Predictors of Sustained Six Months Quitting Success: Efforts of Smoking Cessation in Low Intensity Smoke-Free Workplaces

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1 Originl Article Smoking Cesstion in Workplces Siti Munir Ysin et l 401 Predictors of Six Months Quitting Success: Efforts of Smoking Cesstion in Low Intensity Smoke-Free Workplces Siti Munir Ysin, 1 MBBS, MPH, Msilmni Retneswri, 2 MBBS, MMed (OM), Foong Ming Moy, 3 BSc, MMedScPH, PhD, Khirul Mizn Tib, 4 BSc, MSc, Nurhud Ismil, 1 MD, MPH Abstrct Introduction: This study ims to identify the predictors of 6-month quitting success mong employees involved in workplce smoking cesstion with low-intensity smoke-free policy. Mterils nd Methods: A multicentre prospective cohort study ws conducted mong employees from 2 different public universities in Mlysi. Interventions include t lest 2 sessions of behviourl therpy combined with free nicotine replcement therpy (NRT) for 8 weeks. Prticipnts were followed up for 6 months. Independent vribles ssessed were on sociodemogrphic nd environmentl tobcco smoke. Their quit sttus were determined t 1 week, 3 months nd 6 months. Results: One hundred nd eightyfive smokers volunteered to prticipte. Among the prticipnts, 15% nd 13% sustined quit t 3 months nd 6 months respectively. Multivrite nlysis reveled tht t 6 months, ttending ll 3 behviourl sessions predicted success. None of the environmentl tobcco exposure vribles were predictive of sustined cesstion. Conclusion: Individul predictors of success in intr-workplce smoking cesstion progrmmes do not differ from the conventionl clinic-bsed smoking cesstion. Furthermore, environmentl tobcco exposure in low intensity smoke-free workplces hs limited influence on smokers who succeeded in mintining 6 months quitting. Ann Acd Med Singpore 2013;42:401-7 Key words: Environmentl tobcco smoke, Smoking cesstion, Workplce Introduction Of the world s 1.25 billion dult smokers, 10% (bout million) reside within Southest Asin countries. The smoking prevlence of dily smoking dults (bove 18 yers old) in this region rnged from 14.3% in Singpore to 40% in Los, with Mlysi recording 21% mong dults. 1,2 Interventions to reduce smoking rtes hve hd little impct in Mlysi, with only 2% of reduction in smoking prevlence over 10-yer period (21.5% in 2006, from previous prevlence of 23.5% in 1996). 3 This is despite the fct tht Mlysi hs rectified the World Helth Orgnistion (WHO) Frmework Convention on Tobcco Control (FCTC) since the yer According to the FCTC, ll signtories must follow stted guidelines regrding tobcco control within 5-yer time spn. 5 This includes the enforcement of smoke-free policies t the workplces nd universities. Introduction of smoke-free workplce policy hs been considered to contribute significntly to smoking cesstion in Western societies 6 or developed countries. 7 Nonetheless, in developing countries with high smoking prevlence 8 nd with high proportion of society with poor quitting motivtion, 9,10 such s Mlysi, the impct of smoke-free policy remins uncertin. One wy to mesure smoke-free policy success is by mesuring the perceived existence of environmentl tobcco smoke (ETS) (i.e. exposure to other people s smoking) in the workplce environment. 11,12 Besides workplce smoke-free policy, nother pertinent fctor tht contributes to success in quitting is individul 1 Popultion Helth nd Preventive Medicine, Fculty of Medicine, Universiti Teknologi MARA, Sungi Buloh, Selngor, Mlysi 2 Centre for Occuptionl nd Environmentl Helth, Deprtment of Socil nd Preventive Medicine, Fculty of Medicine, University Mly 3 Julius Centre University of Mly, Deprtment of Socil nd Preventive Medicine, Fculty of Medicine, University Mly 4 Fculty of Informtion Mngement, Universiti Teknologi MARA, Shh Alm, Mlysi Address for Correspondence: Dr Siti Munir Ysin, Popultion Helth nd Preventive Medicine Unit, Fculty of Medicine, Universiti Teknologi MARA, UiTM Sungi Buloh Cmpus, Jln Hospitl, Sungi Buloh, Selngor, Mlysi. Emil: sitimu.ysin@gmil.com

2 402 Smoking Cesstion in Workplces Siti Munir Ysin et l chrcteristics. Success in quitting is ssocited with n older ge of smoking initition 13 nd history of previous quit ttempts, higher nicotine dependence 14 nd nicotine replcement therpy (NRT) dherence. 15 Nonetheless, these were minly self-supported efforts in the conventionl smoking cesstion clinics, with very few concentrting on progrmmes conducted in the workplces. The results for such popultions my be skewed, s smokers ttending workplce progrmmes tend to be less motivted smokers, due to enforcement of ttendnce from the top mngement. 16 Hence, the identifiction of client chrcteristics tht predict success importnt, s this informtion could mtch smokers with workplce strtegy tht is most effective in helping them quit. In this study, we ssess the cesstion results of our 6-month workplce smoking cesstion progrmme nd identify predictors of quitting success, which includes workplce tobcco exposure. We hypothesise tht in workplces with smoke-free policy, the environmentl tobcco exposure will not be significnt predictor of smoking bstinence rtes. Mterils nd Methods A prospective cohort study ws conducted. Dt were collected between November 2009 nd November 2010 in University A, nd between Mrch 2010 nd Mrch 2011 in University B. Both public universities from where the study ws conducted hve smoke-free policies in plce since Such policies include penlties for smoking of up to US$50 per offence, nti-smoking cmpigns nd rod shows. Nonetheless, implementtion of the policy ws rther loose. For exmple, smokers who were cught smoking in the cmpus, were merely given multiple wrnings without stern ctions tken. Hence, in complementing the smoke-free policy in ccordnce to FCTC, the reserchers introduced the first workplce smoking cesstion services in the 2 universities. This ws specificlly trgeting stff members. Student centres nd student college were used s temporry sites for the universities non-clinic-bsed smoking cesstion progrmmes. Ethicl pprovl ws given for the study by the University of Mly, which hd full support from the mngement nd unions of both universities. Informed consent ws obtined from ll prticipnts. This study used convenient smpling, whereby smokers from both universities who were interested in quitting were invited to enrol in the study. Invittions were issued through the stff portl, stff emil, posters, min university websites nd invittion letters through the Hed of Deprtment/ Unit. Eligible prticipnts were dily cigrette smokers (for t lest the pst 12 months). They hd to be ble to communicte in either Bhs Mlysi (the ntionl lnguge) or English. Prticipnts were excluded if they hd ny contrindictions to nicotine replcement therpy such s recent myocrdil infrction, life-thretening rrhythmis, severe or worsening ngin, or llergy to ny component of the mediction. A totl of 185 prticipnts greed to prticipte in this reserch. Smoking Cesstion Tretment Methods Tretment consisted of combined medicl nd cognitive behviourl therpy (CBT). To stndrdise tretments, similr progrmmes were conducted in both universities. All sessions were conducted by one medicl officer nd n ssistnt covering both universities. Medicl tretment consisted of nicotine replcement therpy (NRT) gums/ ptch, depending on the ptients medicl history nd degree of nicotine dependence. NRT ws supplied for mximum period of 2 months, depending on prticipnts requirements. Prticipnts were lso supplied with diry where they were required to quntify the mount of cigrettes they smoked dily. The NRT were supplied during the CBT sessions. CBT involved t lest 2, twice-weekly counselling sessions provided by the sme medicl officer, who hd undergone one month trining in the re. The sessions covered coping strtegies, risks nd benefits of quitting, relpse prevention, stress reduction nd weight control. The questionnires utilised in this study were self-dministered during the counseling sessions prior to tretment. Assessment Methods Sociodemogrphic nd Smoking History: Sociodemogrphic informtion ws gthered vi questionnire dministrtion. Dt gthered included ge group, eduction level, occuptionl sttus nd mritl sttus. Informtion on smoking history gthered included number of cigrettes/dy, ge t which the prticipnt begn smoking nd previous quitting ttempts within the pst yer. Environmentl Tobcco Exposures: Environmentl influences my lso ffect smoking cesstion 11 when smokers re exposed to Environmentl Tobcco Smoke (ETS). The questionnire used here ws dpted from pth nlysis study. 11 It consisted of 3 simple questions nd ws ment to exmine the influence of worksite environment, home environment nd peer smoking on smoking cesstion. This is bsed on the hours of exposure t home nd work by other people smoking within the pst 7 dys, nd the number smoking collegues t work. Notbly, in the study from which this questionnire ws dpted, Likert scle ws used. The questionnire ws trnslted into Mly lnguge for pproprite lnguge suitbility. 17 Bck-to-bck trnsltion nd relibility tests Annls Acdemy of Medicine

3 Smoking Cesstion in Workplces Siti Munir Ysin et l 403 by 3 independent lnguge trnsltors were performed on group of 40 smokers. Relibility tests reveled Cronbch s lph of between 0.80 nd 0.83 nd correltions of between 0.5 nd 0.8. Reported Abstinence nd Quitting Confirmtion: Abstinence ws determined during the first 2 months of follow-up during counselling sessions nd from the diries. The informtion on quitting ws lso collected t 3 nd 6 months post-tretment vi telephone clls. Smoking bstinence ws confirmed by crbon monoxide (CO) reding of <6 ppm using Mini Smokerlyzer (Bedfont Scientific Ltd, Rochester, Englnd) during follow-up. The ex-smokers were visited by the resercher t their work office fter 2 months of follow-up for mesurements. Quitters were smokers who hd chieved prolonged bstinence (did not smoke even single cigrette) from the initil quit dte until the time of ssessment. Point bstinence is referred to 7- dy quit durtion. Subjects who could not be contcted or who did not come for subsequent counselling (refused, chnged phone number, could not be contcted or intentionlly gve the wrong telephone numbers) were considered to hve continued smoking. Dt Anlysis Dt mngement nd sttisticl nlysis were performed with SPSS A vlue of P <0.05 ws tken s sttisticlly significnt level. Univrite logistic regression ws performed to ssess the reltionship between ech vrible nd bstinence t 1 week, 3 months nd 6 months. Multiple logistic regression models for cigrettes/dy nd previous cesstion ttempts ws performed djusting for socio demogrphic vribles, NRT nd clinic sessions. Ech model ws checked for fit by the Hosmer-Lemeshow goodness-of-fit test. Results There were 185 prticipnts in totl, 138 from University A nd 47 from University B. All prticipnts nswered the questionnires on sociodemogrphic nd smoking behviour prior to the tretment progrmme. Forty percent (n = 74) of the smokers ttended only one initil session, 32% (n = 59) ttended 2 sessions within 2 weeks nd 28% (n = 52) ttended 3 sessions. Smoking sttus ws determined mong 100% prticipnts t 1 week, nd 90% (n = 166) t 6 months. Prticipnts who could not be contcted were considered s smokers. Follow-up rtes t 3 nd 6 months were 65% nd 90% respectively. Defulters t 3 months compred to non-defulters were more likely to hve only ttended one session (P <0.05) nd were more likely to be professionl workers (P <0.05). No significnt differences were observed with regrd to ll other bseline results t 6 months. n=103 n=27 n=24 Fig. 1. Smoking cesstion results for point nd sustined bstinence. All subjects were mle with men (SD) ge of 35.9 (10.9) yers. In terms of eduction ttinment, 3% hd only completed elementry school, 58% hd completed both primry nd secondry school nd 39.3% hd ttended college. Most of the prticipnts were from Mly ethnic group (95%), while 10 others were of different ethnic group e.g. Indin. The mjority (93%) of prticipnts were support stff (e.g. technicl workers, clericl workers nd lbourers), while 7% were in the professionl group. Sociodemogrphic bckground nd sociodemogrphic chrcteristics of prticipnts in the 2 public universities were similr (ll P >0.05). On verge, prticipnts reported tht they strted smoking t the men ge of 17 yers (rnge, 9 to 42). The verge number of cigrettes smoked per dy ws 14 (rnge, 2 to 40). The mjority (85%) hd one or more quit ttempts, while 15% hd never ttempted to quit smoking. Abstinence (Point Abstinence nd Abstinence) Of the prticipnts included in the study, 103/185 (55.7%) smokers continued to bstin from smoking t 1 week. The N 80 u m b e r 60 o f 40 p r t i 20 c i p Number of clinic sessions ttended Number of clinic sessions ttended Fig. 2. Number of clinic sessions ttended by prticipnts. 8

4 404 Smoking Cesstion in Workplces Siti Munir Ysin et l number of smokers who sustined bstinence (i.e. never relpse since quitting), ws reduced from 27/185 (14.6%) prticipnts t 3 months to 24/185 (13.0%) by the end of 6 months (Fig. 2). Univrite Predictors of Abstinence t 1 week, 3 months nd 6 months Smokers who hd ttended more thn one session were significntly more likely to quit t week 1. At 3 months nd Tble 1. Adjusted Anlysis of Potentil Predictors of 1 Week Abstinence, 3 Months Abstinence nd 6 Months Abstinence Sociodemogrhic, Smoking History nd Follow-up Results of Point Abstinence t 6 months Vribles Quit for 1 week Quit for 1 week cesstion for 3 months cesstion for 3 months cesstion for 6 months cesstion for 6 months OR (95%CI) Sociodemogrphic Age group (yers) 18 to (43.7) Ref 9 (33.3) Ref 7 (29.2) Ref 31 to (25.2) 1.05 ( ) 4 (14.8) 0.36 ( ) 4 (16.7) 0.74 ( ) 41 to (22.3) 0.48 ( ) 9 (33.3) 1.94 ( ) 8 (33.3) 1.51 ( ) 51 nd bove 9 (8.7) 0.38 ( ) 5 (18.5) 1.53 ( ) 5 (20.8) 2.06 ( ) Eduction level Primry school 4 (3.9) Ref 1 (3.7) Ref 2 (8.7) Ref Secondry school 58 (56.3) NA 15 (55.6) 1.20 ( ) 13 (56.5) 0.29 ( ) Diplom nd bove 41 (39.8) NA 11 (40.7) 1.17 ( ) 8 (34.8) 0.33 ( ) Occuptionl sttus Support group 95 (92.2) Ref 25 (92.6) Ref 22 (95.7) Ref Professionls 8 (7.8) 2.42 ( ) 2 (7.4) 0.88 ( ) 1 (4.3) 1.19 ( ) Mritl sttus Non-mrried 37 (35.9) Ref 5 (18.5) Ref 5 (20.8) Ref Mrried 66 (64.1) 1.70 ( ) 22 (81.5) 3.26 ( ) 18 (79.2) 1.96 ( ) Ethnic group Mly 97 (94.2) Ref 24 (88.9) Ref 21 (87.5) Ref Non-Mly 6 (5.8) 1.99 ( ) 3 (11.1) ( ) 3 (12.5) 6.27 ( )* Smoking history Number of cigrettes/dy <10 14 (13.6) Ref 5 (18.5) Ref 4 (17.4) Ref (86.4) 1.55 ( ) 22 (81.5) 0.78 ( ) 19 (82.6) 0.68 ( ) Age of smoking initition (yers) 8 to 12 8 (7.8) Ref 2 (7.4) Ref 1 (4.3) Ref 13 to (69.9) 1.19 ( ) 19 (70.4) 1.65 ( ) 16 (69.6) 1.99 ( ) 19 nd bove 23 (22.3) 0.63 ( ) 6 (22.2) 0.23 ( ) 6 (26.1) 1.60 ( ) Previous quit ttempts within pst yer 0 14 (13.6) Ref 5 (18.5) Ref 6 (26.1) Ref 1 89 (86.4) 1.70 ( ) 22 (81.5) 0.65 ( ) 17 (73.9) 0.45 ( ) Follow-up vribles NRT dherence Adherent 70 (68.0) Ref 22 (81.5) Ref 19 (79.2) Ref Non-dherent 33 (32.0) 5.99 ( ) 5 (18.5) 2.27 ( ) 5 (20.8) 2.99 ( ) Number of counselling sessions ttended 1 30 (29.1) Ref 4 (14.8) Ref 4 (16.7) Ref 2 48 (46.6) 9.13 ( ) 8 (29.7) 9.10 ( ) 9 (37.5) ( )* 3 15 (14.6) 2.23 ( ) 13 (48.1) (33.3) ( )* 4 or more 10 (9.7) 2.21 ( ) 2 (7.4) ( )* 5.55 ( ) 3 (12.5) ( ) Annls Acdemy of Medicine

5 Smoking Cesstion in Workplces Siti Munir Ysin et l 405 Tble 1. (Con't) Adjusted Anlysis of Potentil Predictors of 1 Week Abstinence, 3 Months Abstinence nd 6 Months Abstinence Sociodemogrhic, Smoking History nd Follow-up Results of Point Abstinence t 6 months Vribles Quit for 1 week Quit for 1 week cesstion for 3 months cesstion for 3 months cesstion for 6 months cesstion for 6 months OR (95%CI) Smoking environment Awre of the university smoking prohibition rule Yes 97 (94.2) Ref 25 (92.6) Ref 22 (91.7) Ref No 6 (5.8) 2.05 ( ) 2 (7.4) 1.30 ( ) 2 (8.3) 2.14 ( ) Smokes on the university cmpus Yes 76 (73.8) Ref 22 (81.5) Ref 20 (83.3) Ref No 27 (26.2) 1.50 ( ) 5 (18.5) 0.98 ( ) 4 (16.7) 0.79 ( ) Smoking exposure Worksite environment (hours) 0 6 (5.9) Ref 1 (3.7) Ref 1 (4.2) Ref 1 to 2 39 (38.2) 3.59 ( ) 4 (14.8) 0.81 ( ) 5 (20.8) 1.09 ( ) 3 to 8 35 (34.3) 1.92 ( ) 12 (44.4) 1.89 ( ) 12 (50.0) 2.31 ( ) 9 or more 22 (21.6) 2.63 ( ) 10 (37.0) 2.62 ( ) 6 (25.0) 2.03 ( ) Home environment (hours) 0 49 (47.6) Ref 12 (44.4) Ref 11 (45.8) Ref 1 to 4 37 (35.9) 1.56 ( ) 9 (33.3) 0.89 ( ) 8 (33.3) 0.93 ( ) 5 to (9.7) 0.68 ( ) 3 (11.1) 2.29 ( ) 3 (12.5) 1.56 ( ) 15 or more 7 (6.8) 2.63 ( ) 3 (11.1) 1.82 ( ) 2 (8.3) 1.58 ( ) Peer influence None 2 (1.9) Ref 0 (0) Ref 0 (0) Ref Very few 6 (5.8) NA 2 (7.4) NA 3 (12.5) NA Less thn hlf 14 (13.6) NA 4 (14.8) NA 5 (20.8) NA Most re smokers 81 (78.6) NA 21 (77.8) NA 16 (66.7) NA Adjusted for ll the vribles in the socio demogrphic, smoking history nd follow-up vribles * P <0.05; P <0.01 NA; One of the group hs 0% quit rte, OR cnnot be computed. 6 months, ttendnce t more clinic sessions hd n odds rtio of 7.0 nd 8.0 for the likelihood of quitting. It ws lso shown tht being non-mly incresed the chnces of quitting t 3 months. Other independent ctegoricl vribles were not predictive of success (Tble 1). Multivrite Predictors of Smoking Cesstion t 1 week, 3 months nd 6 months All vribles from the univrite nlysis were included in this multivrite logistic regression. Vribles ssocited with successful quit sttus t 1 week include ttending more counselling sessions. At 3 months, success ws lso predicted by ttending more thn 1 counselling session (Tbles t week 1- nd 3-month were not shown). Tble 2 concludes tht only 2 vribles predict sustined cesstion t 6 months. Rtes of sustined cesstion t 6 months were significntly higher mong the non-mlys compred with Tble 2. Multivrite Logistic Regression Predicting Abstinence t 6 Months Vribles β SE Wld x 2 df Odds Rtio (95% CI) P vlue Number of counselling sessions ttended: ( ) 0.04 Number of counselling sessions ttended: ( ) <0.01 Number of counselling sessions ttended: 4 or more ( ) 0.08 Ethnic group ( ) 0.04 Adjusted for ll the vribles in the model

6 406 Smoking Cesstion in Workplces Siti Munir Ysin et l the Mlys. Similr to the results t 1 week nd 3 months, ttending 2 nd 3 counselling sessions incresed the chnce of success. Discussion Our im ws to study the cesstion rtes nd predictors of bstinence mong group of university workers ttempting to quit with ssistnce. The 6-month cesstion rte of 22% found here ws slightly lower thn those seen in other workplce cesstion progrmmes t between 20% nd 50% 18 nd were greter thn rtes observed in non-workplce progrmmes, which hve generlly reported rtes of less thn 10%. 19 This finding emphsises the dvntges of such workplce progrmme. Nevertheless, it ws shown tht the point bstinence rte differs from the sustined bstinence rte, nd lower sustined bstinence rte ws noted. The difference observed between point bstinence nd sustined bstinence ws due to cses of relpse in smokers who filed to mintin quit. Our findings indicte tht clinic session ttendnce ws strong predictor of successful cesstion, s it ws noted to be strongly significnt t 1 week, 3 months nd 6 months. The finding tht ttending more thn one session incresed the chnce of success ws in greement with one locl study conducted in 8 Mlysin government cesstion clinics, which found tht smokers who ttended cesstion clinics t lest 4 times were more likely to quit. 20 Although the present study included only minimum of 2 intensive sessions with 1 follow-up session, the intensity of the progrmme likely dded n dvntge in producing similr success rte. Furthermore, nother study suggested tht the mount of contct time nd the number of sessions re not importnt fctors in cesstion rtes provided tht essentil effective elements re incorported to ssist nd motivte the smokers. 21 Being of non-mly descent lso predicted successful quit ttempt t the 6 month time point. This outcome, however, must be interpreted with cution, s there were very few non-mlys in the smple. Hence, the result my not be vlid, especilly when only 3 non-mly smokers quit t 6 months. During the interviews, non-mly smokers (who were predominntly Indin) were observed to be more determined in their quit ttempt nd received greter fmily support thn their Mly counterprts. Lee et l 10 lso found significnt difference with regrd to ethnicity nd smoking cesstion mong Mlysin smokers. Hence, it would lso be of interest to mesure nd document the cross-culturl spects (e.g. motivtionl spects, trditionl methods, culturl perspectives, religious fctors) of the cesstion ttempts mong these ethnic groups, s this my provide insight into wys to improve the cesstion rtes in multi-ethnic group. NRT complince ws found to be significnt predictor of success in previous studies. 22 The present study did not find NRT dherence to be n importnt predictive fctor in quitting. A reson for this is tht mny smokers in this study were not ble to comply with NRT s directed due to intolerble side effects. Another fctor tht ws found not to be significnt ws the environmentl influence vrible or environmentl tobcco smoke (ETS), i.e. exposure to other people smoking. The results indicte tht the externl environment my ply role in quitting in this study popultion but ws not sufficient to produce significnt outcome, s other fctors such s physicin support nd motivtion to quit my dominte. 23 We lso suspect tht, the impct of imposing the workplce smoke-free policy hd reduced ETS nd hence ssist smokers in mintining quit sttus. Evidence from studies with more methodologiclly robust designs (e.g. rndomised controlled tril) is however, required to scertin this. Other fctors tht were found to be positively correlted with successful cesstion rtes in other studies such s ge group, 24 previous quit ttempts, eduction level 25 nd mritl sttus 26 were not found to be correlted to successful ttempt in this study. Resons for this discrepncy could be relted to the homogeneity of the smple in this study, s the mjority of prticipnts were from lower eduction levels nd socioeconomic sttuses. The discrepncy could lso be prtly relted to differences in the culture nd ethnicity of the smokers compred with smokers from Western societies, who hve different perceptions nd norms. Even mong smokers with different motivtion levels nd perception who shre similr bckgrounds, results my differ. 9,10,27 There re lso severl limittions to our present study. Identifying the success rtes mong workers ws not the min purpose of this study nd could hve been strengthened by the inclusion of dditionl vribles such s types of life stressors, helth nd psychitric morbidities. In ddition, the smple ws predominntly mle nd Mly. Thus, the results my only be generlised to South Est Asin countries. Similrly, the use of this convenience smpling method is subject to bis. The results were therefore limited to smokers who intended to quit, nd they my not cpture smokers with very poor motivtion. Conclusion In short, we concluded tht in the cse of conducting workplce cesstion progrmme in smoke-free policy environment, environmentl tobcco exposure does not deter person from chieving long-term bstinence. Nonetheless, individuls who ttended more cesstion sessions hd higher probbility of chieving success with combined medicl nd behviourl therpy. This result is similr to those in clinic-bsed smoking cesstion. Our Annls Acdemy of Medicine

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