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