nucleus accumbens also increases which affects the control of dopamine secretions. When nicotine concentration in the body then decreases, dopamine release in nucleus accumbens falls because desensitize cells fail to produce baseline stimulation. A decrease dopamine secretion in the body because of a decrease in nicotine concentration causes nicotine withdrawal. (Kenny, & Markou, 2006) Nicotine withdrawal is the presence of unpleasant feeling when there is a reduction or cessation in nicotine use. Nicotine withdrawal is defined by Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as a condition of a person, after using nicotine daily for the last several weeks, exhibiting at least four of these symptoms: depression, insomnia, irritability, anxiety, difficulty in concentrating, restlessness and decreased heart rate within 24 hours after reduction or cessation of nicotine use. (Ashton & Streem, 2009) Through the use of tobacco, nicotine has been one of the most heavily used addictive drugs that cause different health diseases. A study in year 2000 states that smoking is practiced by 1.22 billion people and predicts that the number of smokers will stand at around 1.3 billion by year 2010 to 2025. (Guindon & Boisclair, 2003) Tobacco use is the leading preventable cause of morbidity and mortality in many countries. (Shiffman, Mason, & Henningfield, 1998) It is the most common cause of cancer-related deaths including lung

cancer, laryngeal cancer, esophageal cancer, oral cancer, and bladder cancer. (Inoue, 2004) Research suggests that tobacco use results in more than $157 billion in annual health-related costs. (World Health Statistics 2008)

Several factors determine nicotine dependence and the degree of nicotine dependence. These factors include individual factors, genetic factors and psychosocial factors. Individual factor includes variability of nicotine dependence among smokers, the dependence on the personality of the person and the different individual reaction to nicotine. Some smokers dont develop nicotine dependence even after smoking for many years while some develop it within a small period of time.(Shiffman & Paton, 1999) Genetic factors include the recent discovery of scientist that common single - letter variations on chromosomes 8p11 and 19q13 among smokers increase the number of cigarettes smoked per day. (Decode, 2010) Psychosocial factors include both occupational factors and personal factors have an influence on the initiation and extent of smoking. (Hourani, Yuan, Bray, Vincus., 1999) It is believed that smoking is a way in dealing with negative feeling specifically stress. Studies show that Non- smokers who experience higher stress see smoking as a solution or coping strategy. It is also stated that Lower levels of perceived stress were proportional in lesser smoking. (Elkind, 1988) Although the proposition that increase stress may induce smoking is prevalent, different studies also support that increase in occupational stress actually helps in smoking cessation. A study of relationship between stress and nicotine dependence concluded that heavy workload is associated with lower nicotine dependence. The explanation for this conclusion is that a heavy workload may deprive employees to smoke due to lack of time. (Etter, Vu Duc, Perneger, 1991)

. Synthesis of Review of Literature Stress can be a reaction to a short-lived situation or it can last a long time. Stress becomes dangerous when it interferes with your ability to live a normal life over an extended period. Nicotine is a highly addictive product most commonly found in tobacco plants. Through the use of tobacco, nicotine has been one of the most heavily used addictive drugs that cause different health diseases. Nicotine Dependence is the addiction to tobacco because of nicotine. It is the inability to stop using nicotine though it is causing the user harm. Nicotine dependence and the degree of its dependence are determined by different factors including psychosocial factors. These psychosocial factors include occupational and personal factors. Different studies were conducted to support different propositions about the relationship between smoking and occupational stress. Some studies believe that smoking is a way used to deal with stress and an increase in work stress promotes lower possibility in smoking cessation. While some studies concluded that work pressures actually decrease nicotine dependence or smoking because of lack of time to smoke.

THEORETICAL FRAMEWORK In Behavioral System Model of Dorothy E. Johnson, it is stated that equilibrium is a key concept in nursings specific goal. It is defined as stabilized but more or less transitory, resting state in which the individual is in harmony with himself and with his environment. It

implies that biological and psychological forces are in balance with each other. It also emphasized tension which is produced by a stressor as an end product of a disturbance in equilibrium. (Auger, 1976) Nurses in order to be more effective in the clinical setting should therefore learn to achieve equilibrium by managing tensions and stressors. In Adaptation Model by Sister Callista Roy, different stimuli cause coping process in a person. One of the stimuli that affect a person to adapt is the Residual Stimuli. Residual Stimuli are defined as environmental factors within or without the human system with effects in the current situation that are unclear. Coping process is defined as innate or acquired ways of interacting with the changing environment. (Roy, 1984) In this study, occupational stress may be seen as a residual stimulus causing a coping process which may be nicotine dependence or smoking. Lazarus Theory of Stress and Coping, a theory used by Patricia Benner also gives insights about stress and coping. It states that stress and coping is phenomenological; that is, the person is understood to constitute and be constituted by meanings. Stress is described as a disruption of meanings and coping is what the person does about the disruption. (Benner, 1981) In this study, occupational stress may be seen as the disruption in nursing work setting while smoking may be seen as something used to cope with the disruption of meaning.

CONCEPTUAL FRAMEWORK Nicotine dependence is a risk factor for six of the eight leading causes of death. (BMC Public Health, 2010) It is usually used as a coping strategy to deal with stress. The crucial role of health care professionals in nicotine control is to help patient reduce and stop

smoking. In this study, stress was associated to nicotine dependence among nursing students. Nicotine dependence for some student nurses can be a way of stress management instead of using other measures of stress reduction at work. Smoking is described as a way of taking up or coping with the stressful environment which may results to stress overload. Cigarettes were described as stress relieving devices. . Several studies were conducted to know the association of nicotine dependence and stress. Some studies shows that employees who experience stress at work are likely to smoke less than they otherwise would, and thus, they have a lower dependence on nicotine. Possible explanation for the study's findings is that the participants have a heavy workload and can only smoke in their spare time. Another reason may be workplace smoking bans. (Tobacco Induced Disease, 2010). According to the study of the Quit TobaccoMake Everyone Proud an educational campaign for the U.S. military many people may feel they are using tobacco as a way to relax or de-stress but nicotine actually causes the opposite effect. Feelings of calmness and pleasure during smoking are just only short reliefs from stress. They conducted further study and shows that those who depends on nicotine specifically to reduce stress report much higher levels of stress than those who do not use tobacco. Studies suggest that smoking is increased in humans exposed to stressful experiences early in life (Anda et al 1999).

CONCEPTUAL PARADIGM Figure 2.1 Conceptual Model for Stress and Nicotine Dependence