Smoking cessation during the COVID-19 epidemic ‒ A new mode of intervention

Raymond KS Ho 何健生，Helen CH Chan 陳靜嫻，Grace NT Wong 黃雅婷，Patrick WY Fok 霍偉賢

HK Pract 2022;44:116-124

Summary

Objective: The objectives of this study were: (1) to study the feasibility of “mail to quit” smoking service delivery and its efficacy; (2) to collect the views of the participants; and (3) to evaluate the impact of the service on the participants.
Design: Prospective cohort study.
Subjects: Eligible smokers recruited from 1^st December 2020 to 31^st January 2021 were recommended to use the “mail to quit” service.
Main outcome measures: The outcome measures were: quit rate at 26^th week, participants’ satisfaction score and opinion score on the “mail to quit” service. A pre-test and post-test questionnaire on project impact was adopted from Donald Kirkpatrick’s four levels of evaluation.
Results: 161 out of 215 smokers responded to our survey, yielding a response rate of 74.88%. In the area of impact assessment, self-perceived health, life satisfaction score, knowledge gained, skill learned on use of distraction method, buying cigarettes all showed statistically significant improvement. The abstinence rate was 32.7% at 26^th week. The overall mean rating for the “mail to quit” programme was 4.54 (SD 0.69).
Conclusions: The “mail to quit” programme with remote counselling during the COVID-19 pandemic was a feasible and effective means to provide “smoking cessation” intervention for smokers. It was well received by smokers and had significant impact on their smoking behaviour and knowledge gain.

摘要

目的 ： 本研究的目標是：(1)研究“郵件戒煙”服務的可行性及有效性；(2)收集參與者的意見；以及(3)評估該服務。
設計 ： 前瞻性群組研究
對象 ： 招募從2020年12月1日至2021年1月31日符合條件的吸煙者使用“郵件戒煙”服務。
主要結果衡量標準 ： 結果衡量標準是：第26周的戒煙率，參與者的滿意度得分和“郵件戒煙”服務的意見評分。關於專案測試前和測試後的影響，問卷採納了唐納德·柯克帕特里克的四個級別評估。
結果 ： 215名吸煙者中有161人回覆了我們的調查，回覆率為74.88%。在影響評估、自我健康的認知、生活滿意度評分、獲得的知識、使用分心方法的技能、購買香煙都顯示出統計學上的顯著改善。第26周的戒煙率為32.7%。“郵件戒煙”計劃的總體平均評級為4.54(SD 0.69)。
結論 ： 在新冠肺炎大流行期間，帶有遠端諮詢的“郵件戒煙”計劃為吸煙者提供了“戒煙”干預的可行性和有效性的手段。它深受吸煙者的歡迎，並對他們的吸煙行為和知識獲取產生了重大的影響。

Introduction

COVID-19 is a coronavirus outbreak that initially appeared in December 2019 and it has then evolved into a pandemic spreading rapidly worldwide.¹ As of 17 April 2022, over 500 million confirmed cases and over 6 million deaths have been reported globally as reviewed by the WHO. This disease mainly affects the lungs. Smokers are at a higher risk of developing COVID-19 and are also at a higher risk of developing severe COVID-19 complications and deaths.² Smokers may be at an increased risk of contracting the virus due to reduced lung function, impaired immune systems and cross-infection. Cigarette smoking also increases the amount of forced vital capacity (FVC) and stimulates hyperproliferation of the bronchial mucosal glands, resulting in increased mucosal permeability, excessive mucus production and inhibited clearance of mucosal cilia, reducing the airway purification function and harmful microorganism screening in the upper respiratory system, leading to potential pulmonary inflammation.³ A recent meta-analysis revealed that current smoking increases the risk of severe COVID-19 infection by around twofold.⁴ Studies also suggested that even 4 weeks of smoking cessation may decrease the risk of adverse outcomes and respiratory failure associated with COVID-19 infection.⁵

During this pandemic, the fear of contracting a potentially fatal disease, confinement, the possibility of being laid off and the stress from financial problems, could increase the desire to smoke. However, smokers may also perceive their increased risk to COVID-19 infection and its complications, hence may also increase their desire to quit smoking.⁶

The need to remove the protective mask while smoking can facilitate viral transmission. Some governments have imposed a mandatory mask law, and this can make smoking very inconvenient. In Hong Kong, the SAR government had imposed a mandatory mask law to curb the spread of COVID-19 infection. In fact, some smokers had been fined because they took off their masks to smoke in public. Hence the COVID-19 pandemic presents a unique opportunity for smoking cessation. In a survey by Elling et al, one-third of the smokers were more motivated to quit smoking due to the coronavirus.⁷

Tung Wah Group of Hospitals Integrated Centre on Smoking Cessation (TWGHs ICSC) is a community-based smoking cessation service funded by the Hong Kong SAR Government. There are five centres in our New Territories, and they provide free smoking cessation services which include counselling and pharmacotherapy to Hong Kong citizens. Counselling is performed by experienced social workers who have been trained in smoking cessation.

In view of the need for social distancing, staying at home as much as possible and the potential increase in smoking cessation demand, we initiated a “mail to quit” programme offering the mailing of nicotine replacement therapy (NRT) and phone or online counselling.

In the late 1990s, the International Society for Mental Health Online (ISMHO) had already promoted the use of online technologies amongst mental health professionals. In 2001 comprehensive guidelines were developed in the UK by the British Association for Counselling and Psychotherapy (Goss et al., 2001).⁸ Online counselling has numerous advantages. It overcomes the need for travelling, enabling psychological assistance and intervention without face-to-face contact. It is specifically beneficial for those living in geographically remote areas. The visual anonymity associated with telephone counselling can decrease anxiety for the participants. They may be less defensive and more willing to share their feelings and difficulties.^9,10 Reese et al. had studied the attractiveness and client perception of telephone counselling in 2006 and gave a similar conclusion.¹¹

Objective
The objectives of this study were:

1. to study the feasibility of this mode of service delivery and its efficacy
2. to collect the views of the participants
3. to evaluate the impact of the service on the participants

Methods
Study population

A prospective study was carried out to recruit smokers to use the “mail to quit” services from 1st December 2020 to 31^st January 2021. The recruitment part were smokers self-referred to smoking cessation centres via telephone or QR code from advertisement in Facebook, mini-buses, mobile truck in smoking hotspots and smoking cessation hotlines operated by the Department of Health. Participants could enrol in the cessation services via telephone contact or QR code. For those who used the QR code method, they would be directed to a Google form so that they could fill in their particulars, their smoking habits, and their preferred time for future contacts by our counsellors. No personal ID number was collected in the Google form and each participant was assigned a clinic reference number for identification. Participants should be able to read and speak Chinese. Those who were aged less than 18 or above 60, allergic to nicotine replacement therapy (NRT); had chronic medical or mental illness; recent hospitalisation in the past six months, being pregnant or practicing breast feeding and had contraindications for the use of NRT were excluded. We limited participants to these stringent criteria because it was a pilot study, and we would like to play safe from the start. There were multiple routes of recruitment because we would like to recruit as many participants as far as possible. Besides, we had to meet a performance pledge to the Department of Health of HKSAR as there was a significant drop in clinic visits due to the need for social distancing.

All eligible service users were invited to join the study. A verbal consent for the study was explained and obtained by counsellors over the phone at the first intake. Information on the participants’ demographics, smoking habits, past medical history were recorded. Copies of consent forms were then mailed to the participants, who were required to sign and return the consent form to the investigators. After initial assessment through the phone, two weeks supply of the NRT were sent by mail to the eligible participants. A phone call was made several days later to ascertain the receipt of the NRT. Counselling, motivational interviewing and cognitive behavioural therapy were then given by remote counselling via phone or communication software (WhatsApp or WeChat) about twice weekly until the end of treatment which lasted from 8 to 12 weeks. The mailing package included:

1. instructions for the use of NRT,
2. a briefing on the principle and use of NRT for smoking cessation; the preparation needed and ways to deal with craving,
3. NRT patch, gum or lozenges, depending on the clinical conditions.

A guideline on the use of remote consultation as adapted from the UK National Health Service (NHS) 2020 National Centre for Smoking Cessation and Training was issued to all counsellors to follow.¹² All interventions and counselling sessions were similar to our conventional method of smoking cessation programme.

All those reported to have adverse reactions were assessed by counsellors and referrals to our clinic doctor were arranged when necessary.

A questionnaire on the impact of the current programme, adopted from Donald Kirkpatrick’s framework (knowledge, skill, attitude, behavioural change, self-rated life satisfaction, self-rate health, self-rated job satisfaction and self-rated family life satisfaction) was carried out before and at the end of treatment, (Pre-test and Post-test).¹² The outcome measures were quit rate at 26^th week, participants’ satisfaction rating and their opinion on the “mail to quit” service.

The quit rate was defined as 7-day point prevalence abstinence and those who could not be contacted or defaulted would be considered as not quit based on the intention to treat principle. In view of the online consultation, no biochemical validation of abstinence was performed.

Descriptive statistics were used for basic demographics. Continuous variables were expressed as mean ± standard deviation (SD). Categorical variables were presented as numbers and percentages. McNemar’s Chi square test, paired t-test and Fisher’s exact test were used for pre- and post- intervention analysis of variables.

Results
Sample characteristics

During the first intake, 215 subjects consented to participate in the study (Figure 1). At the end of treatment, 161 subjects responded to our survey, yielding a response rate of 74.88%. The characteristics of 215 and 161 participants were listed in Table 1. More than 57% were in the age of 26 to 40 with a male predominance. More than half of them were married and more than 77% were employed. Most of them had previous quit attempts, and about 56% lived in the New Territories, a relatively remote area from the town centre.

Impact assessment

Since only 161 subjects responded to our survey, we limited this group to undergo pre- and post-treatment analysis on the impact assessment and their opinion on the “mail to quit” programme. In the area of impact assessment, self-perceived health, life satisfaction score, knowledge gained, skill learned on the use of distraction method, buying cigarettes all showed statistically significant improvement (Table 2). There was no significant change in family relationship and work efficiency.

Opinion survey and abstinence rate

In the opinion survey, the mean score on the convenience of “mail to quit” programme was 4.65 out of 5 and this might be considered as remarkably high. 92.54% of participants did not have any problem in collecting medication (Table 3). On average it took 2.94 days to secure the medication. 29.2% reported some adverse reactions from NRT. This was similar to NRT dispensed by conventional methods. All of the adverse reactions were minor such as allergic dermatitis, and no major adverse event was reported. The mean rating on the explanation and counselling offered by counsellor was 4.24 out of 5, and mean rating on the use of social media for counselling service was 3.93 out of 5. The mean rating on professional help and motivation on smoking cessation were also high, 4.37 and 4.32 respectively. The overall mean rating for the “mail to quit” programme was 4.54 out of 5 (SD 0.69).

There were 215 participants joining our treatment programme initially and one withdrew later. due to personal inconvenience. 70 participants reported total abstinence (7-day point prevalence) at 26^th week, yielding a quit rate of 32.7%.

Discussion

Since the beginning of the COVID-19 pandemic in February 2020 in Hong Kong, there was a dramatic decrease number of smokers seeking smoking cessation via our service in view of the need for social distancing and fear of contracting the disease, despite a potential increase in the need of smoking cessation from the smokers. This pandemic provided us with an opportunity to review our service and to modify our mode of service delivery to meet the social distancing requirements. The use of remote counselling together with mailing of NRT was thought to be a useful alternative.

In our study, there was significant impact in terms of self-rated health, life satisfaction score, knowledge gain, skill and attitude change and behavioural improvement. There were numerous studies on the health impact and cost effectiveness of smoking cessation programmes. However, we were not aware of any study, either locally or overseas, on the impact of a smoking cessation programme similar to our “mail to quit” during the COVID-19 pandemic.

In the survey opinion with this programme, the overall rating from the participants should be considered as remarkably high. There was no excessive delay in collecting the mail and more than 90% of participants did not have any difficulty in getting the medication. As to online counselling or telephone counselling, most of them considered it to be effective, helpful, and able to serve its purpose, and our counsellors were able to motivate them to quit smoking. One point worth noting is that the score on telephone counselling was higher than counselling via communication software.

On the area of telephone counselling, a study by An LC. et al. indicated that the telephone care increased the use of behavioural and pharmacologic assistance and led to higher smoking cessation rates, compared to routine health care provider intervention.¹⁴ A meta-analysis review by Lichtenstein et al also indicated that there was a significant increase in cessation rates by proactive telephone calls compared to control conditions.¹⁵ The abstinence rate at the 26th week of the current study was 32.7% and this was comparable to a study by Macleod et al¹⁶ who used telephone counselling as an adjunct to nicotine patches in smoking cessation and reported a quit rate of 30.7% at 6 months. However, the methodology of this study was totally different from ours. According to overseas experience, the average abstinence rate at 26^th week was 20-25%. On the other hand, our abstinence rate at 26^th week with conventional method over the past five years was around 43%. This implied that the ‘’mail to quit’’ programme should be considered satisfactory, although it was lower than our conventional method. This could possibly be due to the fact that face-to-face counselling was used in conventional method.

In our study, the ‘’mail to quit’’ service was carried out via one-to-one communication rather than ‘’open’’ messaging, public sharing of information or group counselling. We mailed NRT to the participants without urging them to come to our clinics. This could save their opportunity cost on travelling and time spent. This was much welcomed by the participants as seen from the result of this study. As to the efficacy of mailing of NRT, a study by Cunningham et al has provided evidence of the effectiveness of mailed nicotine patches without behavioural support to promote tobacco cessation.¹⁷ Self-reported abstinence rates were significantly higher among participants who were sent nicotine patches compared with the control group (odds ratio, 2.65; 95% CI, 1.44-4.89). In our study, we have not isolated the effect of mailing NRT alone, although the combined effect of remote counselling and mailing of NRT was remarkable. Based on overseas and the present study, the future of remote counselling on smoking cessation appears favourable and effective.^18,19

The users of remote counselling sampled in this study found it appealing and attractive. It is particularly convenient to those who have to work shift duties or unconventional office hours, or those who cannot afford to come to the clinics. The enrolment by QR code and Google form can be conducted 24 hours a day, hence making enrolment much easier. However, counselling via telephone or communication software may not be best for clients who prefer to see their therapist and for clients who were experiencing severe problems such as unstable mental condition. Another downside of telephone consultation is that we could not detect any non-verbal cues from the participants, their attention span or their understanding during the consultation. In real practice, some participants may be distracted by something else during the consultation process. In the present study, we have also excluded old- age clients, clients with chronic medical illness and mental disease to avoid risk and complications.

Limitations

There were a few limitations in this study. This is an observational study on smokers who were relatively healthy. They did not have any chronic medical conditions or mental illness. They were adult smokers who were aged 60 or below. Therefore, the result cannot be extended to the whole smoking population. There was no control group to compare with the effectiveness of this mode of intervention and there were no benchmarks for the scores. There are many facets of impact assessment and we only limited it to the Donald Kirkpatrick’s four levels of evaluation.^20,21,22 Our survey questionnaire was self-devised with reference from Donald Kirkpatrick’s method, hence there was no gold standard. The quit rate is self-reported abstinence and there is no biochemical validation, although consensus statements indicate that biochemical validation of tobacco cessation may not be required in the present study.²³

Conclusion

In conclusion, the “mail to quit” programme with remote counselling during the COVID-19 pandemic is a feasible and effective means to provide smoking cessation intervention for smokers without chronic medical illness with a satisfactory abstinence rate. It is feasible in terms of administrative procedure, solving technical issues and setting up guideline for remote consultation and smoker’s acceptance. It reduces the risk of social contacts and social exposure during travelling, hence reducing the risk of contracting the virus. There is significant impact on the participants, both in terms of quitting, behavioural change, and knowledge gain. The programme is perceived to be very convenient, helpful and useful and is well received by the smokers. A further large scale control study is worthwhile to validate our findings.

Ethical approval and consent from participants

This study was approved by the Research Ethics Committee of the Tung Wah Groups of Hospitals (No. R2021007). Written informed consent was obtained from all participants prior to their enrolment in the study.

Funding

There is no special funding source for this study. The smoking cessation service was funded by the Department of Health HKSAR Government.

Potential competing interest

Nil declared.

Acknowledgement

We thank all staff involved in this project.

References