PREDICTORS OF QUITTING SMOKING AMONG THE ROYAL THAI NAVY PERSONNEL

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1 Short Report 345 PREDICTORS OF QUITTING SMOKING AMONG THE ROYAL THAI NAVY PERSONNEL Sineenuch Siriwong, Jintana Yunibhand *, Sunida Preechawong Faculty of Nursing, Chulalongkorn University, Bangkok 10330, Thailand ABSTRACT: The purpose of this cross-sectional study was to identify the predictors of quitting smoking among the Royal Thai Navy (RTN) personnel by using a self-report questionnaire based on the Transtheoretical model. A multistage random sampling was used in four divisions of the RTN organization. Two RTN units were randomly selected from each division by a simple lottery method without replacement and 553 RTN personnel were selected by the convenience sampling technique. Data were analyzed and using descriptive statistics to evaluate the sample characteristics and logistic regression analysis was used to calculate the odds ratios with a 95% confidence interval of abstinence rates for each variable, with a statistical level at α = The results indicated that there were six significant predictors of quitting smoking among the RTN personnel. These were length of quit attempt (OR = 1.05, 95% CI = ), family support (OR = 1.51, 95% CI = ), consciousness raising (OR = 1.17, 95% CI = ), social liberation (OR = 0.81, 95% CI = ), self-reevaluation (OR = 0.84, 95% CI = ) and counter conditioning (OR = 1.15, 95% CI = ). Based on the results from this study, it is part of conclusion that RTN policy makers should provide support in forming the quitting smoking groups that would act as a solid connection between the smokers in the RTN and their families. The self-confidence and commitment of those personnel for quitting their smoking must be promoted along with a favorable environment that facilitates the smoking cessation. Keywords: smoking, predictors, navy, Thailand INTRODUCTION The health benefits of quitting smoking can be detected as early as 20 minutes after quitting smoking [1]. Quitting smoking can dramatically reduce the risk of coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), and other chronic diseases which are the leading causes of 1.2 million cigarette smoking- attributable deaths annually worldwide. Despite these health hazards, more than 1.2 billion people in the worldwide are still daily smokers [2]. Several studies have found that smoking prevalence in the military is higher than in the general population. There is evidence that more than 99% of the people that smoke before joining the military service continue to smoke after their tenure [3, 4]. As reported by the Royal Thai Navy (RTN) personnel, the rates of smoking have significantly fluctuated over time and decreasing from 28.5% in 2002 to 13.37% in 2006 while increasing to 15.77% in 2007 [5]. Military leaders realize that smoking affects military fitness levels and performance [6]. Specifically, smoking impairs athletic performance, increases physical injuries during training, and * Correspondence to: Jintana Yunibhand yuni_jintana@hotmail.com heightens basic military training failures, all of which result in illness [7]. In addition, the RTN spends a large amount of money annually to treat smoking- related illnesses. This cost was estimated at 13,265 baht per person per annum for chronic obstructive pulmonary disease and 17,746 baht per person yearly for coronary heart disease [8]. There have been two RTN distinguished projects used to encourage decreased tobacco consumption. The first was the Tobacco Consumption Control Policy in 2004 which encompassed various issues such as knowledge about smoking, awareness of self-help groups, quitting aid hotlines, etc. The second was the Say Good-Bye to Cigarettes project in collaboration with the Thai Health Promotion Foundation upon the occasion of His Royal Highness Majesty the King of Thailand s 80 th Birthday Anniversary in Despite these two projects, there is an indication that still a number of RTN smokers have been unsuccessful in their smoking cessation attempts. Through the transtheoretical model developed by Prochaska and DiClemente [9], smoking cessation has come to be understood with stages of change in five steps: precontemplation, contemplation, preparation, action and maintenance. Precontemplation refers to the period in which

2 346 Short Report smokers are not thinking about quitting their smoking. Contemplation encompasses the time when smokers are seriously thinking about quitting smoking within the next 6 months while preparation is similar to contemplation but the time is shortened to only within the next month interval. Action indicates the period (between 0 to 6 months) of actual smoking cessation. Maintenance is defined as the period 6 months after the action stage has started and continues indefinitely [10]. Based on these stages of change, the model further describes the relationships among these stages, the processes of change, decisional balance, and self-efficacy. By definition, processes of change provide important guidelines for intervention programs serving as independent variables that people need to apply or be engaged in to move from one stage to another. There are ten sub-processes: consciousness raising, dramatic relief, environmental reevaluation, social liberation, self-reevaluation, stimulus control, helping relationships, counter conditioning, reinforcement management and self-liberation [1, 11]. On the other hand, decisional balance reflects the smoker's relative weighing of the pros and cons of quitting smoking and self-efficacy is defined as the belief in smoker s ability to perform the behaviors necessary for quitting smoking outcome. Other demographic factors also play a crucial role in quitting smoking: age, gender, marital status [12, 13], health status, weight, body mass index (BMI), number of previous quit attempts, level of alcohol consumption [13, 14] and level of nicotine dependence [13, 15]. To date, the transtheoretical model (TTM) has been used in many quitting smoking interventions to maintain the longest period of quitting smoking. This research attempted to confirm existing studies that highlight the RTN personnel populations with quitting of smoking. However, based on the transtheoretical model cited, it is evident that little is known in regards to the predictors of quitting of smoking among RTN personnel. The present study thus aimed to identify the predictors of RTN s personnel smoking cessation attempts. Understanding these predictors may help learning each individual s ability to quit smoking and to maintain his/ her smoking cessation attempts. By targeting at an appropriate segmentation of RTN personnel with tailor-made smoking cessation intervention regimens, the goal of reducing the smoking rates among RTN personnel may be achieved. MATERIALS AND METHOD The study used a cross-sectional research design by using a multistage random sampling from four divisions of the RTN organization including the RTN head quarters, forces, logistics, and education. Two units of each division were randomly selected using a simple lottery method without replacement and participants were selected with the convenience sampling technique. The participants were 553 RTN personnel who were on active duty, both commissioned and non-commissioned officers, worked for the RTN, and had quitting smoking experiences for at least one time (24 hours consecutively) in the last year. Data collection The data collection began after the Human Research Board of the Royal Thai Navy Medical Department number RLM 014/54 had approved the study and the study period was from July 15 to September 15, A self-report questionnaire was used to identify predictors related to quitting smoking among participants which included a demographic sheet; the Alcohol Use Disorders Identification Test (AUDIT) [16] and the Fagerstrom Test for Nicotine Dependence (FTND) [17]. The AUDIT test measured alcohol consumption consisting of a 10-item measurment assessing alcohol problems across three major domains, hazardous use (8-15 scores), harmful use (16-19 scores) and alcohol dependence ( 20 scores). The FTND test measures nicotine dependence consisting of a 6-item measurement in adults across three levels, highly dependent (7-10 scores), moderate dependent (4-6 scores) and minimally dependent (< 4 scores). The processes of change questionnaire (PCQ), decisional balance questionnaire (DBQ) and selfefficacy questionnaire (SEQ) were accepted for permission and translation into Thai version from Prochaska. The process of change questionnaire (PCQ) assessed 10 processes consisting of 40 items on five point Likert scale of current frequency of use in the past month including consciousness raising, dramatic relief, environmental reevaluation, social liberation, self reevaluation, stimulus control, helping relationship, counter conditioning, reinforcement management and self liberation, the range was from 40 to 200 scores [18]. The decisional balance questionnaire (DBQ) assessed 10 pros of smoking (odd items) and 10 cons of smoking (even items) consisting of 20 items with a 5-point Likert scale from 1 Not Important to 5 Extremely Important, with ranging from 20 to 100 points [19]. A 20-item of self-efficacy questionnaire (SEQ) assessed self-efficacy to refrain from smoking in various situations [11]. J Health Res vol.26 no.6 December

3 Short Report 347 Participants were asked to indicate how confident they were that they could avoid smoking in each situation using a Likert scale that ranged from 1 (not at all tempted) to 5 (extremely tempted), ranging from 20 to 100 scores. Length of past quit attempt was addressed by the question How long (days) had the RTN personnel ever quit smoking in the past? which measured the number of days to quit attempt. Family support was measured by asking the perception of the RTN personnel on a degree of family members supported for quitting smoking by using 4 rating scales from 1( no support) to 4 (extremely support). The RTN smoking control policy was measured by asking for the perception of the RTN personnel on the RTN smoking control policies by using 5 rating scales from 1 (strongly disagree) to 5 (strongly agree). Quitting smoking was measured by the question Have you smoked a cigarette in the last 7 days? An answer of yes indicated that the participant has not quit smoking (smoker), and an answer no indicated that the participant has successfully quit smoking (ex-smoker). In this study, the content validity of each questionnaire was approved by six experts in quitting smoking area and one expert in instrument development area and the reliability of each questionnaire was tested to establish internal consistency for each questionnaire (Cronbach s α > 0.70), on 30 try out the RTN personnel who had the same characteristic of the sample. Data analysis Descriptive statistics were computed to summarize the participants demographic data, health status, smoking status, quitting smoking, and smoking cessation. The logistic regression analysis was conducted to calculate odds ratios with a 95% confidence interval of abstinence rates for each variable, with a statistical level at α = RESULTS In this study, initially 570 RTN personnel were enrolled, but 553 personnel completed the questionnaire (97.02% response rate). The data analysis resulted in demographic characteristics and predicting factors of quitting smoking from the logistic regression analysis. As shown in Table 1, the demographic characteristics were by frequency, percentage, maximum, minimum, mean, standard deviation. A large percentage of the RTN personnel were in the age group years (39.4%) and nearly half of them were married (49.2%). In addition, most of them did not have a disease (60.6%). More than half of them had exercised (55.7%), and nearly half had a normal body mass index (BMI = kg/m 2 ) (47.6%). The RTN personnel began smoking at the age 20 years and below was around 63.0%, and most of them began smoking before serving in the RTN (80.0%). More than half of them smoked 10 cigarettes and fewer a day (60.6%), and 51.5% smoked more than 10 years. Most of the RTN personnel were regular smokers who smoked cigarettes or other tobacco products at least once cigarette everyday (56.2%), while 43.8% were occasional smokers, who smoked cigarettes or other tobacco products less than every day. One third of them (33.3%) were hazardous drinkers assessed by AUDIT test, and nearly half of them (47.9%) were classified in moderate nicotine dependent level tested by FTND. Lastly, the stage of change for quitting smoking of the RTN personnel indicated that 41.0% of the RTN personnel were in pre-contemplation stage, 13.2% were at the contemplation stage, 19.3% were at the preparation stage, 24.1% were at the action stage and 2.4% were at the maintenance stage. As shown in Table 2, the results from logistic regression indicated that there are six significant predictors of quitting smoking among the RTN personnel. They were length of quit attempt (OR = 1.05, 95% CI = ), family support (OR = 1.51, 95% CI = ), consciousness raising (OR = 1.17, 95% CI = ), social liberation (OR = 0.81, 95% CI = ), selfreevaluation (OR = 0.84, 95% CI = ), and counter conditioning (OR = 1.15, 95% CI = ). Therefore, the best equation of logistic regression for explaining 56.5% of the variance in quitting smoking was: In [odds] = (family support) (length of quit attempt) (consciousness raising) 0.21 (social liberation) 0.17 (self-reevaluation) (counter conditioning). DISCUSSION The findings from this study show distinct predictors of quitting smoking among RTN personnel. It is important to note that the length of past quit attempt was a predicting factor of quitting smoking. Smokers that have experienced long periods of previous abstinence might be more successful because they can draw on their past success [20]. Consistent with projector research, smokers who made a quit attempt in the past year were more motivated to quit smoking. This factor served as a significant predictor for both 1-week abstinence and 6-month abstinence [21-23].

4 348 Short Report Table 1 Demographic of quitting smoking among RTN personnel (n =553) Demographic Number Percentage Age 24 years and under years years Status Single Married Widowed/ Divorced/Separated Health status No disease Have a disease Exercise Behavior No exercise Exercise BMI (kg/m2) Max = 55.49, Min = 14.36, Mean= 23.41, SD= Under and upper Aged at smoking initiation Max = 41, Min = 10, Mean=19.62, SD= years and under More than 20 years Number of cigarettes per day (cigarettes) Max = 40, Min = 1, Mean= 11.04, SD= Number of years smoking 10 years and below More than 10 years Type of smokers Regular smokers Occasional smokers Alcohol consumption level Low risk drinker Hazardous drinker Harmful use Alcohol dependence Nicotine dependent Level (n= 403) Low level Medium level High level Stage of change Pre-contemplation Contemplation Preparation Action Maintenance Consequently, longer duration of previous quit attempts were associated with successful smoking cessation [22-24]. Family support was a predicting factor of quitting smoking. Several epidemiological studies have revealed that high levels of social support had a positive role in the quitting of smoking [12, 25], especially in subjects whose partners participated in their attempt in cooperation participation or reinforcement [26]. Moreover, four significant sub-dimensions of processes of change factors were predictors of quitting smoking in this study. Consciousness raising was defined as the component that forced smokers to change their smoking behavior at each stage. This appeared to be an important predictor of quitting smoking. Schumann and colleagues [27] J Health Res vol.26 no.6 December

5 Short Report 349 Table 2 Predictor model of quitting smoking among RTN personnel (n =553) Variables β S.E. Wald AOR 95% CI p-value Length of quit attempt * Family support * Consciousness raising * Social liberation * Self-re-evaluation * Counter conditioning * Constant * *P-value < 0.05, Nagelkerke R Square = examined the prospective relationships between stage of change transitions and intra-individual increases or decreases in the processes of change. The authors used only data of 786 individual smokers that completed an assessment over a 6- month period and no formal intervention was introduced between measurement occasions. The results identified that consciousness raising had the highest score of four processes of change that can distinguish between subjects moving to another pre-abstinence stage and subjects moving to an abstinence stage. Counter conditioning was defined as a smoker substituting healthy behaviours for smoking. Substituting healthier alternatives or safer substitutes was used to solve the problem behavior, such as nicotine replacement therapy. Sun and colleagues [28] conducted a longitudinal study and compared 14 principles and processes of change applied by successful quitters, relapse and nonquitters over 24 months in a representative sample of 4,144 smokers in intervention and control groups. The successful quitters showed a decrease in the use of experimental processes and an increase in behavioral processes, especially in counterconditioning. This result is also consistent with Carlson et al. [29], who suggested that using counter-conditioning process factors increases more successful quitters at 3-months of smoking cessation rates. In contrast, social liberation and self-reevaluation factors were inversely correlated to quitting smoking. Social liberation was defined as a smoker becoming aware of smoke-free alternatives in society. Policies and social activism are required to create environments in which a healthy alternative appeared as a social norm. Failure to quit was influenced by the process of change for each stage of quitting smoking, colleagues at work place that smoked were the most important factor in an employee s failure to quit, or return to smoking even after years of not smoking [30]. Self-reevaluation was defined as a smoker evaluating his or herself-image as a smoker or nonsmoker. It is exemplified by a belief that one can change and make a firm commitment to change. Making New Year s resolutions and public commitments can represent this process. Smokers believe that one can change and make a firm commitment to change [29]. Due to the nature of the working environment for military personnel that requires many people being together, there are a lot of activities and recreation these personnel do together during the breaks or short sessions away from work. Smoking is one such activity. An environment where there is temptation to smoke among colleagues is one factor that hinders the success in quitting. Even though self reevaluation has been implemented as a resolution among the quitters in the western countries, such mechanism is yet to be an appropriate means for Thai people, especially among servicemen. In Thailand, those who desire to quit smoking lacked a well-organized plan and thus failed to sustain the quitting habit. After a temporary quitting period resulting from their sudden decisions to quit, they returned to smoking and restart unplanned quitting cycles, in addition, smokers often regard danger from smoking as their own risk and came up with the excuses to continue smoking such as I m not hurting anyone but myself- it s my choice to smoke or quit, consequently, they do not aware risks of exposure to second-hand smoke [31]. The study s limitation lies in the self-report data from the participants, who might have either underor over-reported their quitting smoking without support from biochemical verification. Samples were all male representatives from the RTN personnel and further research should include female military personnel and evaluate the effectiveness of cessation intervention with smokerenlistees prior to their entering the Navy, to assess the impact on subsequent career outcomes. CONCLUSION The health benefits of quitting smoking have been shown to be numerous even among the RTN personnel. Six significant factors of quitting smoking among the RTN personnel were length of past quit attempt, family support, consciousness

6 350 Short Report raising, and counter conditioning, while social liberation and self-reevaluation factors were inversely correlated to quitting smoking. Based on the results from this study, it is part of conclusion that RTN policy makers should provide support in forming the quitting smoking groups that would act as a solid connection between the smokers in the RTN and their families. The self-confidence and commitment of those personnel for quitting their smoking must be promoted along with a favorable environment that facilitates the smoking cessation. ACKNOWLEDGEMENT We express our gratitude to the Commission on Health Development Center for Persons with Chronic Health Problems Chulalongkorn University, and Graduate School Chulalongkorn University Fund for the financial support in this study. REFERENCES 1. Rigotti NA, Munafo MR, Stead LF. Interventions for smoking cessation in hospitalised patients. 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