The Importance of Supportive The Importance of Supportive Environment in Facilitating Cessation – Environment in Facilitating Cessation –

Findings from StudiesFindings from Studies

Wee Lei Hum, PhDInstitute for Health Behavioural Research,

Ministry of Health Malaysia

Cititel Mid Valley10 – 11 October, 2011

2nd National Health Promotion Conference 2011

04/11/2304/11/23 22

OutlineDevelopment of Supportive Environment

in HPUnderstanding Smoking Cessation Smoking in MalaysiaFindings from Current StudiesReviews from Other StudiesDiscussion & Conclusion

Development of Supportive Environment in Health Promotion

Commitment of WHO to the goals of Health for All in 1977WHO/UNICEF international conference in Primary Health Care

held in Alma Ata in 1978.1st International conference on HP in Ottawa 1986.2nd International Conference in Adelaide in 1986 – countries

experiences in development & implementation of Healthy Public Policy.

A Working Group on HP in Developing Countries, in Geneva to consider the meaning & relevance of HP to developing countries in 1989.

3rd International Conference on HP and Supportive Environment was held in Sundsvall, Sweden.

To act upon challenges identified in Sundsvall Statement, Agenda 21 & WHO Global Strategy, WHO & UNEP organised a meeting in Kenya in 1993.

The Bangkok meeting represent a 2nd meeting to the translation of the concept of promoting supportive environment for health in Asia Pacific Region, in 1993.

Elements of Supportive Environment

Supportive environment is not an individual concern but for all to act upon.

Focus both on physical and social aspect Establish alliances Establishing supportive environment involves

both individual and community responsesProviding health services not only in times of

needsImplement national policies through settings

approach to facilitate inter sectoral action

IntroductionSmoking prevalence

developed countries - 50% decline in 30 years since 1960’s.

developing countries - increase of 3.4% annually (WHO, 2002).

Despite various efforts to control smoking, it continues to be the single greatest risk to public health problems (Joseph, Velicer, & Prochaska, 1995).

Introduction ..2Malaysia is facing an endless array of

challenges in a bid to control the prevalence of smoking.

Despite the knowledge that tobacco use is the most preventable cause of illness, cigarettes are easily available, highly accessible and legally sold in this country (Clearing House Tobacco Control, 2005).

It is important to reduce the number of people who start smoking and to increase support to those who want to quit (Marcus, Pahl, Ning, & Brook, 2007).

Understanding Smoking CessationDynamic process, repeated attempts and

relapse (Hughes, 2005).Success in quitting smoking is determined

by the interplay of multiple factors (West, 2006).

Differ in readiness and ability to quit smoking despite the effectiveness of various tobacco control interventions strategies (Doran et al., 2006; West, 2004).

Research shows that while the majority of smokers want to stop smoking, most continue to smoke (Thyrian et al., 2008).

Postulations of TheoriesChoice Theory - health related behaviors are

dynamic, not always consistent, unstable planners who act on circumstantial decisions (Skog, 2000).

PRIME theory - how we act at a particular moment can only be influenced by the motivations operating at that time (West, 2009).

Humans are much more driven by immediate emotions rather than rational as commonly assumed (West 2009).

Smokers’ motivation can change quickly and strongly influenced by smoking cues in the environment. Thus, smokers’ motivation to stop smoking may not accurately reflect what they truly feel and think (West, 2004).

SMOKING IN SMOKING IN MALAYSIAMALAYSIA

Changes in Prevalence of Current Smokers by Age(Comparison between NHMS3 with NHMS2)(Comparison between NHMS3 with NHMS2)

0

5

10

15

20

25

30

35

18-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80+

NHMS2 NHMS3Age (yrs)

Availability of Quit Clinics70.6% attempted to quit 2 quit attempts in a yearOnly 38% aware of quit clinicsAwareness was higher among:

rural more educatedprofessionals younger

Recent Published Smoking Cessation Research in Malaysia

2 studies Study design: Retrospective and

Prospective Setting: 5 quit smoking clinics in FT

Study 1Retrospective Study (N = 629)Smokers Past Records, Jan 2006 – June

2007 Measures: Personal particulars, current

and past smoking history, health status, method of quitting, COppm and FTND.

Intervention: Behaviour counseling and NRT.

Study 2Prospective Study (N = 200)

Face to face interview at 1st visit, 4-week and 3-month

Measures: Pre-quit attempt, 4-week post-quit attempt and abstainer/relapser follow-up questionnaire at 3-month

Intervention: Behaviour counseling & NRT

ObjectivesIdentify characteristics of smokers Explore psychological processIdentify difficulties experienced by

smokers Improve clinic intervention

strategies Identify predictors of successful

quitting

RESULTSRESULTS

Male (95%)Younger (35 yrs old)More educated / professional 45.5%Mean age started smoking 16.7Had health problems 32%Average daily cigarettes smoked 17.7Daily average spent RM7.36Mean FTND 4.5

Smokers Characteristics

Reasons to QuitHealth concern Cost of cigarettes Pressure from friends/family Doctor’s advice

Triggerred by the ClinicClinic - decision to quit was made. 32.5% had not been seriously thinking of

quitting before they heard about the clinic and 56.9% heard about the clinic first before deciding to stop smoking.

The main triggers for quitting:-advice from a doctor/nurseexperiencing symptoms due to smokingviewing a poster in the clinicsuddenly realising how bad smoking is cost of smoking.

Conflicting ThoughtsIntention to stop smoking completely for a while.Want to stop smoking but at the same time

enjoy.Allow for an occasional cigarette.Given the fundamental instability of the

intentions of thinking about quitting, smokers are sensitive to environmental stimuli at the moment and act upon it (Hughes et al., 2005).

Smoker will accept the offer of help and may proceed with the attempt and abstain (Larabie, 2005; Pisinger et al., 2005; West, 2009).

Where and When relapse Commonly occurred?

25.0% experienced first lapse immediately or 32.5% during the first week after the quit date.

Home, workplace and eateries - where the first cigarette was smoked (Bliss et al., 1989).

What were they doing?socialising with friends seeing someone else smokedoing nothing in particular

What situation were they in?experience of strong urgesbeing in stressful situations.

Final Model for Predictors of Successful Quitting

Independent predictors after adjustment for confounding 4 Weeks Predictors OR (95%CI)

PreCO2 0.88 (0.82-0.96)

Age 1.07 (1.04-1.10)

Method of quitting  

Abrupt 4.10 (1.682-9.98)

Gradual 1

Cost of cigarettes  

Yes 2.68 (1.21-5.95)

No 1

3 Months Predictors OR (95%CI)Clinics  Tanglin Community Clinic 1Putrajaya Hospital 0.11 (0.03- 0.34)Jinjang Health Clinic 0.41 (0.15- 1.08)Pantai Health Clinic 0.16 (0.05- 0.56)Kampung Pandan Health Clinic 0.07 (0.01- 0.31)

Marital Status  Single/Divorced/Widowed 1Married 2.69 (1.20-6.04)

What led you to come to the clinic (Planning)

 

-Had been thinking to quit smoking 1-Had not been thinking to quit smoking 2.58 (1.11-5.99)

Feeling about smoking  -Do not really mind being a smoker 1-Very unhappy to think of myself as a smoker 2.30 (1.05-5.06)

Motivation level to stop smoking completely  -Extremely strong 1-Very strong 0.24 (0.08-0.71)-Quite strong/ Not very strong 0.11 (0.04-0.33)

Smoking helps me to stay alert  -Yes 0.32 (0.13-0.75)-No 1

Amount of tobacco smoked compared with other smokers

 

-I smoked about the same as most other smokers 1-I smoke more than most other smokers 5.85 (1.88-18.24)-I smoked less than other smokers 2.43 (0.96-6.17)-I do not know 2.18 (0.60-7.90)

24

Multivariate 6 Months Predictors OR

(95%CI)

Clinic Tanglin 1 Putrajaya 0.68 (0.38-1.23) Jinjang 0.76 (0.43-1.34) Pantai 0.11 (0.04-0.28) Kg Pandan 0.14 (0.06-0.34)

Duration of previous abstinence in weeks* 1.01 (1.01-1.02) Age in years* 1.02 (1.00-1.04) Previous attempts made

Yes 1.78 (1.07-2.96) CO reading in ppm* 0.96 (0.93-0.99) * per unit increment

DISCUSSION DISCUSSION

& &

CONCLUSIONCONCLUSION

Decision to Stop Smoking is Made

at HomeMost likely to be exposed to pressure to stop

smoking in the own home (30.0%).External pressure and support is important

by the fact that smokers who are married are more likely to abstain (Honda, 2005, Lee & Kahende, 2007).

Smokers with more children are more likely to succeed and place greater emphasis on the importance of family values (Stevens et al., 1982a).

Smoke Free Homes & Workplace

Bans at the workplace and home are significant predictors of successful quitting (Farkas et al., 1999; Shields, 2005).

Smokers who quit successfully report prohibition of smoking at home (Lee & Kahende, 2007).

The presence of other smokers in the home lower a person’s long-term chances of quitting due to repeated cues to smoke (Frank, Umlauf, Wonderlich, & Askakonzi, 1986).

Working ConditionsSmoking cessation is more successful

among people with a good social support in their job (Fisher et al., 1994).

Less successful among those with (Janzon et al., 2005):-

greater working hoursshift work high physical workload frequently exposed to role conflicts at

work

Triggers from the EnvironmentSmokers were triggered by ‘something else’ that

made them realise how bad smoking is - complexities in the environment which interacts with smokers must have led to this realization and resulted in an urgency to act.

A balance is achieved between competing environmental factors and wants and needs through the `sudden realization of how bad smoking is’, this realization is sufficiently strong to trigger cessation.

The decision made by the smokers to act at that precise moment is a result of the interaction of multiple influences (West, 2009).

Such moments can appear at any time and without smokers realising it (West, 2009).

Doctor’s Brief AdviceCost-effective and most effective non-pharmacological

interventions (1 in 40 smokers) (Coleman, 2004). Higher success rate in those who received advice from

a doctor than family members or friends (Aveyard et al., 2007; Hyland et al., 2006).

Smoking related disease is one of the strongest predictors of abstinence (Edwards et al., 2007).

Physician-administered smoking cessation counselling lasting less than 3 minutes improves quit rates (Fiore, 2000) and increasing the time spent on counselling with follow-up visits can lead to even better outcomes (Coleman, 2004).

Adding NRT to brief advice should provide additional benefits (Raw, 1999).

TreatmentQuitting without clinic support has

relatively low success at only 7% (Hurt, Wolter, & Rigotti, 2002), while clinic interventions to increase the abstinence rate to 16% (Silagy, Lancaster, Stead, Mant, & Fowler, 2006) to 33% (Prochazka, 2000).

Only a minority of smokers attempting to stop smoking actually seek clinic help and use NRT, may reflect a lack of confidence among smokers that clinic interventions help (West, 2004).

Support from the ClinicSmokers receive support and advice from clinics run

by trained smoking cessation personnel are more likely to succeed (West, 2000).

Effectiveness of behavioural support provided by health care professionals with limited training who are providing the service in conjunction with other duties have not shown evidence of efficacy beyond brief advice (Aveyard,2007).

Good clinic support (e.g. enough personnel) is one of the contributors towards clinic performance (Lancaster & Stead, 2005)

Why Treating Smokers is Challenging?

Unstable intentions, conflicting thoughts and beliefs.

Understanding this dynamicity of the smokers mind will enhance intervention strategies.

Generate repeated quit attempts by offering help with stopping to all smokers and not to those who are ready.

Intervene at the opportune moments and encourage all smokers to make decisions to quit smoking by creating tensions and triggers.

Act NowWe cannot predict quitting opportunities

which appear to be fluid in nature (Marlatt et al., 1988; Mook, 1996).

Face many competing priorities in the environment which require us to make decisions and this equally applies to smokers contemplating to quit or to continue smoking. At this time, their action is critical (West, 2009).

At the time when a quitting opportunity presents, we should encourage smokers to act immediately and quit abruptly (Larabie, 2005).

LimitationUrban setting ~ sample composition

similar to census characteristic in NHMS3 Missing data in retrospective studyInvolve more than one clinic, practice and

experiences varied ~ guided by the standard clinical practice guidelines.

ISI Journals1. Wee, L. H., Shahab, L., Bulgiba, A. & West, R. (2011) Stop smoking

clinics in Malaysia: characteristics of attendees and predictors of success. Addictive Behaviours, 36(4), 400-403. doi: 10.1016/j.addbeh.2010.11.011

2. Wee, L. H., Shahab, L., Bulgiba, A. & West, R. (2011) Conflicting motivations and the decision to stop smoking gradually or abruptly – evidence from smokers’ clinics in Malaysia. Journal of Smoking Cessation, 6(1), 37–44. DOI 10.1375/jsc.6.1.37

3. Wee, L. H., West, R., Bulgiba, A. & Shahab, L. (2011). Predictors of 3-month abstinence in smokers attending stop-smoking clinics in Malaysia. Nicotine & Tobacco Research, 13(2), 151-156. doi: 10.1093/ntr/ntq221

4. “Exploring smoker’s beliefs and feelings about smoking and quitting during a quit attempt – findings from a qualitative analysis of the SNAP model” – Under review, smoking cessation

Books & Newspaper ArticlesBook ‘Psychological Process and Factors Related to Smoking Cessation’, 2011 Newspaper Article‘Why are smokers able to abstain from cigarettes during their Ramadan fast’, Sunday Star, 22nd August 2010 Male and married? It’s easier to quit then, New Sunday Times, 6th February, 2011

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