smoking cessation dissertation

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• v.9(7); 2019

Barriers to smoking cessation: a qualitative study from the perspective of primary care in Malaysia

Kooi-yau chean.

1 Department of Family Medicine, RCSI & UCD Malaysia Campus, Penang, Malaysia

Lee Gan Goh

2 Department of Family Medicine, National University Health System, Singapore, Singapore

Kah-Weng Liew

Chia-chia tan, xin-ling choi, kean-chye tan, siew-ting ooi.

3 University of Dublin Trinity College, Dublin, Ireland

Associated Data

This qualitative study aims to construct a model of the barriers to smoking cessation in the primary care setting.

Individual in-depth, semistructured interviews were audio-taped, then verbatim transcribed and translated when necessary. The data were first independently coded and then collectively discussed for emergent themes using the Straussian grounded theory method.

Participants and setting

Fifty-seven current smokers were recruited from a previous smoking related study carried out in a primary care setting in Malaysia. Current smokers with at least one failed quit attempts were included.

A five-theme model emerged from this grounded theory method. (1) Personal and lifestyle factors: participants were unable to resist the temptation to smoke; (2) Nicotine addiction: withdrawal symptoms could not be overcome; (3) Social cultural norms: participants identified accepting cigarettes from friends as a token of friendship to be problematic; (4) Misconception: perception among smokers that ability to quit was solely based on one’s ability to achieve mind control, and perception that stopping smoking will harm the body and (5) Failed assisted smoking cessation: smoking cessation services were not felt to be user-friendly and were poorly understood. The themes were organised into five concentric circles based on time frame: those actionable in the short term (themes 1 and 2) and the long term (themes 3, 4, 5).

Conclusions

Five themes of specific beliefs and practices prevented smokers from quitting. Clinicians need to work on these barriers, which can be guided by the recommended time frames to help patients to succeed in smoking cessation.

Strengths and limitations of this study

• As a qualitative study from the primary care perspective, this paper contributes to the limited literature available on smokers’ lived experiences of their attempts to quit smoking.
• A diversity of participants from different races and from both high and low nicotine dependence were recruited.
• The use of in-depth qualitative methods allowed detailed account of smokers’ experience in smoking cessation.
• Focus group interview was not performed in this study because of participant reluctance and hence the opportunity to observe the interaction among participants was unavailable.

Introduction

Cigarette smoking harms almost every organ of the body resulting in premature death in half of all smokers, 1 and unfortunately there are over one billion smokers in the world. 2 The prevalence of ever having tried to quit smoking varies in different countries, for example, less than 20% of smokers in China and Malaysia reported recent attempts to quit. 3 Additionally, the estimated number of attempts before quitting successfully varied widely, ranging from 6.1 to 142. 4 In those who tried to quit smoking, the abstinence rate at 6 months is only 3%–5% among those who self-quit 5 and 19%–33% among those who opt for pharmacotherapy. 6 We must therefore take an in-depth look from a variety of perspectives to understand the reasons contributing to failures in smoking cessation.

Eighty per cent of smokers in the world live in developing countries. 2 Hence, studies related to quit smoking behaviours conducted in the relevant cultural and socioeconomic settings of developing countries are needed.

Malaysia is a developing country with a complex society—ethnically, linguistically, culturally and religious faiths. It has three major races of Malays, Chinese and Indians, with numerous indigenous ethnic groups. Such ethnic and cultural diversity may make smoking cessation a more complicated task for medical practitioners.

Approximately 22.8% of Malaysians smoke. 7 The smoking rate for adult males is 43% 7 and for adult females is 1.4%. 7 The high prevalence of current smokers is associated with males, Malays, the rural population, government servant and those with low educational background. 7 By ethnic distribution, the prevalence of smokers was the highest among the Malays, followed by Indians, then Chinese. 7 There are no statistics available for indigenous groups. Over the past 12 months, 52.3% of current smokers in Malaysia made an attempt to quit smoking. 7 Overall, less than 10% of current smokers visited a healthcare provider with 75.4% of them having been advised to quit smoking. 7

This study was triggered by the results of one of our smoking related study, ‘Assessing Airflow limitation Among Smokers in a Primary Care Setting’ ( https://doi.org/10.21315/mjms2018.25.3.8 ). In that study, the authors found a high prevalence of airflow limitation among smokers and from it implied urgency in helping smokers to quit smoking. So the triggered research question is what barriers prevented smoking cessation from take place.

This study aims to explore barriers to quitting smoking from the perspective of primary care. We chose a qualitative study because ‘this will be able to capture expressive information about beliefs, values, feelings, and motivations that underlie the behaviour’ 8 of participants. The process of comparing and exploring smokers’ answers to our open questions can also potentially lead us to ‘discover’ new patterns of information regarding barriers to quitting smoking in this unique society. Primary care providers with ‘whole person medical practice’ 9 have the most opportunities to help smokers to quit smoking. Identifying barriers to quitting is an important step in both the 5As approach (Ask, Advise, Assess, Assist and Arrange) and the 5Rs approach (Relevance, Risks, Rewards, Roadblocks and Repetition) 10 in brief intervention. Our study will help primary care practitioners in smoking cessation counselling.

Study design

A grounded theory study method was chosen as this will allow a new understanding of the barriers to smoking cessation from the primary care perspective. This study method may be defined as a ‘general method of comparative analysis’ 11 without pre-existing conceptualisation to uncover social processes. A theory is then constructed through the data analysis, 12 which is presented.

Setting and sample

This study was conducted in Penang, Malaysia during January and February 2017. We recruited participants using purposive sampling, which is a ‘non-probability’ and a criterion based sampling technique. 13 Subjects were selected based on certain characteristics, which will enable a holistic and in-depth exploration of the research topic. From a previous smoking related study in 2016–2017, the authors had a ready list of 191 participants with at least one failed quit attempts. Their demographic profile, smoking history and Fagestrom test for nicotine dependence level were also available. We contacted the eligible participants by telephone to explain the purpose and the nature of the study. Participants had the option to meet with investigators at RCSI & UCD Malaysia Campus or an alternative preferred location (including their homes) for an interview. Sample size was determined on the basis of theoretical saturation. Subjects from both high nicotine dependence (Fagerstrom score 6–10) 14 and low nicotine dependence (Fagestrom score 1–5) 14 were included. Twelve invited smokers refused to participate in the study. Eight of them did not give any reason and four stated that they were too busy. We did not manage to organise any focus group discussion as intended because our participants felt that they were too shy to speak in such a group format. In the smoking cessation barriers model presented in this paper, we defined short-term potential modifiable strategies as less than 3 months of smoking abstinence 15 16 and potential long term strategies as 12 months or longer of smoking abstinence 17 18 based on study designs reported in the current literature (2015 to 2019) obtained from PubMed searches.

Data collection

Informed written consent was obtained from all participants. Fifty-seven one-to-one individual in-depth interviews were conducted by a team of six researchers. The team comprised of two family physicians and lecturers—K-CT (male) and K-YC (female) from RCSI & UCD Malaysia Campus; three medical graduates awaiting internship posting—K-WL (male), C-CT (female) and X-LC (female) and one medical student—S-TO (female) from Ireland. K-YC conducted two pilot interviews and provided training in conducting the interviews for the rest of the team. None of the interviewers were known to the participants. The technique used by interviewers was one-to-one, open-ended questions, semistructured format, conversational with intense probing for deeper meaning and understanding of the responses. Interviewers followed an interview guide ( box 1 ) which was consistent with the concept of being ‘open’ and ‘discovery’ aiming to construct a particular theory. The initial question asked was open-ended to facilitate participants to describe, to reflect and to express values in their own words. Subsequent questions were determined by both the participants’ response and the predetermined questions in the interview guide ( box 1 ). Questions were phrased in a way to get lengthy, detailed answers from participants.

Interview guide

Opening question:

Please share with us your experience in quitting smoking in the past.

How many times have you tried/did you try (before you succeeded)? When was it?

How long did you stop for?

How did you stop smoking?

What caused you to resume smoking after stopping?

What makes the process difficult?

What is your reflection on this experience? What did you learn from this experience?

Would you like to say something we haven’t talked about and that is important for you?

The interviews were conducted in participants’ preferred language which included English, Malay, Mandarin and Hokkien dialect. The duration of interviews took between 20 and 60 min. The interviews were audio-recorded and transcribed verbatim. Non-English interviews were translated to English by the respective interviewers.

The interviewers met up with the participants within 2 weeks of the interviews to verify the accuracy and to correct any transcription errors. At the second encounter, participants were encouraged to provide additional information if they wished.

Data analysis

Data was anonymised and transcribed. All six researchers started line-by-line open coding independently to ensure that the analysis was holistic and inductive. The researchers then met for axial coding and clustering to develop master headings and subsequently higher categories. Fragmented codes were linked by using the techniques of constant comparison, continual checking and clustering of emerging themes to formulate a theoretical model. 19 QDA Miner Lite software 20 was used to assist with code frequency analysis, coding retrieval and Boolean text search.

Patient and public involvement

No patient or public were involved in the design, recruitment and conduct of the study.

We interviewed 57 participants. Table 1 shows the participants’ demographic characteristics in detail.

Demographic characteristics of participants (n=57)

Themes generated from grounded theory

Theme 1: personal and lifestyle factors.

A majority of abstinent participants were unable to resist temptation cues when challenged. Their smoking relapses were attributed to the influence of friends who smoked in social activities or work places.

I felt it was because I mingled with friends who are all smokers. So, if I am the only person who has the plan to stop smoking and mix with friends who are still smoking, that is why… because the cigarette is exposed. I don’t have any choice. (Participant 17)

Participants conceded that relapses in smoking cessation were often related to impaired capacity for self-control and lack of intrinsic motivation.

‘Control… no power of control. Self-control is weak, rather weak. (Participant 13)

Some participants related that the decision to resume smoking was rather impulsive.

Yes, it is a mistake. Because I was already not looking for (cigarette) that time, I already was not craving, but just ‘try, try’. After then, it was like learning again, learning again the taste slowly, it was like normal… tried to discipline ah, err. After 1 week, it was very hard, definitely very hard, (I) want to find a cigarette, then (I) must resist, resist the temptation until 2 weeks then it went. By week 3, I feel that even the smells smoke from other smokers make me not comfortable; not because I was craving for a cigarette, but it was because it was like ‘stinky’. After then, gradually 1 month, 2 months, it is ok lah. It is stable. By third month and fourth month like that, definitely I was not looking (for a cigarette). After then, I started to have the urge for a cigarette, so I want to try again, so it was my fault. It was like ‘play… play’ smoke, smoke again, not because of addiction oh. (Participant 17)

In addition, the withdrawal of extrinsic factors that motivated our participants to stop smoking was felt to be the reason for the resumption of smoking. For example, recovering after sickness, release from prison, no longer in a smoking free zone, no longer taking care of a sick relative or no longer being nagged.

I was admitted to ICU (intensive care unit) for five times in IJN (National Heart Institute). So I smoked again after my bypass, I resumed smoking. (Participant 28)

Theme 2: Nicotine addiction

Cigarettes contain highly addictive nicotine, and participants did report overpowering withdrawal symptoms on quitting.

…Stopped 1–2 months, I felt more tired…If I didn’t smoke, I was not able to open my bowel, I became constipated……If I smoked at night, I slept better.(Participant 26)

I was feeling difficult, breathless at times. I also noticed that I had chest discomfort which was more when I work. I had no choice but to smoke again.(Participant 51)

Psychological dependence was clearly highlighted by the pleasure they experienced from smoking. Participants described experiences which were strongly suggestive of psychological addiction to cigarette smoking, regardless if they realised it or not.

That actual problem is our mind, the brain… because why, you know? When we are not smoking, the brain will tell you: ‘There are other smokers there, could you ask him for one cigarette? (Participant 37)

…because for smoker, you feel that something is missing. So, you tend to ask for a stick. Ask for a stick, you know. Then from then starts again. Two sticks…(Participant 41)

Theme 3: Sociocultural norms

Some participants expressed that the offering of cigarettes from friends and relatives was the main reason for their failure to quit. It was normal for smokers to offer their friends and relatives cigarettes as a sign of goodwill and a close relationship.

My friends… They offer and we don’t refuse it. We take it as a token of friendship. (Participant 43)

In some participants, despite having informed their peers that they had quit smoking, they were still coerced into smoking. The peers gave them the impression that smoking a small amount of cigarettes would not affect their ability to quit smoking.

I actually managed to quit—roughly 3 months. After that, I went for a course in Bangi for a week. There, I had colleagues who smoke, they offered me. I said I didn’t want (to smoke) because I’ve quitted. And they said, ‘Never mind, only one… So he gave me, and I smoked. After that, after lunch, he offered me again. (Participant 9)

For Muslim participants, the withdrawal of social and religious motivation after Ramadan (Fasting month) also increased the tendency to relapse.

The month of ‘puasa’ (the fasting month), I was free for the 1 month. Don’t want lah, I don’t want to smoke in front of my family. Then, when it is during ‘iftar’, smoking will waste a lot of time. So, I let myself relax for 1 month. I wanted to rest during fasting month. For my lungs to cleanse it…After the fasting month, I started back but less (cigarette). Sometimes 3–4 sticks, 5–6 sticks. (Participant 23)

Theme 4: Misconception

Smoking cessation is a complex and dynamic process and most smokers make multiple attempts of reduction and abstinence. 21 Some participants perceived smoking cessation as just a game of the mind.

…to quit smoking depends on will power. For me, this is a game of the mind. We set our mind, err, tomorrow, I don’t want to smoke tomorrow, then I will not smoke tomorrow. (Participant 23)

I smoke for ‘saja’ (just for fun), not because of addiction. But, if it is due to emotional problems, up to here (point to his head); there are a lot of problems not solved, and the feeling is up to here (point to head), this is another experience, then there will be just cigarette only. When the mind is not calm, err, finish one stick then another, again and again. (Participant 17)

Patients usually trust their doctors and therefore take their doctors’ recommendation seriously. Ideally, this advice would include cessation tips and the correction of false beliefs and misconceptions.

I stopped abruptly, so I felt breathless. Then my family brought me to the hospital …Then the doctor scolded me, ‘Did you want to die?’ You cannot stop (smoking) completely all of a sudden. If you want to stop, you need to come to the hospital and meet with the MO (medical officer), the doctor, to get their advice… At least you have to smoke one a day. (Participant 9)

Some participants exaggerated or misinterpreted the effects of smoking cessation as harmful to health.

I stopped for a few months then I became frightened. My friends said once stopped, disease will come. Also, I saw my friend (who) died after stopping (smoking). (Participant 11)

There are side effects when stop smoking, after I stopped smoking, I was diagnosed with high blood pressure and had a heart attack as well. (Participant 28)

One participant who believed that secondhand smoke was more harmful than smoking itself.

If I breathe in secondhand smoke, it is more poisonous than if I smoke myself. (Participant 1)

It was interesting to also highlight the belief that smoking might in fact, be therapeutic.

I had that disease (Idiopathic thrombocytopenic purpura) for a long period, I did not know… I suffered from bleeding gum when I brushed my teeth, sometimes it happened spontaneously. So I resumed smoking. Once I started (smoking)… the gum bleed stopped…smoking is good. (Participant 33)

One participant commented that hand-rolled tobacco leaves were less hazardous than commercial cigarettes.

People said ‘rokok daun’ (tobacco leaves) is better when compare to a cigarette. I cannot ‘tahan’ (stand) without smoking…, so, after discharged from the hospital, my friend recommended ‘rokok daun’(tobacco leaves) to me. The smell is there…I tried it and I continue to smoke…At least, this ‘rokok daun’ is better, and I managed to stop the cigarettes. (Participant 49)

Interestingly, there were participants who developed defense mechanisms themselves to ward off the concept that smoking is dangerous/unacceptable. This was particularly true when the participants felt obliged to refrain from smoking in the presence of young children or other family members.

…Sometimes I smoke alone in my own room. But, I, err, I open the windows. My room has air-conditioner but I don’t even turn it on… ‘I turn on the fan to blow away all the smoke. (Participant 6)

Theme 5: Failed assisted smoking cessation

Some participants tried conventional methods (smoking cessation clinics, nicotine replacement therapy) as well as alternative methods such as electronic cigarettes in their attempts to quit smoking. Most participants expressed that pharmacotherapy was ineffective. This perhaps resulted in a negative impression towards the effectiveness of assisted smoking cessation.

Smoking cessation clinic does not work. I tried chewing the gum, no use. Not working at all. Whatever medications they gave to stop smoking did not work. (Participant 16)

I already bought the type of cigarettes, that ‘blocked’, I am not sure if you have heard that before. The one with three cigarettes that is like when you smoke, it has no taste. May be you can quit, but I cannot. I brought from the pharmacy. (Participant 18)

Non-pharmacological factors also contributed to the dropout from smoking cessation clinics. These included the accessibility of the clinic and the language spoken. Language barriers were highlighted because of multiple languages spoken in Malaysia.

I have been to smoking cessation clinic two times. It is just too troublesome to keep going there. (Participant 27)

But I have gone there (stop smoking clinic). They were all Malay and my Malay is not very (good)… I did not really understand. (Participant 1)

Some participants also noted that they did not know the methods available to quit smoking even though they were willing to try them. Participants implied that their medical practitioners did not convey nor educate them in the methods available to help them to quit smoking.

Doctors don’t teach how to stop. And also nobody help you to stop. Do you think so? So, you don’t know the way to stop. (Participant 24)

A descriptive model from grounded theory

Figure 1 presents a descriptive model showing the relationship among the five grounded theory themes of participants’ perceived reasons for failed quit smoking attempts. Notes accompanying the diagram in figure 1 provided examples of each grounded theory theme.

A grounded theory of barriers to smoking cessation.

The five themes are displayed as five concentric circles to show the relationship of the themes to one another. Theme 1 (Lifestyle & Social Factors) describes the participants perceived the need to ‘avoid presence of smokers, easy access to cigarettes, impaired self-control, and boredom’ in order to avoid nicotine addiction (theme 2). Theme 3 (Social & Cultural Norms) which includes ‘offering and accepting cigarettes as token of friendship’ have had great relapse consequences on abstinent smokers. Theme 4 (Misconception) relates smokers’ lived experiences on why they continue to smoke. Some smokers perceive smoking as a ‘game of the mind’ and they can quit anytime they wish to do so; others continue to smoke because of the misconception that stopping smoking will be harmful to health. Theme 5 (Failed Assisted Smoking Method) describes failures in the healthcare delivery system as perceived by smokers. Participants interviewed in this study had negative experiences of the smoking cessation services received, such as ‘limited accessibility’, ‘language barrier’ and ‘Do not know how the methods work’.

Time frames for overcoming barriers to smoking cessation

In this grounded theory study, we created a model of five themes of smoking abstinence barriers. Two were potentially surmountable in the short term (less than 3 months) and three were potentially surmountable in the long term (12 months or longer) time frames ( figure 1 ).

Smoking cessation is a challenging human process for both patients and doctor alike. Despite many decades of trying, we are struggling to make a significant improvement in cessation rates. A 2014 systematic review of qualitative and quantitative literature by Twyman et al 22 on six vulnerable groups (low socioeconomic; indigenous; mental illness; homeless; prisoners and at risk youths) described three common cessation barriers. These were: smoking for stress management, lack of social support from health and other service providers and a high prevalence and acceptance of smoking in vulnerable communities.

Our study adds to what is known from Twyman et al ’s 22 review. New areas are covered namely; our participants were community based. Demographically, the mean age group (SD) was 58 (10.8); our participants comprise the three major races in Malaysia, with diverse cultural backgrounds. In addition, the uniqueness of the grounded theory method used in this study was that it produced the results on the lived experience of barriers to smoking cessation, which then formed the theory that explained the barriers to smoking cessation.

In Twyman et al ’s study, the duration of ‘short term’ and ‘medium and long term’ in the smoking cessation strategies was not defined. We have defined the time frames based on current literature namely, for short term as less than 3 months 15  16 and long term as 12 months or longer in smoking cessation strategies. 17 18 The two studies agree on lifestyle and individual factors as short-term abstinence strategies, and similarly on cultural factors as long-term abstinence strategies. Misconception as a theme was not identified in Twyman et al ’s paper. We have classified this newly discovered theme as one that requires long-term strategy because the patients who made the remarks were in the precontemplative stage of change namely, smoking cessation ‘as a game of the mind’ and stopping smoking as harmful to health.

There are several conclusions to be taken from this study:

(1) Theme 3: Offering cigarettes to one another is perceived as a sign of friendship and this cigarette culture serves as an impediment to smoking cessation in this society. In China, offering cigarettes is a sign of mutual respect during social events. 23 24 It is customary for a subordinate to light a cigarette for his seniors. 24 Smokers in our community will need to be taught methods of rejecting the offer of cigarettes and reassurance that declining an offer of a cigarette is not seen to be rude.

(2) Theme 3: Smokers find it easier to stop smoking during Ramadan due to the religion, cultural and environmental influences. 25 Although many Muslim smokers (97.7%) 26 in Malaysia smoke fewer cigarettes during Ramadan, only 15% perceive Ramadan as a strong motivator to quit smoking 27 and therefore most relapse after Ramadan. It is also known that such smoking behaviour changes during Ramadan are associated with those of higher incomes, high nicotine dependence and those who are not aware that smoking is ‘haram’ (forbidden). 25 Ramadan should be seen as an excellent opportunity for the implementation of a religious-competent intervention to improve cessation rates.

(3) Theme 4: Our participants revealed a number of misconceptions which were considered to be different from those listed in the literature. 28 For example, misinformation and misconceptions led them to believe that reduction in tobacco consumption is acceptable, but if they were to quit smoking entirely, it will cause disease. Secondhand smoking is perceived to be more harmful than active smoking and therefore they believe that in a smoking environment, active smoking is encouraged. In addition, false beliefs that smoking may be therapeutic or smoking with the fan on or hand-rolled cigarettes are less hazardous is present in this community. Therefore, clinicians should first assess and dispel the relevant false beliefs during counselling sessions.

(4) Theme 1 and Theme 2 interactively: To healthcare practitioners, tobacco smoking is regarded as an addiction. However, to patients, it is regarded as self-determined lifestyle choice. 29 Such discrepancy was observed in this study. It has long been established that nicotine addiction is the biggest cause of failure in smoking cessation. Nicotine can be as addictive as heroin, cocaine or alcohol 30 31 and as a result, attempts to quit smoking are often unsuccessful because of withdrawal symptoms including stress and weight gain. 32 Nevertheless, our participants did not perceive addiction as the major factor of failure, instead they expressed overwhelmingly that quitting smoking is a ‘game of the mind’. Smokers blamed themselves as having poor determination in that stopping smoking is a matter of how they control their mind. This finding is consistent with that of a recent quantitative study 33 which showed that most smokers believe willpower is necessary or sufficient for quitting. Such belief in mind control as the tool to quit smoking undermines the use of formal cessation assistance. The failure to recognise symptoms of addiction of smoking renders smokers to ‘not believe’ in the usefulness of pharmacotherapy. 34 The use of smoking cessation strategies in our setting has been low 35 and we believe such misconceptions contribute greatly to the failure of smoking cessation. Participants were reluctant to receive professional help and preferred to ‘quit’ by themselves. A national survey in 2016 in Malaysia revealed that nearly 80% of former smokers quit without any professional intervention. 35 More work is needed to help smokers to accept that cigarette smoking is highly addictive and that nicotine addiction is very powerful. In addition, healthcare practitioners need to ensure sufficient patient knowledge to improve their confidence to acknowledge withdrawal symptoms and to focus more on the end result during the cessation process.

Limitations

The main limitation of this study is that only in-depth interviews and no focus group interviews were conducted. We did not organise any focus group interviews because the participants were too shy to speak in a group. While the opportunity to observe the interaction among the participants was lost, we managed to gain a more in-depth, detailed account of smokers’ experience without them feeling inhibited to speak in a group.

Another possible limitation is selection bias. The highest education grade completed by the majority (70.1%) of the participants was either primary school or lower secondary education and this could have resulted a ‘less-educated-population’. Nonetheless, we think the data obtained in our study are sufficiently robust to describe reasons contributing to failures in smoking cessation in this community.

Implications and recommendations

We have provided suggestions for applications based on the grounded theory findings in the discussion above. We can use similar grounded theory design to explore theme 2 and theme 5 with the view of defining the extent of ignorance in the symptoms of nicotine addiction; misconceptions and patient concerns on service provision deficiencies and lack of user-friendliness.

In addition, the themes of this model serve as a checklist for clinicians when exploring barriers to smoking cessation. In particular, in step 4 of both the 5A 10 (assist) techniques and 5R 10 (Roadblock) technique of brief intervention for smoking cessation so that appropriate action plan can be tailored accordingly. With all these efforts, hopefully, we could reach better smoking cessation rates.

Five themes of specific beliefs and practices prevented smokers from quitting. Clinicians need to work on these identified categories to help patients overcome barriers to smoking cessation guided by the time frames recommended by the authors. This study highlighted the importance of sociocultural environment and misconception as factors contributing to the failure to quit smoking in this community. Educating smokers to dispel their misbeliefs is crucial. Development of religiously and culturally competent interventions should be considered to reduce relapse rate.

Supplementary Material

Acknowledgments.

We thank all the participants in this study. We are grateful for their involvement and effort.

We also thank Professor Paul Fogarty for his diligent copyediting of this article.

Contributors: K-YC conceived the idea. K-YC and LGG contributed to the design of the study. K-YC, K-WL, C-CT, X-LC, K-CT and S-TO conducted the individual focus interview, translated and transcribed independently. K-YC, K-WL, C-CT, X-LC, K-YC and S-TO carried out thematic analysis as a group and drafted the original manuscript. K-YC and LGG critically revised the manuscript. All authors provided approval of the final manuscript.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data sharing statement: The data that support the findings of this study areavailable from the corresponding author, Chean K-Y upon reasonable request.

Patient consent for publication: Not required.

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Determinants of smoking cessation and abstinence in a Russian smoking-cessation center

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INTRODUCTION

Smoking prevalence in Russia is one of the highest in the world. It leads to significant damage to the National Health Service. The purpose of the present research was to assess the effectiveness of a qualified smoking-cessation (SC) center in Moscow, and to identify the main determinants of smoking cessation.

The subjects of this study were a cohort of smokers (n=524) who had attended the SC service in Moscow between 2012-2015. They were followed, for at least 6 months after receiving the professional counselling in smoking cessation, to assess the results of the assistance and to identify determinants of successful smoking cessation.

Of the smokers, 19% succeeded in reducing by more than half the number of smoked cigarettes, more than 46% of patients completely stopped smoking for different terms: 38% for more than a month and 24% for more than half a year. Odds ratios (ORs) indicated that the probability of successful smoking cessation significantly increased if there was a previous success in smoking cessation: OR 3.71 (95% CI 1.70-8.12); and if there was a high level of motivation to stop smoking OR 4.3 (95% CI 1.92-5.61). The probability of successful smoking cessation decreased with intensity of smoking > 10 cigarettes a day: OR 0.57 (95% CI 0.31-1.02); and an elevated (>7 points) Fagerström-test score OR 0.64 (95% CI 0.37-1.07).

CONCLUSIONS

Degree of motivation and willingness to quit smoking were the principal determinants of the effectiveness in the attempt to quit smoking within our study cohort.

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Tobacco Prevention & Cessation

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Measuring processes of change: applications to the cessation of smoking.

Predictors of cessation in a cohort of current and former smokers followed over 13 years.

The role of desire, duty and intention in predicting attempts to quit smoking., author and article information , affiliations, author notes.

This is an Open Access article distributed under the terms of the Creative Commons Attribution NonCommercial 4.0 International License.

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Thesis (complete)

Front matter, chapter 1: general introduction, chapter 2: smoking and sickness absence: a systematic review and meta-analysis, chapter 3: associations of sustained smoking and smoking cessation with work-related outcomes: a longitudinal analysis, chapter 4: effect of tobacco control policies on information seeking for smoking cessation in the netherlands: a google trends study, chapter 5: effect of the stoptober temporary abstinence campaign on information seeking for smoking cessation: a google trends study, chapter 6: effectiveness of the stoptober temporary abstinence campaign in the netherlands: a longitudinal study, chapter 7: how the stoptober temporary abstinence campaign supports dutch smokers attempting to quit: a qualitative study, chapter 8: general discussion, summary; samenvatting; dankwoord; about the author; list of publications; portfolio; list of abbreviations, disclaimer/complaints regulations.

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Determinants of smoking cessation and abstinence in a Russian smoking-cessation center

Affiliation.

• 1 Russian Cancer Research Center of N. N. Blochin, Russia.
• PMID: 32432198
• PMCID: PMC7232794
• DOI: 10.18332/tpc/76623

Introduction: Smoking prevalence in Russia is one of the highest in the world. It leads to significant damage to the National Health Service. The purpose of the present research was to assess the effectiveness of a qualified smoking-cessation (SC) center in Moscow, and to identify the main determinants of smoking cessation.

Methods: The subjects of this study were a cohort of smokers (n=524) who had attended the SC service in Moscow between 2012-2015. They were followed, for at least 6 months after receiving the professional counselling in smoking cessation, to assess the results of the assistance and to identify determinants of successful smoking cessation.

Results: Of the smokers, 19% succeeded in reducing by more than half the number of smoked cigarettes, more than 46% of patients completely stopped smoking for different terms: 38% for more than a month and 24% for more than half a year. Odds ratios (ORs) indicated that the probability of successful smoking cessation significantly increased if there was a previous success in smoking cessation: OR 3.71 (95% CI 1.70-8.12); and if there was a high level of motivation to stop smoking OR 4.3 (95% CI 1.92-5.61). The probability of successful smoking cessation decreased with intensity of smoking > 10 cigarettes a day: OR 0.57 (95% CI 0.31-1.02); and an elevated (>7 points) Fagerström-test score OR 0.64 (95% CI 0.37-1.07).

Conclusions: Degree of motivation and willingness to quit smoking were the principal determinants of the effectiveness in the attempt to quit smoking within our study cohort.

Keywords: determinants; smoking cessation; tobacco addiction.

© 2017 Levshin V.

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Conflict of interest statement

The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.

• E Renteria1 E, Jha P, Forman D1, Soerjomataram I. The impact of cigarette smoking on life expectancy between 1980 and 2010: a global perspective. Tob Control. 2016;25:551–557. doi: 10.1136/tobaccocontrol-2015-052265. - DOI - PubMed
• Global Adult Tobacco Survey. (GATS) Russian Federation 2009. Country report.
• Marques P, Suhhrek M, McKee M, Rocco L. Adult health in the Russian Federation. Health Affairs. 2007;26(4):1040–51. doi: 10.1377/hlthaff.26.4.1040. - DOI - PubMed
• Zaridze D, Karpov R, Kiselev S, et al. Smoking is the basic cause of mortality in Russia. Journal of RAMS. 2002;9:40–45.
• Federal law RF “About the protection of the health of citizens from the action of that surrounding tobacco smoke and the consequences of the consumption of tobacco” from 23.02.2013 No15-FL.

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Barriers to Smoking Cessation

Info: 4571 words (18 pages) Example Literature Review Published: 9th Dec 2019

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Tagged: Health Public Health

This chapter presents the rationale for conducting research on barriers to smoking cessation amongst people who should know better. A review of current and relevant literature was done to assess current smoking cessation policies and initiatives, barriers to accessing treatment for nicotine dependence, and barriers to quitting.

Following the studies by Doll and Hill in the mid-twentieth century that suggested the detrimental effects of tobacco smoking(Doll and Hill, 1954), educational and clinical researchers have for decades studied the burden of tobacco smoking and the smoking habit in general. The relationship between tobacco smoking and morbidity/mortality, policy making regarding tobacco smoking regulations and their effectiveness, statistics concerning smoking cessation are amongst topic that have all been studied. This thesis is a study of smoking habits and barriers to smoking cessation amongst people who have an understanding of the health implications of tobacco smoking and also to retrieve a firsthand perspective of the effectiveness of already set down policies and tobacco smoking regulation.

Though smoking rates though reduced in comparison to the mid-twentieth century, there still exists high and alarming incidence and prevalence of tobacco smoking with more young people picking up the habit.

Indeed the view of the individuals primarily involved in tobacco smoking is very important in setting up more effective interventions than are present at the moment. Smoking behaviour differs from class to class and from individual to individual. Several studies have suggested that the strength of the habit is dependent on other influencing factors such as gender, age, employment etc. Because of this, we can find that men have a higher tendency to smoke than women, the less educated and people of low socio-economic status will also be observed to smoke tobacco than the educated and people of a high socio-economic class. Putting into consideration these already set up biases, the author sought to find out barriers to quitting tobacco smoking in an environment that has become anti-smoking.

BURDEN OF TOBACCO SMOKING

Tobacco is a greater cause of death and disability than any single disease (WHO, 1997. WHO fact sheets: fact sheet number 154). It is one of the top causes of preventable death globally and is estimated to kill more than 5 million people every year worldwide, most of which are in between low and middle income countries. It is projected that by the year 2030, this figure will rise to about 8 million people. The burden of tobacco cannot go without mentioning its financial implications and costs to the economy. According to the WHO, tobacco’s cost to governments, employers and to the environment includes social, welfare and health care spending, loss of foreign exchange in importing cigarettes, loss of land that could grow food, cost of fire and damage to buildings caused by careless smoking, environmental costs ranging from deforestation to collection of smokers’ litter, absenteeism, decreased productivity, higher number of accidents and higher insurance premiums. It is said to cost America, Germany, and the UK about $76 billion, $14.7billion and $2.26billion respectively (Mackay and Eriksen, 2002).

Apart from the financial burden of tobacco smoking and related illnesses, the quality of life of the smoker who will be exposed to cancer, organ malfunction and failure, loss of life, is also affected.

AWARENESS AND WHAT HAS BEEN DONE

With the appreciation of death, disability and the financial burden of tobacco smoking, various strategies have been placed by countries to help reduce the trend. Mass awareness campaigns have caused a growing number of people to appreciate the ills of tobacco smoking. Following the scientific reports linking tobacco smoking to ill health in the 1960’s, cigarette packs have been carrying health warnings (Mackay and Eriksen, 2002) such as cigarette smoking causes stroke, tobacco smoking hurts babies, cigarette smokers are liable to die young.

Another major intervention following the scientific reports of the 1960’s, was the introduction of tax on tobacco products. In the UK alone, where tax accounts for about 80% on the price of tobacco, and with a 5% annual increase, about 10billion pounds was generated from excise duty and tax on tobacco products in the year 2009 according to the tobacco manufacturers association. Various studies such by researchers have confirmed an inverse relationship between the price of tobacco and it’s consumption (Chaloupka and Warner, 2000).

EFFECTIVENESS OF ANTI SMOKING INTERVENTIONS

Tobacco use is one of the leading causes of preventable illness and death in the world. Once users become addicted to tobacco, quitting becomes hard. Nicotine dependence resulting from tobacco use hampers efforts to sustain abstinence from tobacco for a prolonged period or a lifetime. Many users make multiple attempts to quit, often without the assistance that could double or even triple their chances of success. Proven individual cessation strategies include counselling and behavioural therapy and, except when contraindicated, first-line and second-line medications. 

This section of the literature review will talk about the various smoking cessation policies and treatment for nicotine dependence with a view to analyse them based their effectiveness from previous research.

Smoking cessation interventions include

Individual methods

Cold turkey

Cut down to quit

Psychosocial and Behavioural therapy

Individual therapy

Group therapy

Self help materials

Aversion therapy

Alternative therapy

Acupuncture

Hypnotherapy

Aromatherapy

Laser therapy

Pharmacotherapy

Nicotine Replacement Therapy Gum

Nicotine Replacement Therapy Patch

Nicotine Inhalers

Nicotine lozenges

Nicotine spray

Other medications

Nortriptyline

Tobacco substitutes

Smokeless tobacco

Electronic cigarettes

Smoking herb substitutions.

 Below is a tabular summary of these treatment options for nicotine dependence.

 TOBACCO CONTROL POLICIES

Three important studies from the mid twentieth century provide the first real links between smoking and lung carcinoma. In 1950, Morton Levin publishes first major study definitively linking smoking to lung cancer. In the same year, Ernst L. Wynder and Evarts A. Graham of the United States, found that 96.5% of lung cancer patients interviewed were moderate heavy-to-chain-smokers in their study “Tobacco Smoking as a Possible Etiologic Factor in Bronchiogenic Carcinoma: A Study of 684 Proved Cases,”. Richard Doll and a Bradford Hill publish first report on Smoking and Carcinoma of the Lung in the British Medical Journal, finding that heavy smokers were fifty times as likely as non-smokers to contract lung cancer. (Doll and Hill, 1954).

These studies led to an increased awareness of the link between smoking and cancer subsequently leading to the introduction of policies to help reduce the incidence and prevalence of tobacco smoking.

WHITE PAPER: SMOKING KILLS

In 1998, the UK government released one of the most influential papers and the first of its kind which was designed to tackle head on the problem of smoking in the UK. The policies proposed by this paper and which have been implemented will be discussed briefly.

PRICE INTERVENTIONS

NON PRICE INTERVENTIONS

SMOKING BAN

COMPREHENSIVE BAN ON ADVERTISEMENTS

BETTER CONSUMER INFORMATION

Warning labels on cigarette boxes and tobacco products.

HELP FOR SMOKERS WHO WISH TO QUIT.

(Bank, 2003a)

This has been said to be the most effective policies for tobacco regulation especially for the younger generation and people from economically disadvantaged backgrounds. A price increase of 10% can reduce smoking rates by 8% in low and middle-income countries (Bank, 2003a) while it could be 4% in high-income countries (Joossens et al., 2004).

The UK tax paid tobacco market is worth about £14 billion (Association, 2010), with the tax currently accounting for 73-80% of cigarettes.

Although it has been argued that the demand for tobacco is highly inelastic as there is not a good enough substitute for tobacco and as such a rise in price will give just a small reduction in smoking rates (Gwartney et al., 2009), other studies have shown that while the demand for tobacco is inelastic, it will respond well to an increase in price (Chaloupka and Grossman, 1996).

These are policies set up to inhibit tobacco smoking in the work place and public spaces. They exist also to reduce the rate of second hand smoke. The whole of the United Kingdom became subject to a ban on smoking in enclosed public places in 2007, when England became the final region to have the legislation come into effect. A review of more than 900 studies and government reports looking at the impact of smoking bans across the world showed that there is ample evidence which proves they work, without hurting businesses such as restaurants and bars and the implementation of no-smoking policies have broader benefits for a wider population by increasing smoke-free environments.

COMPREHENSIVE BAN ON ADVERTISEMENT

Comprehensive bans on advertising and promotion of tobacco products have also been shown to reduce smoking. Empirical evidence shows that a fully comprehensive advertising ban covering all media and all forms of direct and indirect advertising reduces tobacco consumption. Similarly, a comprehensive advertising ban also reduces the rate of initiation and maintenance of the habit, in particular among young people. Along with the promotion of a smoke-free environment, the regulation of advertising contributes to making tobacco smoking less attractive, and making non-smoking an accepted social norm. The World Bank estimates that comprehensive bans can reduce tobacco consumption by around 7% (Harris et al., 2006).

Sustained and well founded mass media campaigns have been shown to be effective in the fight against tobacco. Mass media campaigns have been used to better enlighten the public about the facts concerning tobacco smoking, and the associated ill effects of smoking. Macaskill et al buttressed this point in their study suggesting that mass media based health promotion campaigns have the potential to reach a wide segment of the population including those from disadvantaged backgrounds or people with barriers to accessing health services (Macaskill et al., 1992).

A review of smoking prevention and control strategies concludes that the available literature suggests that mass media interventions increase their chance of having an impact if the campaign strategies are based on sound social marketing principles; the effort is large and intense enough; target groups are carefully differentiated; messages for specific target groups are based on empirical findings regarding the needs and interests of the group; and the campaign is of sufficient duration. (Lantza et al., 2000)

Evidence from several countries show that the large warnings introduced recently are effective in reducing smoking rates and increasing public awareness of the dangers of smoking (Bank, 2003b). Hammond et al found out that there were gaps of knowledge about the health risks of tobacco smoking and people who noticed the health warnings on tobacco packs were more likely to appreciate the health risks of tobacco smoking (Hammond et al., 2006)

HELP FOR SMOKERS WHO WISH TO QUIT

This has been an area that has been well invested in by the UK government. The inception of the NHS smoking cessation followed the recommendation of the White Paper Smoking Kills in 1998 (Health, 1998). The service enabled GP’s to refer smokers who really want to give up for a course of specialist counselling, advice and support. The service provided a week’s NRT course for those unable to afford them. Through this service, thousands of people were able to set up quit dates.

BARRIERS TO SMOKING CESSATION

Most of the smoking cessation interventions and policies mentioned above have proven effectiveness, some have showed greater effectiveness when used as combined therapy, while other have no proven form of effectiveness at all.

Statistics on smoking incidence and prevalence rates have clearly shown a decrease over the past years, but smoking rates have been declining by 0.4% annually in the UK (Stayner. et al., 2007). The latest figures for 2008 show that around 10 million adults in Britain smoke cigarettes (Office for National Statistics, 2010) with the highest rates amongst the 20-24 year olds who have 30% of this age group recorded as smokers. This prevalence declines with age to 13% amongst people who are 60 years and over. An increase in smoking cessation rates amongst the elderly group along with an increased incidence rate amongst the younger generation particularly amongst children and teenagers can be said to be responsible for this difference.

These figures are high in spite of the awareness and action on the part of both the government and individuals which has led to the focus of this research which is ‘to find out why smokers who are aware of the hazards still smoke regardless’.

Smokers can be categorised into three groups; those who are aware of the hazards of smoking and want to stop but can’t, those who are aware of the hazards and don’t want to stop, and those who are unaware of the negative effects of tobacco smoking. It will be safe to assume the UK would either fall into the first or second categories. This group of smokers will have considered stopping or even tried stopping at a time but have been unsuccessful at achieving smoking cessation. Surveys have shown that about 70% of smokers will like to stop but can’t (Lader, 2008). Interestingly, 40% of people who have had a laryngectomy and 50% of people who have had lung cancer will resume smoking after undergoing surgery (Stolerman and Jarvis, 1995). Similarly, 70% of smokers who have had a heart attack resume smoking within a year (Stapleton, 1998). When people neglect their health to repetitively satisfy a need gives strong evidence of dependence and addiction.

Tobacco smoking is woven into everyday life and can be physiological, psychological, and socially enforcing.

Physiological dependence: Tolerance / Dependence / Withdrawal symptoms

Nicotine addiction is the primary source of physiological dependence in relation to tobacco smoking and serves to play a major role in continued tobacco use because of its physiological effects on the body. Nicotine is a stimulant drug with the ability to cause both stimulation and relaxation. In smaller doses smoking heightens feelings of excitement and thus relieves fatigue and depression. In larger doses nicotine exerts a calming effect and reduces tension and stress however, the mental and physical state of the smoker can influence the person’s perceptions of the effect of smoking hence the overall experience will be different for different people (CDC, 1988). What seems to be certain is that nicotine is very addictive with tobacco being its method of administration (Physicians, 2000) and is characterised by a compulsive drug seeking behaviour even in the face of negative health consequences. Further buttressing its addictive nature, nicotine has been compared to other drugs of addiction such as heroin and cocaine in relation to their action as a mood/behaviour altering agent. Nicotine’s pharmacokinetics also enhance its potential as a drug of abuse as tobacco smoking causes a rapid distribution of nicotine into the effect achieving its desired effect of pleasure. The effect is short lived because of the short half life of the drug in the system, leading the smoker to want more and more of the drug so as to sustain its pleasurable effects, and this accounts for the tolerance and dependence bit of physiological dependence. Perhaps the hardest part of quitting is dealing with the withdrawal symptoms. High relapse rates have been largely attributed to the inability to deal with withdrawal symptoms. These symptoms include irritability, craving, depression, anxiety, cognitive and attention deficit, sleep disturbances, and increased appetite and may begin within a few hours after the last cigarette, quickly driving people back to the habit. Symptoms peak within the first few days of smoking cessation and usually subside within a few -weeks. For some people, however, symptoms may persist for months. Although withdrawal is related to the pharmacological effects of nicotine, many behavioural factors can also affect the severity of withdrawal symptoms. For some people, the feel, smell, and sight of a cigarette and the ritual of obtaining, handling, lighting, and smoking the cigarette are all associated with the pleasurable effects of smoking and can make withdrawal or craving worse.

Psychological dependence:

Fishbein states that

‘’while one may question the values that some place on certain outcomes or the accuracy of some of their beliefs, a decision to smoke is actually quite reasonable if the decision maker believes that the net effects of smoking are more positive than the net effects of not smoking” (fishbein, 1979).

This statement is in line with the theory of reasoned action which was proposed by Azjen in 1988 suggesting that individuals consider the implications of their actions before they decide to engage in certain behaviours or not (Ajzen & Fishbein, 1980), clearly suggesting that knowing that smoking kills might not be enough to deter an individual to stop smoking. Balancing the positive effects of smoking with negative effects, and eventually favouring the positive effects can lead to continued smoking. Some of these perceived positive effects will be discussed below.

Smoking as a pleasurable activity: nicotine as mentioned above has the ability to combine with a number of neurotransmitters in the brain and may contribute to the following reinforcing effects: Dopamine which is responsible for Pleasure, suppress appetite, Norepinephrin which is responsible for arousal, Acetylcholine for arousal and cognitive enhancement, serotonin for mood modulation, appetite suppressant, Beta-endorphin to reduce anxiety. In smaller doses smoking heightens feelings of excitement and thus relieves fatigue and depression. In larger doses nicotine exerts a calming effect and reduces tension and stress. Much of its positive effects as an anxiety reducer, or a mood enhancer or relaxant has been argued to be contained in nicotine’s fast ability to counter the symptoms of nicotine withdrawal. Symptoms of withdrawal when repetitively relieved by a nicotine fix, the individual tends to attribute these good effects to the act of tobacco smoking.

Stress relief and tension reduction: In addition to pleasure, the somatic sensations created by smoking produce a feeling of relaxation. This seems to indicate that smoking fulfils some need in persons who are in need of stress-relief, for whatever reason. It has been noted that smoking is more prevalent in persons under stress: it is more frequently a habit among more arousable and more anxious persons than it is among more tranquil people, and those whose careers entail more pressure are more frequently smokers. It is a relief from the body’s response to stress, which the smoker is seeking in his/her cigarette. This psychological need for stress-relief in a smoker may be one element to explain why beginning smokers persevere with the habit, given that it is initially not a pleasurable experience for them, and force themselves to overcome the initial feelings of disgust. Beginning smokers are aware that smoking can provide a relief from the stress in their lives and will pursue that stress-relief ignoring the now ubiquitous health warnings: they perceive their need for relief to be the greater need, thus outweighing the possible health hazards or at least putting such warnings to the back of their minds.

Weight suppressant: as earlier mentioned, active components of tobacco can act as appetite suppressants and thereby reducing food intake, ultimately leading to weight suppression. On stopping smoking, this effect wears off and along with better taste appreciation, there is increased appetite, more eating and eventually weight gain. Weight gain has been a recurring theme in past studies on smoking cessation.

Habitual: this is when smoking becomes a habit and is linked to other activities for example people who have a need to smoke when drinking. A repetitive and predetermined sequence of events is hard to break. The intimate coupling of behavioural rituals and sensory aspects of smoking with nicotine uptake gives ample opportunities for secondary conditioning. For a smoker who smokes about 20 sticks a day, “puff by puff” delivery of nicotine to the brain is linked to the sight of the packet, the smell of the smoke, and the scratch in the throat some 70 000 times each year. Similarly, if smoking is linked to a particular feeling or emotion, a recurrence of that emotion can serve as a trigger to smoke.

Socio-cultural influence

Certain social and cultural factors can influence smoking habits. The focus theory of

norms predicts that making a norm more prominent will increase its influence on

behaviour as long as the norm remains prominent (Cialdini et al., 1991).

The effect of social influence on healthy behaviour and attitude is explained more explicitly by the Fishbein’s Theory of Reasoned Action (Fishbein and Ajzen, 1975) which proposed that the attitude toward a behaviour and the subjective norm for that behaviour combine to predict behavioural intention. Behavioural intention in turn is predictive of actual behaviour (Sheppard, Hartwick & Warshaw, 1988). This theory and a later refinement of it termed the Theory of Planned Behavior (Ajzen, 1991) have been tested across a wide variety of contexts.

These theories put forward an important role for what they termed the subjective norm in determining behavioral intentions. The subjective norm consists of the individual’s beliefs about whether persons who play important roles in the life of the individual would want him or her to engage in the behavior in question as well as the individual’s motivation to comply with these people. As such, a subjective norm can be said to be a form of an injunctive norm (Rimal and Real, 2003) that is, a code of behavior that brings with it implied social rewards and repercussions.

These models tend to account for social reasons for smoking such as the influence of

family, friends, colleagues, culture, geographic location, profession, gender, etc. an

example would be that an individual is more likely to smoke if close family members,

peer groups, and/or colleagues at work smoke uninhibitedly. Similarly that individual

will find it harder to attain smoking cessation when his immediate sphere of contact

do not regard that as something worth doing.

Other barriers to quitting.

Barriers to seeking help for nicotine dependence.

Roddy et al’s study on barriers to gaining access to smoking cessation services amongst deprived smokers concluded that these smokers generally had a low awareness of the services available to help them, and despite this, had misconceptions about their availability and effectiveness. Other findings from this study showed that these smokers did not seek treatment for fear of being judged or stigmatized and a fear of failure at quitting(Roddy et al., 2006).

Appreciation of health hazard

A study on socio-economic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke from the 2002 International Tobacco Control four country survey revealed that lower economic status was associated with a lower awareness and misunderstanding surrounding the hazards or effects of smoking.

Another possible barrier to quitting smoking in spite of an awareness of the health risks to smoking, these health risks of smoking may not immediate and as such might not be seen as relevant to the individual at smoking initiation and progression to a smoking habit. Jamieson and Romer found that there was no evidence to show that the perception of risks of smoking amongst adolescents aged 14 – 22 had no effect on smoking initiation and progression to a smoking habit. According to them, young people do not take into account the health risks of smoking before smoking initiation, but as the addiction kicks in, the smoker becomes aware that he or she is addicted and eventually leads to a consideration of the health risks. In contrast, adults see these health risks as a more immediate threat possibly because of age and tend to appreciate these risks better than adolescents. This perception of risk is a major influence on the decision to quit smoking as the smoker will consider quitting if the perceived risk is higher than the positive effects of smoking.

Finally, the addictive properties of tobacco can be underestimated with smokers thinking quitting tobacco is something they can decide to do at anytime, leading to a further indulgence in the habit.

With increasing health warnings, smoking trends have significantly reduced. Great Britain in 2005 had about 24 per cent of adult 16yrs and over smoking. This is in contrast to 45 per cent in the 1970’s (survey, 2005). Still an alarming number of people smoke and if current smoking patterns continue, there will be more than one billion deaths attributable to tobacco smoking in the 21st Century compared with 100 million deaths in the 20th Century (Vineis, 2008)

There have been many documented reasons why the incidence and prevalence

rates are still high. Some of these reasons include that smoking patterns in some

particular classes have increased for example women, teenagers, and the younger

adult population (UK, 2010). Others have argued the effectiveness

of smoking cessation initiatives and policies that have been put in place, and the relapse rate of quitters has also been questioned.

What seems to be increasingly obvious now is that mere knowledge of the health implication of smoking is not enough to reduce the incidence and prevalence of tobacco smoking. The author with this study, attempted to find out what issues prevent a smoker from quitting despite knowing the health implications of smoking.

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