Summary

Objective:To find out specific characteristics of the difficult-to-quit smokers among patients attending primary care clinics.

Design: A semi-structured quantitative and qualitative questionnaire survey.

Subjects: A total of 96 patients who smoke and refuse to quit, and attending our primary care clinics, were recruited to fill in a questionnaire for the survey during the sampling period from July 2004 to December 2004.

Main outcome measures: Quantitative data, including demographic data, smoking attitude, knowledge towards smoking, psychological influences, social situation, peer influences and usual lifestyle were collected. Qualitative data revealed the reasons of their non-quitting behaviour and these were grouped into 3 main themes.

Results: Quantitatively, nearly 50% of the difficult-to-quit smokers in this survey started smoking at <20 years old and a similar percentage started between the ages of 21-30 years old. Smoking habit of parents, friends and colleagues were also noted to be associated with their not quitting. Lack of regular exercise (<2x per week) and eating in HK style caf /fast-food shops were their usual lifestyle. Interestingly, alcohol drinking was found in only around 30% of the difficult-to-quit smokers in our survey. Qualitatively, the perceived beneficial effect of smokers (stress alleviation and relief of boredom) and concern about weight gain were particularly emphasized.

Conclusion: Based on the findings in this preliminary survey, we believe that early identification of adolescents/young adults who lack regular exercise, like eating in HK style caf /fast-food shops and have smoking parents/friends/colleagues may be helpful in preventing their initiation to smoking. For those who have already started the habit, understanding their life stresses, fear of weight gain and lack of motivation would be useful to help them stop smoking.

Keywords: Difficult-to-quit smokers, questionnaire survey, primary care clinics, initiation to smoking, stop smoking.

摘要

目的：確定到基層醫療診所就診的病人中難戒煙者的具體特點。

設計：半結構化定量和定性問卷調查。

對象：共有96位到基層醫療診所就醫並拒絕戒煙者參加了本次問卷調查。取樣的時間為2004年7月至12月。

測量內容：收集的定量資料包括人口統計學資料、有關吸煙的態度或知識、心理影響、社會情況、夥伴的影響和平常的生活方式。定性資料揭示了其不戒煙行為的原因，並分為3個主題。

結果：從定量方面來說，本次調查發現難戒煙者，近50%20歲以前開始吸煙，此外還有類似比例的人在21-30歲之間開始吸煙，這與父母、朋友和同事是的吸煙習慣具有相關性。缺乏定期鍛煉（<2次/周）及在港式咖啡店/速食店就餐是其日常的生活方式。有意思的是，本次調查中，僅有約30%的難以戒煙者飲酒。定性結果突出吸煙者感到的吸煙的好處（緩解壓力和消除無聊感）以及對體重增加的擔心。

結論：根據此次初步調查的結果，我們認為及早發現那些缺乏定期鍛煉、喜歡在港式咖啡店及速食店就餐，而且父母/朋友/同事有吸煙的青少年/青年，有助於防止他們開始吸煙。對那些已經養成吸煙習慣的人，瞭解其生活壓力、對體重增加的恐懼以及缺乏動力的情況，會有助於他們戒煙。

主要詞彙：難戒煙者、問卷調查、基層醫療診所、開始吸煙、戒煙

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Introduction

Tobacco is the single largest preventable cause of death in the world.¹ It is currently responsible for the death of one in ten adults worldwide. 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 According to the Thematic Household Survey performed in 2003,⁴ there were 819,700 daily smokers, accounting for 14.4% of the population aged 15 or above. More than 86% of them were male.

Some smokers would like to quit their addiction but they needed professional help. Over 34% of smokers in Hong Kong had tried to quit smoking without success.⁴ For those who had never tried quitting before, more than 17% of them expressed their intention to do so.⁵

What about the rest of the smokers who never tried or never intended to quit smoking? The 2003 survey showed that around 58% of daily cigarette smokers had neither tried nor wanted to give up smoking.⁴ Various overseas studies revealed that the reasons for not being willing to give up smoking can be divided into 3 main groups,^6-21 namely (i) physical factors (older age, female sex, familial tendency, nicotine dependence and high daily consumption like smoking more than 25 cigarettes per day; (ii) psychological factors (denial, depression/anxiety, excessive stresses, less cognitive coping skill and negative behaviour) and (iii) social factors (socioeconomic deprivation, heavy drinking, sedentary lifestyle, low social support, smoking behaviour of friends or superiors at work, early initiation, low educational attainment, presence of an adult smoker in childhood residence, parental smoking, unmarried status). A few studies among Chinese^22-23 showed that individual educational attainment, self-control ability, influence of others and lack of effective methods were associated with the non-quitting behaviour. However, these studies may not apply to the specific group of our clinic population in Hong Kong because of the different background and perception to smoking.

In order to find out the specific characteristics of smokers from the group of patients who attend our primary care clinics, we conducted a preliminary survey to explore some of their reasons for their non-quitting smoking behaviour.

Methods

Recruitment of patients

In our survey, difficult-to-quit smokers were defined as smokers who had no plan or made no attempt to quit smoking at the time of consultation and included those who had tried to quit but failed to succeed. We provided every clinician working within our clinic cluster with a written protocol on identification of smoking patients for our survey. The clinicians identified them consecutively from the smoking status recorded on the front page of the medical record cards during their daily consultation during the sampling period. When smokers were identified, the clinicians would ask the following standard question according to the protocol: "Are you thinking of quitting smoking in the next six months or have you thought of smoking cessation in the past six months?" If the response was "Yes", the patient would be recruited into the survey. Once patients were identified as difficult-to-quit smokers, they would be invited to complete a questionnaire immediately after signing a consent form and return the questionnaire and consent form to a designated staff member in the clinics.

Data collection

A questionnaire (see Appendix A) was designed based on the findings published in previous overseas studies to reveal the specific characteristics of difficult-to-quit smokers.^6-23 The items chosen were according to the strength of those studies. The Chinese translation of the questionnaire was performed by an experienced translator in our department. The reliability of this questionnaire was checked before its utilization. First, the questionnaire was tested and re-tested for the possibility of difficulty in understanding the questions or instructions. Moreover, it was also examined to detect for any collusion, variability of response to each question and the effect of the questions' positioning. Lastly, the questions in this questionnaire were adjusted for different response patterns. The survey was then conducted from July 2004 to December 2004. All patients recruited (a total of 96 smokers) agreed to participate in this survey. Completed questionnaires were checked, coded and then entered into a database for analysis.

Statistical analysis

Statistical analysis was performed for quantitative data by using SPSS program version 12.0. Qualitative data were collected and analysed by 2 independent researchers. The results were transcribed, coded and categorized into themes. The Chinese responses were translated into English using the Oxford English Dictionary.

Results

Number of participants

A total of 96 smokers, who were not willing to quit smoking, were recruited sequentially to complete the questionnaires for the survey. The results were categorized into 6 groups as follows:

Quantitative data

1.	Demographic data
	(a)	Sex and age
		There was highly significant difference in the prevalence between male and female difficult-to-quit smokers. More than 90% of the participants were male. More than half (64.6%) were in the 41-60 years old age range.
	(b)	Marital status
		Majority of the participants were married (85.4%).
	(c)	Educational level
		A majority had secondary level education (62.5%). One-fourth of the participants had received education at tertiary or above level.
2.	Smoking attitude and knowledge towards smoking
	(a)	Smoking habit
		Nearly half of the participants started smoking between the age of 21-30 years old. Moreover, approximately 47% and 44% of the participants smoked <10 cigarettes/day and between 11-20 cigarettes/day respectively. (Figure 1)
	(b)	Attitude towards smoking
		Nearly two-third of the participants believed that smoking was affecting their health, smoking could not improve sleeping quality or sexual performance and smoking was not useful in maintaining body shape.
3.	Psychological influences
	(a)	Lifestress
		More than two-third of the participants felt stresses in daily life but the same proportion of the participants had good social support and coping strategy. Emotional problems were found in around one-third of the participants.
4.	Social situation
	(a)	Alcohol consumption
		Nearly two-third of the participants did not drink alcohol. (Figure 2)
	(b)	Monthly income
		There was no obvious difference in monthly income among the participants.
	(c)	Type of housing
		Nearly two-third of the participants owned their home. The remaining participants lived in rented housing (17.7%) or public housing (21.9%).
5.	Peer influences
	(a)	Influence from others
		Difficult-to-quit smokers were more likely to have smoking parents, smoking friends and colleagues (71.9%, 95.8% and 78.1% respectively). (Figures 3-5)
6.	Usual lifestyle
		A minority of the participants (17.7%) exercised more than 3 times per week. About two-third of the participants watched television for 2 to 4 hours a day. Nearly 90% of the participants liked eating in Hong Kong style cafS. (Figures 6-8)

Qualitative data

An open-ended question was: "What are your reasons for not quitting smoking?" Eighteen out of the ninety-six respondents answered this question. The responses were transcribed, translated and categorized into three themes: gains in smoking, side-effects of quitting smoking and lacking in motivation. One respondent said, "It was an agony to quit smoking!"

For the theme: gains in smoking, some respondents said, "Smoking could alleviate stress", and "decrease boredom." For side-effects in smoking cessation, one respondent was concerned about weight gain. In the lack of motivation theme, some said they were "not ready", "not determined", "no perseverance", "lack of will or willpower" and "due to previous failure". One respondent said it was because he was only taking a small amount only."

Discussion

Demograhic data, smoking attitude and knowledge towards smoking

The smoking prevalence by sex and the number of cigarettes consumed in this survey showed that majority of difficult-to-quit smokers were male (91.7%) and approximately 90% of them consumed less than 20 cigarettes per day. This was comparable to the Hong Kong Thematic Household Survey done in 2003⁴ (86.8% male and 13.2% female and 93.8% consumed similar number of cigarettes every day).

However, comparing with the same survey, there were some unexpected differences in this study.

First, concerning the age range, 64.6% of the smokers in this study were between 41-60 years old which was different from the survey done in 2003 when only around 33.9 % of chronic smokers were in the same age range.

Furthermore, 61.5% of daily cigarette smokers in the 2003 Thematic Household Survey started smoking before 20 years old whereas in our survey, only around 40% and 50% of them started smoking at <20 years old and between 21-30 years old respectively.

Interestingly, the participants had the following responses concerning the effect of smoking on health _ 61.5% agreed on harmful effect on health; effect on sexual performance _ 80.2% disagreed on enhancement on sexual performance; improvement of sleep quality _ 66.4% disagreed there was sleep quality improvement and maintenance of body shape _ only 7.3% believed smoking can maintain body shape.

Psychological influences, social situation and peer influences

Other findings in this survey were not similar to overseas research results which showed a positive relationship between difficult-to-quit smokers and heavy drinking, low educational attainment, socioeconomic deprivation, poor support, depression/anxiety, denial and poor coping strategy.^6-9 In our survey, we did not find such association.

On the other hand, the following findings matched the overseas studies,^{6-8, 13,15,17} which included 71.9% having smoking parents; 95.8% smoking friends and 78.1% smoking colleagues; sedentary lifestyle (more than two-thirds exercised less than 3 times per week); and stresses in daily life (more than 60% claimed having stresses in daily life).

Usual lifestyle

Regarding eating habit, which had not been addressed in previous studies, nearly 90% and 80% of our smokers liked eating in HK style cafs and fast food shops respectively. The majority of our smokers did not have regular exercise.

Implications from the findings

1.	Quantitative data
	Based on the findings observed, early age of starting to smoke may mean an early intervention to prevent the initiation to smoking is important, particularly for the adolescent and young adult group.
	In addition, smoking habit of parents, friends and colleagues may influence the smoking behaviour of the difficult-to-quit smokers. Hence, not only individual intervention is important but also the quitting of smoking among their significant others.
	The lack of exercise and eating in HK style cafs/fast-food shops are particularly common among our difficult-to-quit smokers. Early identification and appropriate intervention in this group of young adults may be helpful. To further discourage their smoking habit, legislation against smoking in HK style cafs/fast-food shops should be implemented as soon as possible. On the other hand, alcohol drinking is not useful in predicting who will be at risk of persistent smoking.
2.	Qualitative data
	One of the main reasons of the respondents not quitting smoking was to alleviate stress and decrease boredom. In smoking cessation counselling, we can explore the life stressors of smokers in different settings, for example, work and family, and advise on stress management and relaxation techniques. For unfavourable side-effect of smoking cessation, primary health care professionals can clarify myths and emphasize the smoking-related health hazards. For those who lack motivation, primary health care professionals can promote smoking cessation by using the evidence based 5 As: Ask, Assess, Advise, Assist and Arrange according to the Guidelines of smoking cessation, New Zealand Guidelines Group.24 If the opportunity is right, we should provide motivational interventions as specified in the 5 Rs25:

Relevance	-	encourage the smoker to identify why quitting is personally relevant
Risks	-	ask the smoker to identify negative consequences in both the short and long term
Rewards	-	ask the smoker to identify and discuss specific benefits of quitting
Roadblocks	-	assist the smoker to identify barriers and specific impediments to quitting
Repetition	-	reinforce the motivational message at every opportunity and reassure that repeated quit attempts are not unusual.

Limitations of this survey

There are a few limitations in this survey. First, the sample was selected from different clinics with heterogenous characteristics. Second, the questionnaire was just a preliminary tool for this survey with no validation done yet. Third, no statistical comparison could be performed due to the absence of a control group in this survey and hence the results obtained in this survey may be biased.

Conclusion

In this preliminary survey done in our primary care clinics, which serve patients in different regions in Hong Kong, we find that age group, usual lifestyle and smoking habit of parents, friends and colleagues may be associated with difficult-to-quit smoking behaviour among our smokers. Hence, early identification and appropriate intervention in daily general practice consultation may prevent the beginning of smoking in our patients. On the other hand, legislation against smoking in public places such as HK style cafs or fast-food shops should be implemented in order to encourage more difficult-to-quit smokers to stop their habit. For those who have already started smoking, understanding of the underlying reasons such as their life stresses, fear of weight gain and lack of motivation may help them to quit.

Acknowledgement

We would like to give our special thanks to Dr Luke CY Tsang, Dr Ng Kwok Keung, Dr Lai Tat Chau, Douglas, Dr Tam Ka Wae, Tammy, Dr Lau Man Wai, Dominic and Dr Ng Mei Yee for their support in this paper.

Key messages

1. Nearly half of the difficult-to-quit smokers started their habit at an early age.
2. Persistent smoking behaviour may be associated with smoking habit of parents/friends/colleagues, eating preference in HK style caf/fast-food shops and lack of regular exercise.
3. Major obstacles towards smoking cessation included perceived beneficial effects of smoking and concern about weight gain.

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References