JRHS Journal of Research in Health Sciences

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1 JRHS Journl of Reserh in Helth Sienes journl homepge: Originl Artile Preditors of Rediness to Quit Stges nd Intention to Quit Cigrette Smoking in 2 nd 6 Months in Lenon Nelly Lyoun (MPH) 1,2,3 *, Souheil Hllit (MS, MPH) 3,4,5,6,7, Mirn Wked (MD) 8, Zein Aoun Bh (MD) 9, Iselle Godin (PhD) 1, Mihele Drmix (PhD) 1, Psle Slmeh (PhD) 3,10 1 Reserh Center in Epidemiology, Biosttistis nd Clinil Reserh, Shool of Puli Helth, Free University of Brussels, Brussels, Belgium 2 Dotorl Shool of Sienes nd Tehnologies, Lenese University, Beirut, Lenon 3 Shool of Phrmy, Lenese University, Beirut, Lenon 4 Fulty of Phrmy, Sint Joseph University, Beirut, Lenon 5 Fulty of Phrmy, Holy Spirit University, Kslik, Lenon 6 Ouptionl Helth Environment Reserh Tem, Popultion Helth Reserh Center, Bordeux University, Bordeux, Frne 7 Reserh Deprtment, Psyhitri Hospitl of the Cross, Jl Eddi, Lenon 8 Deprtment of Pulmonology, St George Hospitl University Medil Center; Fulty of Mediine, Blmnd University, Lenon 9 Deprtment of Pulmonry nd Critil Cre Mediine, Hotel-Dieu de Frne, Beirut, Lenon 10 Fulty of Mediine, Lenese University, Beirut, Lenon ARTICLE INFORMATION ABSTRACT Artile history: Reeived: 17 Ferury 2017 Revised: 21 April 2017 Aepted: 03 My 2017 Aville online: 11 My 2017 Keywords: Cigrette Smoking Motivtion Rediness potentil Smoking Cesstion * Correspondene Nelly Lyoun (MPH) Tel: Emil:nelly_lyoun@hotmil.om Bkground: We imed t exmining quitting ehviors mong Lenese igrette smokers in order to lrify hrteristis of dults who were more likely to intend to quit smoking. Study design: A ross-setionl study. Methods: This study ws onduted etween Mrh 2014 nd Mrh 2015, involving 382 ptients rndomly hosen from 5 outptient linis in 5 hospitls in Lenon. A stndrdized questionnire ws ompleted inluding soio-demogrphi hrteristis, smoking ehvior, hroni respirtory symptoms, Fgerstrom sle, Mondor sle, pkging pereption, quitting ehvior nd rediness to quit ldder. Results: 40.8% of prtiipnts reported hving higher stges of rediness to quit while 33% nd 7.9% of them intended to quit in 2 nd 6 months lter, respetively. er stges of rediness to quit were ssoited with high to quit smoking (OR=1.98; P=0.007), hroni wheezing nd rel quit ttempt durtion of 1 month (OR=2.35, P=0.020 nd OR=2.15, P=0.003, respetively). ly motivted smokers (OR=1.83, P=0.040), who would hve hnged their fvorite pk due to the grphil wrnings (OR=2.11, P=0.010) nd who hd pst quit ttempt (OR=4.39, P<0.001) hd more intention to quit in 2 months. Hving pst quit ttempts would inrese the intention to quit in 6 months y 7.48 times (OR=7.48, P=0.007). Conlusions: Signifintly higher intentions to quit igrette smoking were ssoited with higher nd influened y shoking imges nd helth relted wrnings on too oxes. We hope our results will initite puli helth edutionl progrms nd interventions to surge the intention to quit igrette smoking s the first step of quitting. Cittion: Lyoun N, Hllit S, Wked M, Aoun Bh Z, Godin I, Drmix M, Slmeh P. Preditors of Rediness to Quit Stges nd Intention to Quit Cigrette Smoking in 2 nd 6 Months in Lenon. J Res Helth Si. 2017; 17(2): e Introdution S moking remins primry puli helth onern worldwide despite its deresing frequeny in developed ounties 1. It is the primry voidle reson of hroni moridity nd mortlity 2. Aording to WHO report in 2015, on the glol too epidemi, the smoking frequeny in Lenon rehed 36.2% 1, the highest in the Middle Est nd North Afri region 3. Cigrette smoking is the prinipl risk ftor for the dmging onsequenes on the respirtory nd rdiovsulr systems 4, ute exertions of respirtory illness, nd ssoited moridity s well s mortlity 4. The stges of hnge (SOC) theory hs een used in mny intertive progrms to ssist with the smoking esstion proess 5. It onsiders tht smoking esstion is proedure progrm onsisting of five l phses 6, eh representing hnged hronologil nd l feture of ehviorl ltertion nd djustment 7. The first three out of five stges define the individuls rediness to quit smoking. These phses onsist of:. pre-ontempltion (no intention to quit);. ontempltion (intention to quit smoking during the susequent 6 months); nd. preprtion (determintion to quit smoking within the susequent 30 dys). Individuls re onsidered to e in the tion stge one they quit smoking for 6 months nd in the mintenne stge if they quit for period of 6 months to 5 yers. However, if they stopped smoking for more thn 5 yr, they re onsidered to e t the termintion

2 2 / 8 Rediness & Intention to Quit Cigrettes stge. The hllenges to quitting smoking remin t 1- nd 6- month follow-up 7. Moreover, to quit is n importnt onept in the smoking esstion proedure 8 ; lthough studies revel lk of ompromise on how suh is well-defined nd mesured 9. In the generl puli, high levels s stted y smokers who hve high determintion to quit, hve een orrelted with the serh for esstion support 10. Hene, multiple ftors were ssoited with the person s rediness to quit smoking. Mny smokers who try to quit ite desire to improve their helth s the min reson 11. Furthermore, demogrphi ftors (gender, ge, mritl sttus, inome, nd edution) were studied to ompre etween smokers who hd quit ttempts or not, s well s etween suessful nd unsuessful quitting ttempts 12. In spite of n inresed frequeny of smoking in Middle Est region, few reserhes were done on the intention to quit smoking in Ar ountries. Therefore, the min ojetives of this study were to exmine quitting ehviors mong Lenese igrette smokers in order to lrify hrteristis of dults who were more likely to intend to quit smoking, etter define quitting ehviors mong these smokers nd ultimtely estlish effetive interventions for igrette dult smokers. Methods Study design nd ethis this prospetive study ws onduted etween Mrh 2014 nd Mrh 2015 in 5 outptient linis in 5 hospitls in Lenon, rndomly enrolling ptients to enter the study. The Lenese University pproved the study s n oservtionl study; respeted prtiipnts utonomy nd onfidentility re oserved; nd priniples of the Delrtion of Helsinki re followed. Prtiipnts Sujets were rndomly hosen to omplete stndrdized questionnire in the witing rooms of respirtory outptient linis nd of smoking esstion enter loted in one hospitl in Beirut; Eligile prtiipnts were urrent exlusive dult igrette smokers defined s urrently smoking 1 igrette per dy nd visiting the lini for n ordinry hekup or for n ute respirtory disese inluding pneumoni, ronhitis or hroni ostrutive pulmonry disese. Ptients seeking dvie for smoking esstion progrm were lso eligile to prtiipte. Prtiipnts were interviewed in Ari y helth re provider trined to use stndrdized questionnires. This study design hs een previously desried in the Itlin popultion 13, 14. Smple Size The smple size ws lulted using the following formul of Chrn nd Bisws 15 : n = Z².p(1 p) where Z=1.96 d² (when the onfidene intervl is 95%), p= expeted proportion in popultion sed on other studies, nd d=solute error or preision (5%). Bsed on the report of the Centers for Disese Control nd Prevention report done in the United Sttes where 68.8% of urrent dult smokers wnt to ompletely stop smoking 16, we lulted miniml smple size of 330 ptients required to llow for dequte power for ivrite nd multivrite nlysis to e rried out on severl ftors nd to give 95% proility of mesuring the prevlene of intention to quit with 5% ury. Tools nd vriles The pretested questionnire from the stndrdized questionnire of the Amerin Thori Soiety ws given to ll prtiipnts 17. It ws dpted to lol Ari lnguge (the ntive lnguge in Lenon); detils out the trnsltion proess were presented in nother study 18. Ptients needed n verge of 20 min to omplete the questionnire. Soiodemogrphi hrteristis, inluding ge tegorized into 45 yr nd >45 yr, gender, region tegorized into Beirut, Mount nd North, employment sttus divided into employed, unemployed nd never employed, edutionl level divided into low edution (illiterte, primry, omplementry nd seondry levels) versus high edution (university level) nd the mritl sttus tegorized into mrried versus single sttus (single, divored or widowed) were ssessed. Conerning the smoking ehvior, we sked out the igrette smoking sttus, the numer of igrettes smoked per dy tegorized into 1 to 9, nd >25 igrettes per dy 14, the fmily smoking sttus tegorized into 1 person who smoked in the sme house versus >1 person, if the ptient smoked indoor, the numer of smokers t work tegorized into 1 smokers or >1 person nd sumission to too smoking t work. The ge of igrette smoking onset ws tegorized into 10 to 14, 15 to 17 nd 18 yr 19. The presene of hroni respirtory symptoms ws defined s n ffirmtive nswer to multiple questions; Chroni respirtory prolems were ssessed using the following definitions using the Interntionl Study of Asthm nd Allergies in Childhood (ISAAC) questionnire 20 : Chroni respirtory disese dignosed y dotor, reported hroni ough, reported hroni phlegm, hroni ronhitis defined s ough nd phlegm for >3 months per yer sine 2 yers, ough nd phlegm for >3 weeks nd hroni wheezing. More detils out the hroni symptoms were presented lredy 13. The igrette smoking sttus ws mesured vi the Fgerstrom sle. Sores were tegorized into 1-4 low dependeny nd 5 high dependeny 14. The to quit smoking ws mesured using the Mondor sle; sores were tegorized into 12 refleting low to quit nd >12 refleting high to quit 21. In order to ssess the pkging pereption, two different types of wrnings were shown to the smokers during the interview: Only text (urrent wrning used in Lenon) versus pitoril shoking wrnings (i.e., disesed lungs, throt ner nd rotting teeth). To quntify the effet of the wrning, two questions were sked; detils out the textul nd pitoril effet on the quitting ehvior were presented lredy 13. Quit ttempts were ssessed y sking smokers, how mny times during the lst yer hve you stopped smoked for 1 dy (24 hours) or longer? Responses were tegorized into zero quit ttempts nd 1 quit ttempt. Rel quit ttempts durtions were ssessed y sking smokers: how long hve you een stying without smoking ny igrette? Answers were tegorized into 1 month nd 1 month. Intention to seriously quit igrette smoking in 2 months no/yes. Intention to seriously quit igrette smoking in 6 months no/yes.

3 Nelly Lyoun et l 3 / 8 We ssessed the to quit smoking y using the rediness to quit ldder. The Ldder is ontinuous mesure of to hnge smoking ehvior tht uses 10-point sle with responses rnging from 1 = "I hve deided to ontinue smoking" to 10 = "I hve lredy quit smoking." Vlidity studies hve demonstrted tht the Ldder is ssoited with ognitive nd ehviorl indies of rediness to onsider smoking esstion (e.g., intention to quit, niotine ) nd performs s well or etter thn the stging lgorithm in prediting smoking rte, quit ttempts nd esstion We divided the sle into 2 sugroups, the low-motivted one inluding the pre-ontempltion (not thinking out quitting) phses nd the high-motivted one ontining the ontempltion (thinking out quitting ut not redy to quit), preprtion (getting redy to quit), tion (quitting) nd mintenne (remining non-smoker) phses. Sttistil nlysis Dt nlysis ws performed on SPSS softwre version 23 (Chigo, IL, USA). Ctegoril dt were shown s solute frequenies nd perentges. Two sided sttistil tests were used; Chi-2 test or the Fisher's ext test for dihotomous or multinomil qulittive vriles. Regrding multivrite nlysis, 3 logisti regressions were performed, tking into ount the vriles in the ivrite nlysis tht showed P-vlue < ; potentil onfounders my e eliminted only if P>0.2, in order to protet ginst residul onfounding 25. Furthermore, we onsidered the rediness to quit (low versus high to quit), the intention to quit smoking in 2 months (Yes/No) nd the intention to quit smoking in 6 months (Yes/No) s dependent vriles respetively. The sttistil signifine ws set t P-vlue< Results We lulted the reliility of eh sle to ssess the qulity of our dt. We otined high Cronh lphs for ll sles s follows: Mondor sle (0.757) nd Fgerstrom sle (0.789). In totl, dt ws olleted from 382 igrette smokers with response rte of 88%. Tle 1 summrizes the soiodemogrphi hrteristis of those igrette smokers. Sixty one perent of the prtiipnts were mles; more thn hlf were more thn 45 yr old. The first ivrile nlysis ws onduted tking the rediness to quit s the dependent vrile. The results showed tht smokers hving hroni wheezing were signifintly more motivted to quit (17.9% versus 9.5%, P=0.020), sme s people with high s shown y the Mondor sle sore (58.3% versus 34.3%, P<0.001). Furthermore, smokers with no uriosity to sk speilist to help them to quit smoking were less motivted to stop smoking (P<0.001), while smokers who hve ever stopped smoking for t lest one month due to the textul wrning lredy implemented on igrette pkges nd who onsidered it is very importnt to report helth wrnings on pks were highly motivted to quit with (30.1% versus 16.2%, P<0.001) nd (60.3% versus 35.2%) respetively. In ddition, smokers who hve 1 quit ttempt were remrkly motivted to quit (80.8% versus 59%, P<0.001) (Tle 2). Tle 1: Soiodemogrphi hrteristis of igrette smokers in Lenon. Cigrette (n=382) Ftor Numer Perent Gender Mle Femle Age group 45 yr yr Mritl sttus Mrried Single Edution Work sitution Employed Unemployed Never employed Residene Beirut Mount Lenon North Numer of smokers in the fmily 1 person > 1 person Numer of persons smoking inside the house No Yes Numer of persons smoking t work 1 person > 1 person Sumission to smoke t work No Yes The results of the ivrite nlysis tking the intention to quit in 2 months s the dependent vrile, showed tht smokers living in Beirut nd Mount Lenon, s well s employed nd hving hroni wheezing hd higher intention to quit in 2 months (P<0.001, P=0.05 nd P=0.05 respetively). In ddition, highly motivted persons hd signifintly more intention to quit in 2 months (62.7% versus 33%, P<0.001), while this ltter group reveled tht they would hnge the fvorite igrette rnd if the mnufturing ompny deides to use shoking imges nd onsider shoking pitures hve hypothetilly greter effet thn simple wrning text urrently used with (64.1% versus 40.5%, P<0.001) nd (83.8% versus 56.9%, P<0.001) respetively. Evidently, people with n intention to quit in 2 months hd signifintly more quit ttempts (83.3% versus 55.5%, P<0.001) (Tle 3). When tking the intention to quit smoking in 6 months s the dependent vrile, the ivrite nlysis results showed tht people who smoked indoor nd those with high hd signifintly higher intention to quit (83.3% versus 64%, P=0.040) nd (60% versus 33%, P=0.004) respetively. Smokers with n intention to quit in 6 months onsider shoking wrnings hve hypothetilly greter impt thn simple wrning text urrently used on their ehvior with (83.3% versus 56.9%, P=0.006). Clerly, people with n intention to quit in 6 months hd signifintly more quit ttempts (83.3% versus 55.5%, P=0.004) (Tle 4).

4 4 / 8 Rediness & Intention to Quit Cigrettes Tle 2: Bivrite nlysis tking the willingness to quit igrette smoking s dependent vrile. (n=210) (n=156) Ftor Numer Perent Numer Perent P vlue Residene Beirut Mount Lenon North Sumission to smoke t work No Yes Smoking work person >1 person Wheezing No Yes Fgerstrom Mondor sle Greter effet of shoking imges No Yes Curiosity wrning disgree Disgree Agree gree Stop smoking No Yes Importne of helth wrnings d disgree Disgree Agree gree Rel quit ttempt durtion * month month Greter effet of imges: greter effet of shoking imges on too oxes thn wrning text Curiosity wrning: uriosity to sk speilist for help in quitting Stop smoking: ever stopped smoking due to the wrnings d Importne of helth wrnings: Importne of helth wrnings on igrette oxes The first logisti regression tking rediness to quit s the dependent vrile showed tht highly motivted smokers s shown y the Mondor sle nd smokers hving hroni wheezing would signifintly hve n inresed rediness to quit y pproximtely 2 times (P=0.007, OR=1.98; 95% CI: 1.21, 3.26 nd P=0.020, OR=2.35; 95% CI: 1.15, 4.81, respetively). In ddition, smokers hving lot of uriosity to sk speilist for help in quitting nd hving rel quit ttempt durtion of 1 month or more would signifintly hve more rediness to quit y 6.8 times nd 2.15 times susequently (P<0.001, OR=6.8; 95% CI: 3.36, nd P=0.003, OR=2.15; 95% CI 95%: 1.30, 3.54, respetively) (Tle 5). Tle 3: Bivrite nlysis of intention to quit smoking in 2 months s dependent vrile No (n=200) Yes (n=126) Ftors Numer Perent Numer Perent P vlue Residene Beirut Mount Lenon North Sumission to smoke t work No Yes Work sitution Employed Unemployed Never employed Wheezing (yes) No Yes Fgerstrom sle Numer of igrette igrettes igrettes igrettes 20 igrettes Age of smoking onset yr yr yr Mondor sle Greter effet of imges No Yes Curiosity wrning disgree gree Agree Disgree Chnge igrette rnd No Yes Importne of helth wrnings d disgree gree Agree Disgree Quit ttempt Yes ( 1 quit ttempt) Greter effet of imges: greter effet of shoking imges on too oxes thn wrning text Curiosity wrning: uriosity to sk speilist for help in quitting Chnge igrette rnd: hnge igrette rnd if shoking imges on igrette ox d Importne of helth wrnings: Importne of helth wrnings on igrette oxes.

5 Nelly Lyoun et l 5 / 8 Tle 4: Bivrite nlysis of intention to quit smoking in 6 months s dependent vrile No (n=200) Yes (n=30) Vriles Numer Perent Numer Perent P vlue Gender Mle Femle Smoking indoor No Yes Presene of respirtory diseses No Yes Fgerstrom sle Mondor sle Stop smoking No Yes Influened y helth wrnings No Yes Chnged your smoking hits No Yes Greter effet of imges No Yes Curiosity wrning d disgree gree Agree Disgree Chnge igrette rnd e No Yes Importne of helth wrnings f disgree gree Agree Disgree Types of wrning lels g Textul Grphi Both Quit ttempt No (<1 quit ttempt) Yes ( 1 quit ttempt) Stop smoking: ever stopped smoking due to the wrnings Influened y helth wrnings: Influened y the helth wrnings on igrette pkges Greter effet of imges: greter effet of shoking imges on too oxes thn wrning text d Curiosity wrning: uriosity to sk speilist for help in quitting e Chnge igrette rnd: hnge igrette rnd if shoking imges on igrette ox f Importne of helth wrnings: Importne of helth wrnings on igrette oxes g Types of wrning lels: Types of wrning lels on igrette pks more effetive in quitting Tle 5: Logisti regression tking the willingness to quit igrette smoking s dependent vrile Motivtion Vriles OR (95% CI) Smoking t work 1 person >1 person (0.35, 0.96) Mondor sle (1.21, 3.26) Wheezing No Yes (1.15, 4.81) Greter effet of imges No Yes (1.22, 4.05) Curiosity wrning disgree Disgree (0.61, 2.88) Agree ( 0.77, 3.63) gree (3.36, 13.74) Importne of helth wrnings disgree Disgree (0.67, 3.82) Agree (0.53, 3.07) gree (1.15, 4.04) Rel quit ttempt durtion 1 month month (1.30, 3.54) Greter effet of imges: If these shoking imges were used on too oxes, would they hve greter effet thn simple wrning text urrently used? Curiosity wrning: uriosity to sk speilist for help in quitting Importne of helth wrnings: Importne of helth wrnings on igrette oxes A seond logisti regression ws onduted tking the intention to quit in 2 months s the dependent vrile. Smokers residing in Mount Lenon nd North Lenon versus the ones residing in Beirut hve signifintly less intention to quit smoking in 2 months y 18% nd 67% respetively (P=0.01, OR=0.82; 95% CI: 0.40, 1.64 nd P=0.010, OR=0.33; 95% CI: 0.15, 0.75 respetively). ly motivted smokers nd smokers hving hroni wheezing hve more intention to quit in 2 months y 83% nd 2.27 times respetively (P=0.040, OR=1.83; 95% CI: 1.03, 3.28 nd P=0.050, OR=2.27; 95% CI: 1.00, 5.15 respetively). Additionlly, smokers who onsidered reporting helth wrnings on pkges is ruil nd who hd pst quit ttempt hd more intention to quit in 2 months y 4.41 nd 4.39 times respetively (P<0.001, OR=4.41, 95% CI: 2.26, 8.60 nd P<0.001, OR=4.39, 95% CI: 2.24, 8.64, respetively) (Tle 6). A third logisti regression tking the intention to quit smoking in 6 months s dependent vrile reveled tht people who smoke indoor nd the ones who hve delred disese y physiin would signifintly hve more intention to quit in 6 months y more thn 5 times nd 4 times respetively (P=0.03, OR=5.13; 95% CI: 1.17, nd P=0.05, OR=4.27; 95% CI: 1.01, respetively). In ddition, smokers who were more influened y the helth wrnings on pkges (y redution of dily numer of igrette smoked), hd more intention to quit in 6 months y 4.7 times (P=0.02, OR=4.73, 95% CI: 1.25, 17.90), while onsidering the report of wrnings on igrette oxes s eing very importnt nd hving lot of uriosity to seek help to quit would signifintly inrese the intention to quit in 6 months (P=0.010, OR=9.38; 95% CI: 2.01, nd p<0.001, OR=18.18, 95% CI: 5.02, respetively). Moreover,

6 6 / 8 Rediness & Intention to Quit Cigrettes hving pst quit ttempts would inrese the intention to quit in 6 months (P=0.007, OR=7.48; 95% CI: 1.73, 32.43) (Tle 7). Tle 6: Logisti regression tking the intention to quit smoking in 2 months s dependent vrile Intention to quit Vriles No Yes OR (95% CI) Residene Beirut Mount Lenon (0.40, 1.64) North (0.15, 0.75) Wheezing smokers No Yes (1.00, 5.15) Mondor sle (1.03, 3.28) Numer of igrettes per dy 5 igrettes igrettes (0.08, 1.59) igrettes (0.46, 6.38) 20 igrettes (0.42, 3.98) Importne of helth wrnings disgree Disgree (0.13, 1.61) Agree (0.26, 1.65) gree (2.26, 8.60) Chnging the fvorite rnd No Yes (1.17, 3.80) Quit ttempts No Yes (2.24, 8.64) Importne of helth wrnings: Importne of helth wrnings on igrette oxes Chnging the fvorite rnd: If your fvorite igrette rnd/ompny deide to hnge the look of its igrette oxes with shoking imges on smoking helth dmge, would you think of hnging it? Tle 7: Logisti regression tking the intention to quit in 6 months s dependent vrile Intention to quit Vriles No Yes OR (95% CI) Gender Mle Femle (0.08, 1.13) Smoking inside the house No Yes (1.17, 22.41) Disese delred y dotor No Yes (1.01, 18.05) Influened y helth wrnings No Yes (1.25, 17.90) Importne of helth wrnings disgree Disgree (0.56, 20.55) gree (2.01, 43.55) Curiosity wrning disgree Disgree (0.02, 3.07) Agree (0.04, 4.34) gree (5.02, 65.78) Quit ttempts No Yes (1.73, 32.43) Influened y helth wrnings: Influened y the helth wrnings on igrette pkges Importne of helth wrnings: Importne of helth wrnings on igrette oxes Curiosity wrning: uriosity to sk speilist for help in quitting Disussion Our results showed tht smokers who re highly motivted to quit smoking, hving one or less smoker t work, with hroni wheezing defined s (whistling sounds herd on expirtion more thn 2 yers), who onsider shoking pitoril wrnings s more effetive thn textul ones lredy implemented on igrettes pkges in helping to redue/stop smoking, who onsider the helth wrnings on pks s very importnt, hving pst quit ttempt during the lst yer nd rel quit ttempts durtion for 1 month or more, were ll ftors ssoited with the stges of rediness to quit. Previous studies showed tht ernings 26, the level of edution 26, mle gender 27, pst quit ttempts 28, hving longer durtion of pst quit ttempts 28, hving lower niotine 28, worrying out future helth 28 were ll ftors ssoited with quit intentions in igrette smokers. The ssoition etween smoking onstrints nd intention to quit is not well explored. Smokers who hve one smoker or less t work showed more rediness to quit, in line with the results of Frks et l. 29, where restriting smoking ws linked to n importnt impt on quitting ttempts. The sme uthors lso found tht living in smoke-free homes nd working in smoke-free workples hd signifint influenes on esstion 29. Another Koren study 30 showed tht the intention to quit ws ssoited with home smoking limittions ut not with workple smoking restritions. This finding supports the ft tht smoking prohiitions my inrese smokers to think out quitting nd inspire them to ttempt to quit 29, thus promoting smoking esstion. Any rule put into prtie should e ssessed regulrly for reinforement, euse the influene of new rule on smokers intentions to quit my e t its uttermost initilly nd then my lessen with time fter its implementtion 31. Interestingly, helth wrning lels seem to guide upoming quitting ttempts minly through their ility to ffet eliefs nd judgements out the dngers of smoking, whih in turn help to promote wreness onerning the d onsequenes of smoking on one s helth, leding to stronger intentions to quit. By mking wrning lels more prominent nd ppeling, they should hve greter hne to hnge ehvior 32. Our results onsolidte previous results, with these wrnings inresing the rediness to quit, nd the intention to quit in 2 nd 6 months respetively. Therefore, stronger ntitoo messges nd shoking pitoril wrnings out the helth effets of too onsumption on too pkges my lso further reinfore the users intention to quit too. Conerning the influene of hroni wheezing, smokers hve more rediness to quit nd more intention to quit in 2 months versus non wheezers, in line with nother study 33. Furthermore, ptients who hd respirtory disese dignosed y their dotor hd more intention to quit in 6 months. Consequently, ptients with respirtory diseses my e perfetly positioned to profit from interventions tht ontrol their respirtory symptoms nd motivte them to quit. Our results onsolidte previous results where, s mesured y Mondor sle, hs een ssoited with more rediness to quit nd intention to quit in 2 months 34. Moreover, the findings tht smokers from the pitl Beirut hd more intentions to quit thn smokers who were residing outside the ity, highlight the ft tht the limited too use prevention nd esstion mpigns in the ity re not rehing

7 Nelly Lyoun et l 7 / 8 the trget popultion to enourge them to try to quit, in ontrst with nother study 35. Our results were expeted sine lower soioeonomi sttus individuls hve higher mounts of too use, re less expeted to suessfully quit, nd my lso e less likely to intend or ttempt to quit 36. Furthermore, surveyed smokers delred tht the use of shoking imges on the igrette oxes would signifintly inrese the rediness to quit nd intention to quit in the 2 months. These results re omprle to nother study tht showed nti-too messges in the medi, in resturnts, nd in puli trnsporttion were preditors for intention to quit too 37. Looking t the preditors of quit intention, soiodemogrphi ftors suh s ge did not signifintly predit intention to quit too, whih is onsistent with the findings of previous reserhes 37. However, mle gender ws signifintly ssoited with the intention to quit in 6 months in our study, in opposite to the results of these studies 37. Smoking is urrently responsile for third of ll ner deths in mny western ountries. Too smoking plys strong role in the etiology of orl ner, nd orl ner risk n e redued y ontrolling of too smoking in different ountries 38. Furthermore, moderte nd hevy smoking rry higher risk of lung ner in women thn in men, nd this differene does not seem to e explined y lung volume 39. Another study estimting the eonomi urden of mjor ner due to smoking in Irn showed tht smoking ws responsile for 16.5% of ner deths, 17.2% of yers of potentil life lost nd 21% of the ost of produtivity 40. With ll eing sid, dditionl efforts re suggested to e mde y onerned uthorities to set up wreness mpigns in order to inrese lertness on dngers of igrette smoking nd implement new lws to derese igrette smoking in puli ples nd enourge these dolesents to emre helth-promoting onduts. Our study hs severl limittions. This ws rosssetionl design nd therefore, we were unle to drw usl ssoitions with suh design. The totl smple size is eptle, withdrwn from 3 governortes in Lenon, however, nnot e extrpolted to the whole popultion. The replition of this study in different settings nd geogrphi lotions would provide etter generlizility of the results. A seletion is is still, however, possile euse of the refusl rte. The use of questionnire in ptients my not lwys e urte: prolems in question understnding, rell defiieny nd over or under evluting symptoms, whih n led to possile informtion is. In ddition, we relied on eh sujet s self-reported dt, whih might ontin some potentil soures of is, suh s seletive memory (to rememer or not rememer experienes or events tht ourred t some point in the pst) or soil desirility is s result of the tendeny of smokers to se their nswers on wht they think is theoretilly right not wht they usully do. Conlusions Findings of this study improved urrent knowledge out the intention to quit igrette smoking. Signifintly higher intentions to quit igrette smoking were ssoited with higher nd influened y shoking imges nd helth relted wrnings on too oxes. We hope tht our results will initite puli helth edutionl progrms nd interventions to surge the intention to quit igrette smoking s the first step of quitting. Aknowledgements Speil thnks to ll persons who helped us in the dt olletion nd entry. Conflit of interest sttement The uthors hve nothing to dislose. Funding None. lights er stges of rediness to quit were ssoited with high, hving hroni wheezing nd rel quit ttempt durtion of 1 month or more. Hving pst quit ttempts would inrese the intention to quit in 6 months. er intentions to quit igrette smoking were ssoited with higher. er intentions to quit ws influened y shoking imges nd helth relted wrnings on too oxes. Inititing puli helth edutionl progrms nd interventions to surge the intention to quit igrette smoking re wrrnted. Referenes 1. World Helth Orgniztion. Report on the glol too epidemi. WHO We Site; 2015 [ited 10 Jn, 2017]; Aville from: ln.pdf?u=1 2. Doll R, Peto R, Whetley K, Gry R, Sutherlnd I. Mortlity in reltion to smoking: 40 yers' oservtions on mle British dotors. BMJ. 1994; 309: World Helth Orgniztion. WHO report on the Glol Too Epidemi: Wrning out the dngers of too. Genev: WHO; Lyoun N, Sleh N, Brour B, Awd S, Rhidi S, Al-Hjje A, et l. Wterpipe effets on pulmonry funtion nd rdiovsulr indies: omprison to igrette smoking in rel life sitution. Inhl Toxiol. 2014; 26: Chill K, Lnster T, Green N. Stge-sed interventions for smoking esstion. Cohrne Dtse Syst Rev. 2010: CD Kuehr J, Frisher T, Krmus W, Meinert R, Prht T, Lehnert W. Cotinine exretion s preditor of pek flow vriility. Am J Respir Crit Cre Med. 1998; 158: DiClemente CC, Prohsk JO, Firhurst SK, Velier WF, Velsquez MM, Rossi JS. The proess of smoking esstion: n nlysis of preontempltion, ontempltion, nd preprtion stges of hnge. J Consult Clin Psyhol. 1991; 59: Colemn T. Motivtion, physil tivity nd smoking esstion. Ptient Edu Couns. 2010; 79:

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