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Thoughts, Feelings and Behaviours of Clients Attending Five Stop-
Smoking Clinics in MalaysiaWee Lei Hum
Awang Bulgiba Robert West
Malaysia Council for Tobacco Control Conference 2009
UKM, Medical Centre, Cheras8 – 9 August, 2009
Outline
• Aims• Quit smoking in Malaysia• Methods• Brief on PRIME Theory• Results • Summary of findings • Implications of finding• Plan for future analysis
Aim of the Study
• To provide a better understanding of the processes involved in quitting smoking
– Factors that led smokers to seek help to stop smoking
– Smokers’ planning in making decisions to quit smoking with the clinic
– Feelings about stopping smoking– Smokers’ self-identity
Quit Smoking Clinics• 294 clinics nationwide • Only 38% of smokers aware of quit smoking
clinics• Awareness higher among:
– more educated – professionals & – younger smokers
• 71% of current smokers had ever attempted to quit
(NHMS3)
Study Design and SamplesSetting
• 5 quit smoking clinics (Tanglin, Pantai, Jinjang, Kg.Pandan & Putrajaya Hospital)
Study design• Cross sectional study & part of prospective study
Method of data collection• Face-to-face interviews
Participants • All smokers attended QSC for 1st time (June
2007 – May 2008) (N = 200) • Referred by a doctor, walk-in or call-in
Summary of Topics Covered • Background information
- personal particulars, smoking history, current smoking and health status
• Processes involved in smokers’ decisions to quit smoking - Planning, tensions, triggers, confidence level
and motivation
• The instruments used were prepared in two languages using the process of back translation
PRIME Theory (West,2006)
• Broad theory of motivation to understand how behaviour change occur in everyday life
• Focus on the planning, tensions, triggers and moment
• Every moment we pursue what we most wanted or needed at that time
• Wants – anticipated pleasure or satisfaction of imagined outcome
• Needs – anticipated relieve
PRIME Theory…2
• The decision to make a change in behaviour involve making a personal `rule’
• E.g. if a personal rule is `not to smoke’ and the feeling of not smoking is more beneficial, then the smoker will consciously takes steps to fulfill the rule when face with smoking cues, wants and needs to smoke
PRIME Theory …3
• PRIME Theory predicts that the nature of the not smoking rule may have major effects on the success of the quit attempts
• If the smokers rule is `to try not to smoke’ the motivation in the smoker is expected not to be strong enough to prevent him from smoking in challenging situations
• If the rule is that smoking is not permitted at all, then the boundaries of the rule are more clearly define
• However, for the rule to be able to overcome consistent strong wants or needs to stop smoking, the smokers need to have `deep identity’ as a non-smoker
SamplesN %
Age group (Mean = 35, SD = 12)15 - 24 years old 36 18.0
25 - 34 years old 78 39.0
35 - 44 years old 36 18.0
45 - 54 years old 33 16.5
55 years old and above 17 8.5
SexMale 191 95.5
Female 9 4.5
Ethnic group
Malay 129 64.5
Chinese 34 17.0
Indian 35 17.5
Others 2 1.0
N %
Educational levelPrimary school 13 6.5
Secondary school 100 50.0
Tertiary 87 43.5
OccupationProfessional, technical and business 91 45.5
Clerical, service and arm forces 46 23.0
Craft, plant and machinery and elementary 32 16.0
Retired, unemployed, housewife and student 31 15.5
Marital statusMarried 119 59.5
Single/Divorced/Widowed 81 40.5
Smoking History and Current Smoking
N %Age at first smoke (Years)(Mean = 17, SD = 4, Median = 16)10 years and below 5 2.5
11 – 15 years 78 39.0
16 – 20 years 95 47.5
21 years and above 22 11.0
Longest time without cigarettes (Mean=12, SD=36, Median = 1)0 – 4 weeks 149 74.55 weeks and above 51 25.5
N %
Household smokers
No smoker 104 52.0
One smoker 49 24.5
Two smokers 25 12.5
3-6 smokers 22 11.0
Daily average amount spend, RM (Mean = RM7, SD = 4)
Below RM 5 35 17.5
RM 5 – RM 10 140 70.0
RM 11 – RM 15 14 7.0
RM 16 and above 11 5.5
Smoking History and Current Smoking
N %Fagestrom test score (Mean = 4, SD = 3, Median = 4)Low (0-3) 69 34.5
Moderate (4-5) 59 29.5
High (6-10) 72 36.0
Place where decision to quit was madeAt home 107 53.5At a clinic or hospital 54 27.0At work 21 10.5Walking down the street 10 5.0Somewhere else 8 4.0Health problem
Yes 64 32.0
N %
Average cigarettes smoked per day (Mean=18, SD=11, Median = 15) Below 10 sticks 30 15.0
10 -15 sticks 72 36.0
16 – 20 sticks 66 33.0
21 sticks and above 32 16.0
Present method of quitting
Abrupt 123 61.5
Gradually 77 38.5
What Led Smoker to Come to the Clinic
67.5%
32.5%
I had already been thinking a lotabout trying to stop smoking
I had not been thinking seriouslyabout trying to stop smoking
What smokers were actively thinking when made decision to quit
3.5%
11.5%15%
19.5%
28%30%32%
45%46.5%49%51%
60.5%
67%
82%
Wor
ried f
uture
healt
h He
alth
suffe
ring
Conc
ern fa
mily he
alth
Family
aske
d to s
topRe
alisa
tion
smok
ing c
ostly
Disli
ked a
ddict
ionFa
mily's
nagg
ingDo
ctor a
sked
to st
opFa
mily/fr
iends
had q
uitFr
iend's
enc
ourag
emen
tAs
hamed
to be
a sm
oker
Smok
ing re
strict
ion
Othe
rs
26.50%
9%8%
7% 6.50%5% 5%
3%
30%
Experiencingsymptomslinked tosmoking
Suddenlyrealising howbad smoking
is
Advice frommy doctor or
a nurse
The price ofcigaretteswent up
Seeing aposter or
reading aboutthe clinic
Knowingsomeone else
who wasstopping
Seeingsomeone else
get ill fromsmoking
Others I realisedsmoking isagainst my
religiousbeliefs
Single Event that Finally Led Smokers to Quit
• Table page 9 - paper
Trigger
Tension Advice from
doctor or nurse (%)
Experience symptoms linked to
smoking (%)
Seeing a poster
or reading about the clinic (%)
Knowing someone stopping
(%)
Seeing
someone else get ill from
smoking (%)
Suddenly
realized how bad smoking
is (%)
The price of cigarette went
up (%)
Health was suffering because of smoking 20.9 30.2 7.0 4.7 2.3 20.9 9.3
Concern for future health 17.4 21.7 15.2 8.7 4.3 15.2 15.2 Concern about family health 20.6 26.5 11.8 8.8 2.9 14.7 8.8 Smoking is too expensive 16.1 19.4 9.7 9.7 3.2 16.1 19.4
Family pressure 11.8 26.5 17.6 8.8 5.9 11.8 8.8 Nagging from family members 4.8 23.8 14.3 4.8 9.5 14.3 14.3 Doctor told to stop 38.9 16.7 5.6 0.0 5.6 16.7 11.1 Did not like being addicted 7.4 22.2 22.2 11.1 3.7 14.8 11.1
Ashamed to be a smoker 0.0 37.5 37.5 0.0 0.0 12.5 12.5 Realize smoking was pointless 8.0 20.0 24.0
8.0 4.0 20.0 12.0 Friend/family quitted successfully 21.1 21.1 10.5 15.8 5.3 0.0 15.8
Motivation from a friend 11.8 23.5 11.8 5.9 11.8 11.8 11.8 Seeking non-smoking areas 22.2 11.1 22.2 11.1 0.0 11.1 11.1
Tension and trigger in smokers who had not been seriously thinking to quit smoking before they heard about the clinic
Trigger
Tension Advice from
doctor or nurse (%)
Experience symptoms linked to
smoking (%)
Seeing a poster or
reading about the clinic (%)
Knowing someone stopping
(%)
Seeing
someone else get ill from
smoking (%)
Suddenly
realized how bad smoking is
(%)
The price of cigarette
went up (%)
Realized
smoking is against my
religious beliefs (%)
Health was suffering because of smoking 4.4 41.8 4.4 4.4 7.7 29.7 0.0 4.4
Concern for future health 4.2 33.1 5.9 6.8 5.9 30.5 4.2 5.1 Concern about family health 3.4 29.9 4.6 8.0 6.9 32.2 4.6 6.9
Smoking is too expensive 1.6 32.3 4.8 9.7 6.5 24.2 11.3 8.1 Family pressure 4.4 36.8 2.9 8.8 4.4 27.9 4.4 7.4 Nagging from family members 7.0 34.9 4.7 4.7 11.6 20.9 4.7 7.0
Doctor told to stop 14.3 40.5 4.8 2.4 4.8 28.6 0.0 4.8 Did not like being addicted 4.8 28.6 6.3 7.9 7.9 30.2 4.8 4.8
Ashamed to be a smoker 4.5 22.7 0 9.1 13.6 31.8 0.0 13.6 Realize smoking was pointless 5.5 23.3 5.5 5.5 9.6 32.9 5.5 6.8 Friend/family quitted successfully 5.4 29.7 5.4 10.8 13.5 24.3 2.7 5.4
Motivation from a friend 9.1 40.9 0 9.1 4.5 18.2 4.5 9.1 Seeking non-smoking areas 7.1 14.3 0 14.3 14.3 28.6 0.0 7.1
Tension and trigger in smokers who had been seriously thinking to quit smoking before they heard about the clinic
Feelings about Smoking
54.0%
46.0%
I am very unhappy to think of myselfas ‘a smoker’
I do not really mind being ‘a smoker’even though I know I should stop
Enjoyment of Smoking
39.0%
44.5%
16.5%
Yes, very much Yes, a little No
Feelings Experienced Before the Appointment at the Clinic Following
Decision to Attend Clinic
8.0%8.0%
48.0%
70.5%
Happy aboutbecoming a non-
smoker
Worried not beingable to succeed in
stopping
Worried about whatwould be missing as
of a smoker
No specific feelings
Steps Taken Before the Appointment with the Clinic Following the Decision to Attend
Clinic
9.0%
54.0%
37.0%
I tried to reduce theamount I smoked
I carried on smokingnormally
I stopped smokingimmediately
Perceptions of the Benefits of Smoking
8.5%
25.5%36.0%
56.0%
73.5%77.5%
Stops frombeing bored
Stay calm instressfulsituations
Providesenjoyment
amongfriends
Stay alert Feel betterwhen bad
thingshappened
Keep fromgetting too
fat
Current Feelings
45.5%
54.5%
I know in my heart that I will stop thistime and never smoke again
I hope that I will succeed this time
Intentions on the Current Attempt to Quit Smoking
85.0%
11.5%3.5%
I definitely intend to stopsmoking completely and
never smoke again
I intend to stop smokingcompletely for a whilebut I have not decidednever to smoke again
I may allow myself theoccasional cigarette or
another form of tobacco
Confidence in Quitting Smoking Completely
29.0%
52.0%
15.5%
3.5%
Very confident Quite confident Not veryconfident
Not sure
Motivation to Quit Smoking Completely
4.5%
39.0%36.0%
20.5%
Extremely strong Very strong Quite strong Not very strong
Summary of Finding (1)
• Younger smokers • Professional group• Significant minority of smokers had not
been thinking seriously of quitting before they heard about the clinic
• Health related reasons are the main tensions experienced by smokers
Summary of Finding (2)
• The complexity of the smokers’ feelings about quitting:-
– Majority were happy about the idea of becoming a non-smoker
– More than half tried to reduce the amount of cigarettes they smoked before the appointment
– Majority intended to stop smoking completely and had strong motivation to quit but about half worried they may not succeed
– They enjoyed smoking, perceived smoking helped to reduce stress, stopped being bored, and to enjoy while with friends
Summary of Finding (3)
• Provide new insights on how we perceive and treat smokers
• Although smokers differed in their readiness to quit smoking early in their quit attempts, they experienced inner conflicts and had shown instability in their thoughts and feelings towards smoking and quitting
• While in the state of vulnerability, they showed stronger emotional commitment by opting to quit abruptly
30
Summary of Finding (4)• Triggers to quit smoking can happen unexpectedly,
therefore the smokers are unprepared and will act upon the moment of opportunity - (Skog, O.J. 2000)
• Those who had not been thinking to quit might be triggered to do so and may accept the offer of help and will go on to succeed - (Pisinger et a. 2005)
• Smokers quit attempts do not necessarily happen in a structured manner and usually hard to predict.
• If it is hard to predict smokers future behaviors, how can we ask them to plan their quit attempts?
Implications of Finding
• Recognise ambivalence in:-– Smokers’ feelings about smoking– Substantial minority don’t mind being a smoker
• Acknowledge that many smokers take active steps before quit date
• Recognise that a substantial minority are triggered by learning about the clinic
• Create a challenge to health care professionals to strategise their interventions
Plans for Future Analysis
• Smokers are being followed up to assess their processes of quitting smoking and how they relate to success in the:-– Immediate post quit period (up ~ 4 weeks) – Intermediate post-quit period
(up to ~ 3 months)
Acknowledgements• We thank Dr Salehuddin Abu Bakar, Deputy Director,
Dept. of Health, Federal Territories, and Putrajaya Hospital for approving this research to be carried out in their clinics. We are grateful to all the dedicated health care personnel.
Contributors: • Prof. Robert West (UCL) had the original idea for this
study, data analysis and editing this paper for publication• Prof Awang Bulgiba assisted in the statistical analysis• Funding: The Ministry of Health Malaysia
Interview with Smokers
Training Session
Smoking Cessation Team
Quit Smoking Clinic