The Importance of Supportive
Environment in Facilitating Cessation –
Findings from Studies
2nd National Health Promotion Conference 2011
Wee Lei Hum, PhD
Institute for Health Behavioural Research,
Ministry of Health Malaysia
Cititel Mid Valley
10 – 11 October, 2011
Outline
 Development of Supportive
Environment in HP
 Understanding Smoking Cessation
 Smoking in Malaysia
 Findings from Current Studies
 Reviews from Other Studies
 Discussion & Conclusion
3/22/2016
2
Development of Supportive
Environment in Health Promotion
 Commitment of WHO to the goals of Health for All in 1977
 WHO/UNICEF international conference in Primary Health Care held in
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Alma Ata in 1978.
1st International conference on HP in Ottawa 1986.
2nd International Conference in Adelaide in 1986 – countries experiences in
development & implementation of Healthy Public Policy.
A Working Group on HP in Developing Countries, in Geneva to consider
the meaning & relevance of HP to developing countries in 1989.
3rd International Conference on HP and Supportive Environment was held
in Sundsvall, Sweden.
To act upon challenges identified in Sundsvall Statement, Agenda 21 &
WHO Global Strategy, WHO & UNEP organised a meeting in Kenya in
1993.
The Bangkok meeting represent a 2nd meeting to the translation of the
concept of promoting supportive environment for health in Asia Pacific
Region, in 1993.
Elements of Supportive
Environment
 Supportive environment is not an individual concern
but for all to act upon.
 Focus both on physical and social aspect
 Establish alliances
 Establishing supportive environment involves both
individual and community responses
 Providing health services not only in times of needs
 Implement national policies through settings
approach to facilitate inter sectoral action
Introduction
 Smoking prevalence
 developed countries - 50% decline in 30
years since 1960’s.
 developing countries - increase of 3.4%
annually (WHO, 2002).
 Despite various efforts to control smoking, it
continues to be the single greatest risk to
public health problems (Joseph, Velicer, &
Prochaska, 1995).
Introduction ..2
 Malaysia is facing an endless array of challenges in
a bid to control the prevalence of smoking.
 Despite the knowledge that tobacco use is the
most preventable cause of illness, cigarettes are
easily available, highly accessible and legally sold
in this country (Clearing House Tobacco Control,
2005).
 It is important to reduce the number of people
who start smoking and to increase support to
those who want to quit (Marcus, Pahl, Ning, &
Brook, 2007).
Understanding Smoking Cessation
 Dynamic process, repeated attempts and relapse
(Hughes, 2005).
 Success in quitting smoking is determined by the
interplay of multiple factors (West, 2006).
 Differ in readiness and ability to quit smoking
despite the effectiveness of various tobacco control
interventions strategies (Doran et al., 2006; West,
2004).
 Research shows that while the majority of smokers
want to stop smoking, most continue to smoke
(Thyrian et al., 2008).
Postulations of Theories
 Choice Theory - health related behaviors are dynamic, not
always consistent, unstable planners who act on
circumstantial decisions (Skog, 2000).
 PRIME theory - how we act at a particular moment can
only be influenced by the motivations operating at that
time (West, 2009).
 Humans are much more driven by immediate emotions
rather than rational as commonly assumed (West 2009).
 Smokers’ motivation can change quickly and strongly
influenced by smoking cues in the environment. Thus,
smokers’ motivation to stop smoking may not accurately
reflect what they truly feel and think (West, 2004).
SMOKING IN
MALAYSIA
Changes in Prevalence of Current Smokers by Age
(Comparison between NHMS3 with NHMS2)
35
30
25
20
15
10
5
0
18- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80+
19 24 29 34 39 44 49 54 59 64 69 74 79
NHMS2
NHMS3
Age (yrs)
Availability of Quit Clinics
70.6% attempted to quit
 2 quit attempts in a year
 Only 38% aware of quit clinics
 Awareness was higher among:
 rural
 more educated
 professionals
 younger

Recent Published Smoking Cessation
Research in Malaysia
 2 studies
 Study design: Retrospective and Prospective
 Setting: 5 quit smoking clinics in FT
Study 1
Retrospective Study (N = 629)
 Smokers Past Records, Jan 2006 – June 2007
 Measures: Personal particulars, current and
past smoking history, health status, method
of quitting, COppm and FTND.
 Intervention: Behaviour counseling and NRT.
Study 2
Prospective Study (N = 200)
 Face to face interview at 1st visit, 4-week and
3-month
 Measures: Pre-quit attempt, 4-week postquit attempt and abstainer/relapser followup questionnaire at 3-month
 Intervention: Behaviour counseling & NRT
Objectives
 Identify characteristics of smokers
 Explore psychological process
 Identify difficulties experienced by
smokers
 Improve clinic intervention strategies
 Identify predictors of successful
quitting
RESULTS
Smokers Characteristics
 Male (95%)
 Younger (35 yrs old)
 More educated / professional 45.5%
 Mean age started smoking 16.7
 Had health problems 32%
 Average daily cigarettes smoked 17.7
 Daily average spent RM7.36
 Mean FTND 4.5
Reasons to Quit
 Health concern
 Cost of cigarettes
 Pressure from friends/family
 Doctor’s advice
Triggerred by the Clinic
 Clinic - decision to quit was made.
 32.5% had not been seriously thinking of quitting
before they heard about the clinic and 56.9% heard
about the clinic first before deciding to stop smoking.
 The main triggers for quitting: advice from a doctor/nurse
 experiencing symptoms due to smoking
 viewing a poster in the clinic
 suddenly realising how bad smoking is
 cost of smoking.
Conflicting Thoughts
 Intention to stop smoking completely for a while.
 Want to stop smoking but at the same time enjoy.
 Allow for an occasional cigarette.
 Given the fundamental instability of the intentions of
thinking about quitting, smokers are sensitive to
environmental stimuli at the moment and act upon it
(Hughes et al., 2005).
 Smoker will accept the offer of help and may proceed
with the attempt and abstain (Larabie, 2005; Pisinger et
al., 2005; West, 2009).
Where and When relapse
Commonly occurred?
 25.0% experienced first lapse immediately or 32.5% during
the first week after the quit date.
 Home, workplace and eateries - where the first cigarette
was smoked (Bliss et al., 1989).
 What were they doing?
 socialising with friends
 seeing someone else smoke
 doing nothing in particular
 What situation were they in?
 experience of strong urges
 being in stressful situations.
Final Model for Predictors of
Successful Quitting
Independent predictors after adjustment for confounding
4 Weeks Predictors
OR (95%CI)
PreCO2
0.88 (0.82-0.96)
Age
1.07 (1.04-1.10)
Method of quitting
Abrupt
4.10 (1.682-9.98)
Gradual
1
Cost of cigarettes
Yes
2.68 (1.21-5.95)
No
1
3 Months Predictors
Clinics
Tanglin Community Clinic
Putrajaya Hospital
Jinjang Health Clinic
Pantai Health Clinic
Kampung Pandan Health Clinic
Marital Status
Single/Divorced/Widowed
Married
What led you to come to the clinic (Planning)
-Had been thinking to quit smoking
-Had not been thinking to quit smoking
Feeling about smoking
-Do not really mind being a smoker
-Very unhappy to think of myself as a smoker
Motivation level to stop smoking completely
-Extremely strong
-Very strong
-Quite strong/ Not very strong
Smoking helps me to stay alert
-Yes
-No
Amount of tobacco smoked compared with other
smokers
-I smoked about the same as most other smokers
-I smoke more than most other smokers
-I smoked less than other smokers
-I do not know
OR (95%CI)
1
0.11 (0.03- 0.34)
0.41 (0.15- 1.08)
0.16 (0.05- 0.56)
0.07 (0.01- 0.31)
1
2.69 (1.20-6.04)
1
2.58 (1.11-5.99)
1
2.30 (1.05-5.06)
1
0.24 (0.08-0.71)
0.11 (0.04-0.33)
0.32 (0.13-0.75)
1
1
5.85 (1.88-18.24)
2.43 (0.96-6.17)
2.18 (0.60-7.90)
6 Months Predictors
Clinic
Tanglin
Putrajaya
Jinjang
Pantai
Kg Pandan
Duration of previous abstinence in weeks*
Age in years*
Previous attempts made
Yes
CO reading in ppm*
Multivariate
OR
(95%CI)
1
0.68 (0.38-1.23)
0.76 (0.43-1.34)
0.11 (0.04-0.28)
0.14 (0.06-0.34)
1.01 (1.01-1.02)
1.02 (1.00-1.04)
1.78 (1.07-2.96)
0.96 (0.93-0.99)
* per unit increment
24
DISCUSSION
&
CONCLUSION
Decision to Stop Smoking is Made
at Home
 Most likely to be exposed to pressure to stop smoking
in the own home (30.0%).
 External pressure and support is important by the fact
that smokers who are married are more likely to
abstain (Honda, 2005, Lee & Kahende, 2007).
 Smokers with more children are more likely to succeed
and place greater emphasis on the importance of
family values (Stevens et al., 1982a).
Smoke Free Homes &
Workplace
 Bans at the workplace and home are significant
predictors of successful quitting (Farkas et al., 1999;
Shields, 2005).
 Smokers who quit successfully report prohibition of
smoking at home (Lee & Kahende, 2007).
 The presence of other smokers in the home lower a
person’s long-term chances of quitting due to repeated
cues to smoke (Frank, Umlauf, Wonderlich, & Askakonzi,
1986).
Working Conditions
 Smoking cessation is more successful among
people with a good social support in their job
(Fisher et al., 1994).
 Less successful among those with (Janzon et al.,
2005): greater working hours
 shift work
 high physical workload
 frequently exposed to role conflicts at work
Triggers from the Environment
 Smokers were triggered by ‘something else’ that made
them realise how bad smoking is - complexities in the
environment which interacts with smokers must have led
to this realization and resulted in an urgency to act.
 A balance is achieved between competing environmental
factors and wants and needs through the `sudden
realization of how bad smoking is’, this realization is
sufficiently strong to trigger cessation.
 The decision made by the smokers to act at that precise
moment is a result of the interaction of multiple influences
(West, 2009).
 Such moments can appear at any time and without
smokers realising it (West, 2009).
Doctor’s Brief Advice
 Cost-effective and most effective non-pharmacological
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interventions (1 in 40 smokers) (Coleman, 2004).
Higher success rate in those who received advice from a
doctor than family members or friends (Aveyard et al., 2007;
Hyland et al., 2006).
Smoking related disease is one of the strongest predictors of
abstinence (Edwards et al., 2007).
Physician-administered smoking cessation counselling
lasting less than 3 minutes improves quit rates (Fiore, 2000)
and increasing the time spent on counselling with follow-up
visits can lead to even better outcomes (Coleman, 2004).
Adding NRT to brief advice should provide additional
benefits (Raw, 1999).
Treatment
 Quitting without clinic support has relatively low
success at only 7% (Hurt, Wolter, & Rigotti, 2002),
while clinic interventions to increase the
abstinence rate to 16% (Silagy, Lancaster, Stead,
Mant, & Fowler, 2006) to 33% (Prochazka, 2000).
 Only a minority of smokers attempting to stop
smoking actually seek clinic help and use NRT,
may reflect a lack of confidence among smokers
that clinic interventions help (West, 2004).
Support from the Clinic
 Smokers receive support and advice from clinics run by trained
smoking cessation personnel are more likely to succeed (West,
2000).
 Effectiveness of behavioural support provided by health care
professionals with limited training who are providing the service
in conjunction with other duties have not shown evidence of
efficacy beyond brief advice (Aveyard,2007).
 Good clinic support (e.g. enough personnel) is one of the
contributors towards clinic performance (Lancaster & Stead,
2005)
Why Treating Smokers is
Challenging?
 Unstable intentions, conflicting thoughts and
beliefs.
 Understanding this dynamicity of the smokers mind
will enhance intervention strategies.
 Generate repeated quit attempts by offering help
with stopping to all smokers and not to those who
are ready.
 Intervene at the opportune moments and encourage
all smokers to make decisions to quit smoking by
creating tensions and triggers.
Act Now
 We cannot predict quitting opportunities which
appear to be fluid in nature (Marlatt et al., 1988;
Mook, 1996).
 Face many competing priorities in the
environment which require us to make decisions
and this equally applies to smokers contemplating
to quit or to continue smoking. At this time, their
action is critical (West, 2009).
 At the time when a quitting opportunity presents,
we should encourage smokers to act immediately
and quit abruptly (Larabie, 2005).
Limitation
 Urban setting ~ sample composition similar to
census characteristic in NHMS3
 Missing data in retrospective study
 Involve more than one clinic, practice and
experiences varied ~ guided by the standard
clinical practice guidelines.
ISI Journals
1.
Wee, L. H., Shahab, L., Bulgiba, A. & West, R. (2011) Stop smoking clinics in
Malaysia: characteristics of attendees and predictors of success. Addictive
Behaviours, 36(4), 400-403. doi: 10.1016/j.addbeh.2010.11.011
2.
Wee, L. H., Shahab, L., Bulgiba, A. & West, R. (2011) Conflicting motivations and
the decision to stop smoking gradually or abruptly – evidence from smokers’
clinics in Malaysia. Journal of Smoking Cessation, 6(1), 37–44. DOI
10.1375/jsc.6.1.37
3.
Wee, L. H., West, R., Bulgiba, A. & Shahab, L. (2011). Predictors of 3-month
abstinence in smokers attending stop-smoking clinics in Malaysia. Nicotine &
Tobacco Research, 13(2), 151-156. doi: 10.1093/ntr/ntq221
4.
“Exploring smoker’s beliefs and feelings about smoking and quitting during a quit
attempt – findings from a qualitative analysis of the SNAP model” – Under
review, smoking cessation
Books & Newspaper Articles
Book
‘Psychological Process and Factors Related to Smoking
Cessation’, 2011
Newspaper Article
‘Why are smokers able to abstain from cigarettes during
their Ramadan fast’, Sunday Star, 22nd August 2010
Male and married? It’s easier to quit then, New Sunday
Times, 6th February, 2011
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