A case study of perceptions about smoking and smoking cessation interventions among members of an uniform disciplinary force in Hong Kong

Douglas T C Lai 黎達洲, Dominic M W Lau 劉敏維

HK Pract 2005;27:286-293

Summary

Objective: To determine the perceptions about smoking and smoking cessation interventions among members of an uniform disciplinary force in Hong Kong.

Design: Qualitative study with focus groups and questionnaires.

Subjects: 32 uniform officers attending a smoking cessation talk held in early January 2004, at an officer's club.

Main outcome measures: Perceptions about smoking and smoking cessation interventions.

Results: The main emerging theme was that subjects continued to smoke because they perceived smoking as pleasurable, believed that it improved their work performance, and smoked for its socializing effect. Some thought that quitting smoking was a matter of willpower alone, while others were not confident that they could succeed on their own and perceived support was inadequate. Some were willing to quit if there was an imminent threat to their health but not quit for preventive purposes. There was low awareness of the addictive nature of nicotine, the effectiveness of nicotine replacement therapy and the available smoking cessation services in Hong Kong.

Conclusion: Brief advice by family physicians and the use of nicotine replacement therapy are practical ways and evidence-based to help busy smokers quit.

Keywords: Smoking, Smoking cessation, nicotine replacement therapy, disciplinary force, primary care.

摘要

目的： 確定香港記律部隊成員對吸煙和戒煙措施理解。

設計： 專題小組訪談和問卷調查式的定性研究。

研究對象： 出席2004年1月初舉辦的戒煙演講的 32名人士。

主要測量內容： 對吸煙和戒煙措施的理解。

結果： 繼續抽煙的原因在於他們認為吸煙能令人愉快、有助於提高工作成效並具有社交的功能； 有些人認為戒煙只是意志力的問題，其他則認為難以靠自己的力量改變吸煙的習慣，而且缺乏足夠的支持； 如果吸煙馬上會危及其健康，有些人會願意戒煙，但不會為了預防的目的而戒煙。人們對尼古丁的成癮性質、 尼古丁替代療法的好處、以及香港現有的戒煙服務瞭解不多。

結論： 由家庭醫生提供簡要的建議和尼古丁替代療法，是幫助忙碌的吸煙者戒煙實用，而已證明行之有效的方法。

詞彙： 吸煙、戒煙、尼古丁替代療法、記律部隊、基層醫療。

Introduction

Tobacco smoking is the single largest preventable cause of death in the world.¹ In Hong Kong, although the prevalence of daily smokers has been decreasing steadily since 1982, smoking still kills over 5600 people every year, or 15 people per day.^2,3 In 2003, there were about 819,700 daily smokers in Hong Kong, of whom 86% were male.⁴ More than 34% of smokers in Hong Kong had tried but failed to quit.⁴ Of those who had never attempted to quit, more than 17% expressed the intention of doing so.⁵ Reasons for continuing smoking are often complicated and involve individual attitudes, ideas and personal experiences. Understanding these may help health care workers find more effective ways to help. The purpose of this study was to understand participants' beliefs about smoking and their experiences with smoking cessation services.

Method

We recruited a total of 32 uniform officers who voluntarily attended a smoking cessation talk organized by the disciplinary force and the Tobacco Control Office of the Department of Health. The participants were divided into four focus groups. Each group consisted of eight participants, led by one trained facilitator and one recorder (each either a doctor or a nurse).

We used four board topics for discussions. The questions were derived from a review of the relevant literature and discussion among research team colleagues. The four topics included (1) perceived difficulties in quitting smoking; (2) past experiences with quitting; (3) past experiences with anti-smoking health services and (4) anti-smoking services needed.

Subjects were encouraged to say what they felt. Their views were recorded in Chinese as far as possible and were later translated into English by the interviewers. The interviewers were instructed not to express their own opinions during the discussion. The discussion lasted about one hour and was concluded by asking the participant to fill in a questionnaire with basic demographic data and smoking history. We did not audiotape the discussions.

The results of the four focus groups were pooled together for analysis. The transcripts were reviewed by two individual researchers and main themes were identified. Quotations were selected to illustrate the views expressed. As this study was qualitative rather than quantitative, we did not present our findings numerically. Respondent validation was not undertaken in this study.

Results

1. Participants



31uniform officers completed the questionnaire. 28 were current smokers and 3 were ex-smokers. All were male and most (84%) were aged between 30 and 50 years of age. The mean smoking duration was twenty years. Among the current smokers, most (97%) did smoke in the previous 7 days and 54% were not considering quitting in the next month. 36% had never attempted quitting, while about half of them had tried at least once (see Tables 1 & 2).


2. Perceived obstacles in quitting



The most common response was that smoking has a socializing effect. Many participants noted that they were more likely to smoke when they were in the company of other smokers, or would smoke more at social gatherings.

A typical response was:

"All my colleagues smoke. We smoke at work and after hours in pubs and karaoke."

Several officers also mentioned the pleasure associated with smoking:

"It relaxes me!"

"Smoking after meal was particularly pleasurable."

Another officer mentioned that:

"quitting made me feel blue."

Some felt that smoking helped them remain vigilant when working long hours:

What else can I do when I am tired whilst on duty?"

Some had tried to quit but had resumed smoking because of withdrawal symptoms, e.g. headaches, feeling 'edgy' and weight gain. Others did not believe that they could succeed in quitting and did not even try:

"There is nothing I can do to break this habit."

Some felt that they lacked adequate support from either health services or family:

"I found it insurmountable to do it on my own."

Some believed that smoking addiction was purely psychological and that quitting was a matter of willpower alone. These respondents did not have faith in medical therapy, such as nicotine replacement therapy (NRT).

"It's in the heart."

"NRT is just redundant."

3. Perceived benefits of quitting

A few officers, on the other hand, mentioned that quitting resulted in noticeable improvements in their exercise tolerance, better family relationships, chances of promotion and conveyed a better image.

"My wife and daughter were proud of me after I quit smoking successfully."

"Quitting can help in my promotion."

4. Risks evaluation



Many thought that they could quit on their own, but would do so at some later date.

Some believed they would be lucky and would not have complications of smoking.

"It is not going to be me."

Others said that they would continue to smoke as long as there was no imminent threat to their health. One commented,

"I once suspected that I had coronary artery disease, but as soon as my test results were normal, I resumed smoking right after leaving the hospital."

Another commented,

"I was hospitalized for a thyroid problem, and was able to refrain from smoking completely during the entire stay in hospital (for 5 days), but as soon as I get better, I started smoking again. That's life!"

Antismoking service

What they wanted ............

1. Accessibility



Most of the respondents expressed the need for conveniently located antismoking services with hours that extended to outside normal office hours:

"I am very busy and cannot attend the antismoking services during 9-5."

2. Comprehensiveness



Many noted that the ideal antismoking service would be a one-stop service, with pre-check, necessary investigations (e.g. chest radiography), doctor's consultation and medications dispensed all at the same visit.

"I always wish that the service could be swift and to the point."

One officer suggested organizing smoking cessation camps and "crash" courses.

3. Motivation



Some participants felt that they would find it motivating if there were some reward for quitting, such as a certificate, souvenir or recognition from superiors. Some suggested that it would help if they were excused from duty in order to participate in smoking cessation programmes.

Some found their religious beliefs and family support to be helpful motivating factors.

4. Information giving



Many officers commented that information was most helpful when it involved real-life examples, risks figures and encouraging success stories:

"I can then better visualize the degree of hazards to me rather than just having a general idea."

Discussion

There is evidence that smoking is more common in the disciplinary forces than in other sectors of society.⁶ For this reason, this study targeted a disciplinary force, with a view to exploring its members' perceptions around smoking.

The evidence-based approach to helping patients quit smoking involves (1) brief advice by a physician, (2) nicotine replacement therapy and (3) antidepressants such as bupropion.⁷

Many of the subjects in this study lacked motivation, due perhaps to lack of confidence in their ability to quit, inadequate support services or not knowing how to access them. Studies have shown that brief (less than or equal to 5 minutes) advice on quitting given by physicians to smokers during an office visit results in higher quit rates compared to no advice.⁸ Although success rates are better with more intensive counselling, brief interventions appear to be more feasible for family physicians, given the time constraints and the reluctance of many patients to enter intensive programmes.¹⁰

The Stage of Changes model conceives smoking behaviour change as a process involving movement through a series of five motivational stages, including precontemplation, contemplation, preparation, action and maintenance. Interventions based on this model have been shown to enhance motivation¹¹ and predict cessation.¹² For patients unwilling to quit, it is helpful to identify the reasons for resistance. For example, the family physician can dispel the myth that smoking improves concentration and explain the addictive nature and withdrawal effects of nicotine. Patients willing to make an attempt to quit should be given specific advice about how to proceed, including setting a quit date and information on the various pharmacological treatments available. Many respondents believed that willpower alone is sufficient for successful quitting. Some believed they would have no difficulty quitting when they chose to. These beliefs might reflect a lack of understanding of the addictive effects of nicotine. Cigarette dependence is a chronic relapsing condition.¹³ Many smokers must repeatedly struggle to achieve long-term abstinence.

The use of NRT results in at least doubling the quit rate. For example, a meta-analysis of 17 randomized trials estimated the efficacy of the nicotine patch as 27% at the end of treatment and 22% at 6 months compared with 13% and 9%, respectively, for placebo.¹⁴ Smokers willing to quit should be offered NRT to increase the success rate.

Limitations and further study

One of the limitations of this study was that all of the uniform officers who attended were male. In the future, it would be helpful to explore the views of female officers. As the subjects were recruited voluntarily, the sample might not be representative. A larger scale qualitative study might give further insights into people's perceptions about smoking and smoking cessation.

Conclusion

In summary, a practical way of helping smokers who are willing to quit involves brief advice and the use of NRT as the first line treatment. Family physicians are in a particularly good position to provide this service to busy patients who can consult only outside regular office hours.

There are in addition many organised smoking cessation services in Hong Kong. A complete list can be found on the Tobacco Control Office, Department of Health website (www.tobaccocontrol.gov.hk).

Acknowledgement

Special thanks to the following: Dr Luke CY Tsang, Consultant, Dr Kelly LC Choi, Dr Lam Wing Kwun, Health Promotion Committee, Professional Development and Quality Assurance, Tobacco Control Office, Department of Health.

Key messages

1. There was low awareness of the addictive effect of nicotine among the participants.
2. There was low awareness of the effectivness of nictoine replacement therapy (NRT).
3. Family physicians are in a position to dispel myths about smoking and hence decrease the resistance to change.
4. Brief advice and the use of NRT offered by a family physician are practical first-line treatments for smokers.