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2nd National Health Promotion Conference 2011 Wee Lei Hum, PhD

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1 The Importance of Supportive Environment in Facilitating Cessation – Findings from Studies
2nd National Health Promotion Conference 2011 Wee Lei Hum, PhD Institute for Health Behavioural Research, Ministry of Health Malaysia Cititel Mid Valley 10 – 11 October, 2011

2 Outline Development of Supportive Environment in HP
Understanding Smoking Cessation Smoking in Malaysia Findings from Current Studies Reviews from Other Studies Discussion & Conclusion 4/1/2017 2

3 Development of Supportive Environment in Health Promotion
Commitment of WHO to the goals of Health for All in 1977 WHO/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.

4 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 responses Providing health services not only in times of needs Implement national policies through settings approach to facilitate inter sectoral action

5 Introduction Smoking 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).

6 Introduction ..2 Malaysia 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).

7 Understanding Smoking Cessation
Dynamic 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).

8 Postulations of Theories
Choice 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).


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

11 Availability of Quit Clinics
70.6% attempted to quit 2 quit attempts in a year Only 38% aware of quit clinics Awareness was higher among: rural more educated professionals younger

12 Recent Published Smoking Cessation Research in Malaysia
2 studies Study design: Retrospective and Prospective Setting: 5 quit smoking clinics in FT

13 Study 1 Retrospective 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.

14 Study 2 Face to face interview at 1st visit, 4-week and 3-month
Prospective 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

15 Objectives Identify characteristics of smokers
Explore psychological process Identify difficulties experienced by smokers Improve clinic intervention strategies Identify predictors of successful quitting


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

18 Reasons to Quit Health concern Cost of cigarettes
Pressure from friends/family Doctor’s advice

19 Triggerred by the Clinic
Clinic - 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/nurse experiencing symptoms due to smoking viewing a poster in the clinic suddenly realising how bad smoking is cost of smoking.

20 Conflicting Thoughts Intention 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).

21 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 smoke doing nothing in particular What situation were they in? experience of strong urges being in stressful situations.

22 Final Model for Predictors of Successful Quitting
Independent predictors after adjustment for confounding 4 Weeks Predictors OR (95%CI) PreCO2 0.88 ( ) Age 1.07 ( ) Method of quitting Abrupt 4.10 ( ) Gradual 1 Cost of cigarettes Yes 2.68 ( ) No

23 3 Months Predictors OR (95%CI) Clinics Tanglin Community Clinic 1
Tanglin Community Clinic 1 Putrajaya Hospital 0.11 ( ) Jinjang Health Clinic 0.41 ( ) Pantai Health Clinic 0.16 ( ) Kampung Pandan Health Clinic 0.07 ( ) Marital Status Single/Divorced/Widowed Married 2.69 ( ) What led you to come to the clinic (Planning) -Had been thinking to quit smoking -Had not been thinking to quit smoking 2.58 ( ) Feeling about smoking -Do not really mind being a smoker -Very unhappy to think of myself as a smoker 2.30 ( ) Motivation level to stop smoking completely -Extremely strong -Very strong 0.24 ( ) -Quite strong/ Not very strong 0.11 ( ) Smoking helps me to stay alert -Yes 0.32 ( ) -No Amount of tobacco smoked compared with other smokers -I smoked about the same as most other smokers -I smoke more than most other smokers 5.85 ( ) -I smoked less than other smokers 2.43 ( ) -I do not know 2.18 ( )

24 24 24


26 Decision to Stop Smoking is Made at Home
Most 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).

27 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).

28 Working Conditions Smoking 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 hours shift work high physical workload frequently exposed to role conflicts at work

29 Triggers from the Environment
Smokers 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).

30 Doctor’s Brief Advice Cost-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).

31 Treatment Quitting 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).

32 Support from the Clinic
Smokers 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)

33 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.

34 Act Now We 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).

35 Limitation Urban setting ~ sample composition similar to census characteristic in NHMS3 Missing data in retrospective study Involve more than one clinic, practice and experiences varied ~ guided by the standard clinical practice guidelines.

36 ISI Journals 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), doi: /j.addbeh 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 /jsc 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), doi: /ntr/ntq221 “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

37 Books & Newspaper Articles
‘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

38 References Aveyard, P., & West, R. (2007). Managing smoking cessation. British Medical Journal, 335, Bliss, R. E., Garvey, A. J., & Heinold, J. W. (1989). The influence of situation and coping on relapse crisis outcome after smoking cessation. Journal of Consulting and Clinical Psychology, 57(3), Clearing House Tobacco Control. (2005). Tobacco control in Malaysia: a long winding road. Poison Centre, Universiti Sains Malaysia. Coleman, T. (2004). Use of simple advice and behavioural support. British Medical Journal, 328, Edwards, R., McElduff, P., Jenner, D., Heller, R. F., & Langley, J. (2007). Smoking, smoking cessation, and use of smoking cessation aids and support services in South Derbyshire, England. Journal of the Royal Institute of Public Health, 121, Farkas, A. J., Gilpin, E. A., Distefan, J. M., & Pierce, J. P. (1999). The effects of household and workplace smoking restrictions on quitting behaviours. Tobacco Control, 8, Fisher, E. B., Bishop, D. B., Gilmour, L. T., Capello, M. T., Ashenberg, Z. S., & Newman, E. (1994). Social support in worksite smoking cessation: qualitative analysis of the EASE project. American Journal of Health Promotion, 9, Frank, R. G., Umlauf, R. L., Wonderlich, S. A., & Askakonzi, G. S. (1986). Hypnosis and behavioral treatment in a worksite smoking cessation program. Addictive Behaviours, 11, Honda, K. (2005). Psychological correlates of smoking cessation among elderly ever-smokers in the United States. Addictive Behaviours, 30, Hughes, J. R., Keely, J. P., Fagerstrom, K. O., & Callas, P. W. (2005). Intentions to quit smoking change over short periods of time. Addictive Behaviours, 30, Hurt, R. D., Wolter, T. D., & Rigotti, N. (2002). Bupropion for pharmacologic relapse prevention to smoking: predictors of outcome. Addictive Behaviours, 27, Janzon, E., Engstrom, G., Lindstorm, M., Berglund, G., Hedblad, B., & Janzon, L. (2005). Who are the 'quitters'? a cross-sectional study of circumstances associated with women giving up smoking. Scandinavian Journal of Public Health, 33, Joseph, L. F., Velicer, W. F., & Prochaska, J. O. (1995). Applying the Transtheoretical model to a representative sample of smokers. Addictive Behaviours, 20(2),

39 References Lancaster, T., Hajek, P., Stead, L., West, R., & Jarvis, M. (2006). Prevention of relapse after quitting smoking - a systematic review of trials. Archives of Internal Medicine, 166, Larabie, L. C. (2005). To what extent do smokers plan quit attempts? Tobacco Control, 14(6), Lee, C., & Kahende, J. (2007). Factors associated with successful smoking cessation in the United States. American Journal of Public Health, 97(8), Marcus, S. E., Pahl, K., Ning, Y., & Brook, J. S. (2007). Pathways to smoking cessation among African American and Puerto Rican young adults. American Journal of Public Health, 97, Marlatt, G. A., Curry, S. J., & Gordon, J. R. (1988). A longitudinal analysis of unaided smoking cessation. Journal of Consulting and Clinical Psychology, 56, Mook, D. G. (1996). Motivation: the organization of action. New York: Norton. Pisinger, C., Vestbo, J., Borch-Johnsen, K., & Jorgensen, T. (2005b). It is possible to help smokers in early motivational stages to quit: the Inter99 study. Preventive Medicine, 40, Prochazka, A. V. (2000). New developments in smoking cessation. Chest, 117, 169S-175S. Raw, M., McNeill, A., & West, R. (1999). Smoking cessation: evidence-based recommendations for the health-care system. British Medical Journal, 318, Shields, M. (2005). The journey to quitting smoking. Health Reports, 16(19-36). Silagy, C., Lancaster, T., Stead, L., Mant, D., & Fowler, G. (2006). Nicotine replacement therapy for smoking cessation. Cochrane Library, 3. Skog, O. J. (2000). Addict's choice. Addiction, 95, Stevens, P. A., Greene, J. G., & Primavera, L. H. (1982). Predicting successful smoking cessation. Journal of Social Psychology, 118(2), Thyrian, J. R., Panagiotakos, D. B., Polychronopoulos, E., West, R., Zatonski, W., & John, U. (2008). The relationship between smokers' motivation to quit and intensity of tobacco control at the population level: a comparison of five European countries. Public Health, 8(2), 1-6. West, R. (2000). Behavioural support programmes for smoking cessation: needs and opportunities. European Journal of Public Health, 10, West, R. (2004a). ABC of smoking cessation: assessment of dependence and motivation to stop smoking. British Medical Journal, 328, West, R. (2006b). Theory of addiction: Blackwell Publishing, UK. West, R. (2009). The multiple facets of cigarette addiction and what they mean for encouraging and helping smokers to stop. Journal of Chronic Obstructive Pulmonary Disease, 6(4), World Health Organisation. (2002). Smoking fact sheet: smoking statistics. Retrieved from




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