Patterns and predictors of smoking cessation among smokers attending smoking cessation clinics in Peninsular Malaysia

Abstract

Introduction: This study seeks to identify the socio-demographic and behavioral characteristics of smokers (aged 18 and above), thus develop a predicting model for tobacco abstinence receiving cessation services for tobacco dependence at the Smoking Cessation Clinics (SCC) in government Primary Health Centers in Malaysia. These predictors would improve the effectiveness and efficiency of these clinics. Methods : Smokers who sought smoking cessation therapy at the SCCs from 1 st January 2004 to 31 st December 2004 were chosen randomly from clinic's registries, and 254 smokers were recruited from 8 clinics chosen through stratified random sampling. Data analyses were performed with SPSS 12.0. 17.3% of smokers attending SCCs were able to quit smoking for at least six months. Results : Factors significantly contributing to quitting success were elderly smokers (above 40 years old), smoked for more than 15 years, smoked less than ten sticks per day, had a previous history of quitting attempt, self referral to the clinic, high confidence level, attended SCC at least four times, each counseling session lasted for at least 30 minutes and were satisfied with the clinic service. In logistic regression model, smokers aged 40 years and above were 6.7 times more successful to quit, high level of confidence were nine times more successful, smoked more than ten sticks per day were ten times less successful, self referred smokers were ten times more successful and attending for at least 30 minutes counseling session were 12 times more successful. Conclusion : This study concludes that more concerted effort is needed to approach various groups of target population and SCCs clinic services need to be improved.

Full text

Journal of Community Health 2008: Volume 14 Number 1
17
ORIGINAL ARTICLE
PATTERNS AND PREDICTORS OF SMOKING CESSATION AMONG SMOKERS ATTENDING
SMOKING CESSATION CLINICS IN PENINSULAR MALAYSIA
W.P Sh. Ezat 1, A.A Selahuddeen 2, S.M Aljunid 1, Z Zarihah 2
1 Department of Community Health, UKMMC, 2 Ministry of Health Malaysia
ABSTRACT
Introduction: This study seeks to identify the socio-demographic and behavioral characteristics of
smokers (aged 18 and above), thus develop a predicting model for tobacco abstinence
receiving cessation services for tobacco dependence at the Smoking Cessation Clinics
(SCC) in government Primary Health Centers in Malaysia. These predictors would improve
the effectiveness and efficiency of these clinics.
Methods : Smokers who sought smoking cessation therapy at the SCCs from 1st January 2004 to 31st
December 2004 were chosen randomly from clinic’s registries, and 254 smokers were
recruited from 8 clinics chosen through stratified random sampling. Data analyses were
performed with SPSS 12.0. 17.3% of smokers attending SCCs were able to quit smoking
for at least six months.
Results : Factors significantly contributing to quitting success were elderly smokers (above 40 years
old), smoked for more than 15 years, smoked less than ten sticks per day, had a previous
history of quitting attempt, self referral to the clinic, high confidence level, attended SCC at
least four times, each counseling session lasted for at least 30 minutes and were satisfied
with the clinic service. In logistic regression model, smokers aged 40 years and above were
6.7 times more successful to quit, high level of confidence were nine times more successful,
smoked more than ten sticks per day were ten times less successful, self referred smokers
were ten times more successful and attending for at least 30 minutes counseling session
were 12 times more successful.
Conclusion : This study concludes that more concerted effort is needed to approach various groups of
target population and SCCs clinic services need to be improved.
Keywords : Smoking cessation, Smokers, Smoking Cessation Clinics.
Correspondence to: Sharifa Ezat Wan Puteh, Community
Health Department, UKM, Medical Centre.
Tel: 03-91455901, Fax: 03-91737825
(e-mail:sh_ezat@yahoo.com)

Journal of Community Health 2008: Volume 14 Number 1
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INTRODUCTION
The problems of tobacco consumption have been
devastating. If effective and efficient strategies
are not implemented towards curtailing these
problems, they would further lead to escalating
public health disasters. Smoking cessation has
significant health benefits but effective strategies
are lacking cessation support 1. Among the
services to support cessation, Smoking Cessation
Clinics were reported to be effective 2, 3. Support
and treatment to help smokers stop is one of a
range of approaches to tobacco control. Tobacco
consumption is a chronic condition that for the
majority of smokers requires repeated and
persistent effort to overcome this condition.
Theoretical analysis of smoking cessation
suggests that it is a process, not a single event 4.
Stage of change theory suggests that smokers
move from being content to smoke, thinking
about quitting, planning to quit, attempting to
quit, maintaining cessation or relapsing to
smoking. Smokers may cycle through some or
all of the stages many times before they achieve
long-term cessation. Therefore quitting remains a
daunting task for smokers.
Guidelines have been issued for health care
providers to actively encourage patients to stop
consuming tobacco 5, 6. There are almost five
million smokers in Malaysia and most would
want to quit if help is rendered to them. Studies
have shown that almost 40% of smokers want to
stop smoking at one time or another and many
have tried to do so but have difficulty succeeding
because of its powerful addiction 7, 8, 9. Clinics
and predictors of smoking cessation among
clinic attendants in Malaysia are lacking. More
information on this would help in improving the
effectiveness and efficiency of the Smoking
Cessation Clinic (SCC). This paper describes
the characteristics of the smokers who used the
SCC. The purpose of this study was to identify
the socio-demographic and behavioral
characteristics of smokers and to develop a
model to predict tobacco abstinence among
smokers receiving cessation services for tobacco
dependence at the Smoking Cessation Clinics in
government Primary Health Centers in
Peninsular Malaysia.
METHODOLOGY
This was a descriptive study, involving smokers
aged 18 years and above who sought smoking
cessation therapy at the SCCs in government
primary health centers from 1st January to 31st
December 2004. Smokers were recruited from
eight clinics throughout Peninsular Malaysia.
The states in Peninsular Malaysia were stratified
into four zones and one state was randomly
selected from each zone. The states were Kedah
(northern zone), Perak (central zone), Johor
(southern zone) and Kelantan (eastern zone).
Each zone would contribute randomly two
clinics and each clinic contributes 35 smokers
from the Smoking Cessation Clinic registry.
There were a total of 280 smokers selected from
the eight clinics in these states but the minimum
sample size was 252.
Face to face interview was attempted for all
smokers recruited, failing which the smokers
were interviewed by telephone. The interview
was either conducted in the clinic or at home.
Standardized questionnaires were used to gather
the information. Inclusion criteria were smokers
from clinics having at least 40 patients
throughout year 2004, smokers with minimal
information available in the clinic registry,
smokers agreeable to be interviewed and for
verification test. Smokers from outside the study
area and smokers with acute psychiatric illness
or active drug addiction were excluded from the
study. Smokers reported as quitters had a breath
CO level analyzed.
Smokers were defined as those having smoked
more than 100 sticks of cigarette in their lifetime.
The dependent variable was status of the smoker,
either able to quit or unable to quit after
attending the SCC. Able to quit is defined as
having stopped smoking and sustained
abstinence at least more than six months after the
quit date. The independent variables were; sex,
age, referral source, marital status, education
level, occupation, presence of household
smokers, history of parents smoking, reason for
attending SCC, age at which smoking began,
level of nicotine dependence 9 (Fagerstrom Test),
number of cigarettes per day, number of years of
smoking, presence of concomitant illness,
previous attempts to quit smoking, reasons for
difficulty in quitting, confidence of quitting,
religious perspective on smoking and satisfaction
on SCC services.
RESULTS
The response rate for this study was 92%. There
were 26 smokers who were not contactable via
the address or the telephone number provided. A
sample comprised of 254 smokers interviewed
was analyzed. 201 smokers (80%) were
interviewed in person and the others were

Journal of Community Health 2008: Volume 14 Number 1
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interviewed by telephone. Of the 254 smokers,
98% (n=251) were male and 2% (n=3) female,
with a mean age of 43.9 (SD of 12.1) years old.
In terms of education level, 36.6% (n=93) had
primary or no formal education and 63.4%
(n=161) had completed secondary or university
studies. The occupational class of the smokers
in the study were, 24% (n=61) were manual
workers, 23.6% (n=60) were non manual
workers, 24% (n=61) were self employed and the
rest were from other occupational classes. The
study revealed 71% (n=180) of smokers were
earning RM 1,500 and below a month. 87.8%
(n=223) of the smokers reported that their father
were smokers and 13.4% (n=34) had household
who are smokers. With regards to age of starting
smoking, the mean age were 17 years old (SD of
2.5). The mean score on the Fagerstrom test
was 5.8 (SD of 1.5) points. The reasons for the
smokers to attend the clinic 18.5% (n=47) were
self referral, 41.3% (n=105) were referred for
chronic illnesses, 34% (n=87) referred following
screening in the outpatient and 6% (n=15)
following no smoking campaigns. With regards
to the Islamic religion’s perspective on smoking,
89% (n=193) stated smoking as ‘makruh’, 7%
(n=15) stated as ‘haram’ and 4% (n=9) did not
know. Table 1 shows the result of the other
variables studied.
Table 1 Association between Smokers Characteristics with Smoking Status
Characteristic
features Frequency
Smokers Frequency
Quitters % of Quitters Statistical
Test
Smokers’ Age (years old)
Less than 40 87 7 7.4%
40 and above 113 37 17.3%
Chi square test
X2=10.16
p=0.001
Duration of Smoking
15 years and < 35 2 5.4%
> than 15 years 175 42 19.4%
Chi square test
X2=4.295
p=0.038
Number of Cigarette/day
10 sticks and less 8 6 42.9%
> than 10 sticks 202 38 15.8%
Fischer exact
test
p = 0.02
History of Previous Quit
Attempt
Yes 128 34 21%
No 82 10 10.9%
Chi square test
X2=4.194
p=0.041
Using Nicotine Replacement
Therapy (NRT)
Used 119 25 17.4%
Did not use 101 19 17.3%
Chi square test
X2=0.000
p=0.985
Number of clinic sessions
Less than 4 146 4 2.7%
4 and more 64 40 38.5%
Chi square test
X2=54.95
p=0.0001
Confidence Level
Having Confidence 115 41 26.3%
No Confidence 95 3 3.1%
Chi square test
X2=22.660
p=0.001
Satisfaction with clinic
services
Satisfied 182 44 19.5%
Not satisfied 28 0 0%
Fischer exact
test p=0.01
TOTAL 210 44 17.3%

Journal of Community Health 2008: Volume 14 Number 1
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Of the patients included in the study, 17.3%
(n=44) were abstinence for more than six months.
The rest were unable to quit smoking. Of the
smokers who were unable to quit, 50% (n=105)
cited withdrawal symptoms, 18% (n=38) on
socializing, 12.4% (n=24) on craving, 12.4%
(n=24) on work stress and the others on various
other reasons for them not able to quit smoking.
The significant variables influencing the
smokers to quit were smokers age 40 years old
and above, smoked for more than 15 years,
smoked more than ten sticks per day, had a
previous history of quitting attempt, self referral
to the clinic, high confidence level, attended
QSC at least four times, each counseling session
lasted for at least 30 minutes and were satisfied
with the clinic service (Table 1).
These variables were entered into the logistic
regression model, five variables were found to be
significant. The model revealed that smokers
aged 40 years and above were 6.7 times more
successful, smokers with high level of
confidence were nine times more successful,
smokers who smoked more than ten sticks per
day were ten times less successful, smokers who
self referred to the clinic were ten times more
successful and smokers attending at least 30
minutes counseling session were 12 times more
successful. Table 2 and 3 shows the logistic
regression modeling used for predicting the
status of smokers attending the Smoking
Cessation Clinic.
Table 2: Coding of variables used in Logistic Regression Modelling
VARIABLES CODE FREQUENCY
Occupation 0 Manual
1 Non Manual
81
173
Duration of smoking 0 15 years and less
1 more than 15 years
37
217
Confidence level 0 not confident
1 confident
98
156
Previous quitting attempts 0 no
1 yes
92
162
Using NRT 0 no
1 yes
144
110
Satisfaction 0 not satisfied
1 satisfied
28
226
Age 0 less than 40 years old
1 40 years old and above
94
160
Cigarette stick per day 0 10 and less
1 more than 10
92
162
Referral 0 other methods
1 self referral
207
47
Duration of each counselling
session
0 30 minutes and less
1 more than 30 minutes
241
13
Smoking status
(Dependent Variable)
0 still smoking
1 able to quit
210
44

Journal of Community Health 2008: Volume 14 Number 1
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Table 3: Logistic Regression Model to Predict the Status of Smokers Attending SCC
Variables Coefficient
Regression ß
p Odds Ratio Confidence Interval 95%
Occupation 0.350 0.479 1.419 0.538 3.743
Age 1.901 0.004٭6.696 1.866 24.028
Confidence level 2.185 0.002٭8.888 2.219 35.595
Previous quitting
attempts
0.001 0.998 1.001
0.336 2.987
Using NRT -0.832 0.068 0.435 0.178 1.062
Duration of smoking 0.892 0.396 2.439 0.311 19.146
Cigarette stick per
day
-2.239 0.009٭0.107 0.020 0.571
Referral 2.309 0.0001٭10.068 3.640 27.846
Duration of each
counselling session
2.452 0.011٭11.606 1.741 77.387
Satisfaction 21.292 0.997 17660 00.00
Constant -3.098 0.003 0.045
٭ Significant level of p<0.05
DISCUSSION
The smoking cessation rate in this study was
17.3%. This rate is lower than most of the
studies conducted in the SCCs in developed
countries 5, 10, 11 . Their studies quoted a quit rate
of 25% - 35% but methods used to measure
abstinence vary from study to study. Several
authors have evaluated the potential disparity
between self reported results and those obtained
using objective measures of the CO level 12 . The
results however, differ according to the study
population. For smokers who have undergone
smoking cessation treatment the difference was
small 13. In our study, the criteria used to
determine success was self reporting, but CO
level of less or equal to 6 ppm using a breath
analyzer was used to verify the smokers’ status.
When we compared the self reported quit rate to
the quit rate verified by CO analyzer, the rates
changed from 17.3% to 15.3% but the findings
using self reporting and validation did not differ
significantly. A meta-analysis of the validity of
self-reporting recommends the use of
biochemical validation in interventional studies
12. However, self reporting has been described
as a useful tool that is less expensive and more
accessible than biochemical validation.
The characteristic features of smokers
attending the SCCs in the primary health care
facilities were studied. The features positively
associated with smokers quitting smoking were
age 40 years and above, having smoked for more
than 15 years, having smoked more than ten
cigarettes per day, having previous attempts to
stop smoking, confidence on ability to stop,
having attended the clinic for at least four times,
undergoing at least 30 minutes of counselling in
each session and satisfied with the services in the
QSC. There were a few factors which were not
shown to be significantly associated with
quitting although other studies have shown a
positive association. The usage of NRT has been
proven to be effective in treating tobacco
dependence 3. This was not shown in our study.
This could be due to the selection problem, as
five of the clinics in our study did not prescribe
NRT and neither was it bought by the smokers.
A better design to check this would be to
compare smokers from clinics using NRT and
smokers from clinics not using NRT.

Journal of Community Health 2008: Volume 14 Number 1
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Our study showed that smokers aged 40 years
and above were six to seven times more likely to
stop smoking. This was consistent with the
report 10 that 74% of smokers attending the SCCs
in England were aged 35 years and above. The
rate of quitters increased significantly as the age
increase with 61% of smokers quitting at age 60
years and above. The other factor seen in our
study was the mean age of smokers attending the
SCCs were aged 44 years old. There were not
many smokers in the 20 – 30 years old age group.
More concerted effort is required to attract this
age group. Involvement and assistance of non
governmental organizations and the community
at large is required to attract this group.
Our finding that smokers with 15 years
of smoking history was significantly associated
with quitting is consistent with some studies
where the duration of smoking were associated
with abstinence 14 although other reports did not
showed similar association 11. However, this
association was not predictive of quitting. The
number of cigarettes smoked per day was
showed to be significantly associated with
quitting. This was the only features of nicotine
dependence which were significant. Smokers
who smoked more than ten sticks per day were
ten times less successful to quit. The study
showed that majority of smokers attending SCCs
in Malaysia were heavy smokers and they were
unsuccessful in quitting. The effectiveness of
the program needs to be looked into especially
providing NRT to this group of smokers.
Those with previous history of quitting
attempt seems to have better outcome than those
who had no previous quitting attempt. However,
it was found to be not predictive of quitting
although the difference was significant. This was
inconsistent with result obtained in research
based samples where previous quitting attempt
was associated with predictive quitting outcome
15. Those who had previous quitting attempt
might have gain confidence on their ability to
quit the next time. This was seen in this study
which showed that those with confidence on
their success on quitting were nine times more
successful than those with no confidence. It
might be likely that multiple attempts to quit
smoking improves the confidence level in the
smokers.
Our results showed that those smokers
who self referred to the SCCs were more
successful in quitting than those who were
referred for other causes. This might be due to
the difference of motivation and confidence in
these two groups. Those who were screened in
the outpatient and referred to the SCC were not
ready to quit. It was found that smokers who
self referred to the clinic were ten times more
successful to quit than those who were referred
for some other reasons16, 17 . The reason for the
referral was not important but the readiness of
the smokers to quit which would be more
predictive of quitting. Therefore, it is important
to motivate smokers to quit and when they are
ready, to refer them to the SCC.
Our study showed that it is pertinent for
smokers to attend the SCC at least four times and
for 30 minutes each session. This would enable
them to be adequately counseled and prepare
them with all the required skills to help them quit.
Our result showed that those who attended the 30
minutes counseling were twelve times more
successful to quit. Other studies have shown that
the duration of counseling session would
influence the outcome in a smoker 3.
CONCLUSION
The study revealed the characteristic features of
the smokers attending the SCCs in the primary
health care facilities. The variables positively
associated with smokers quitting smoking were
age 40 years and above, having smoked for more
than 15 years, having smoked more than ten
cigarettes per day, having previous attempts to
stop smoking, confidence on ability to stop,
having attended the clinic for at least four times,
undergoing at least 30 minutes of counseling in
each session and satisfied with the services in the
SCC. There were a few factors which were not
shown to be significantly associated with
quitting. These factors were shown to be
positively associated in other studies. With
verification of smoking status, a difference of
2.0% in the quit rate was obtained which was in
accordance to other studies. This study
concludes that more concerted effort is needed to
approach various groups of target population pro
actively rather than awaiting passively for
smokers to attend the clinic. The characteristic
features demonstrated positively to predict
quitting outcome should be used to improve the
services in the clinic.

Journal of Community Health 2008: Volume 14 Number 1
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