INTRODUCTION
Tobacco use is recognized as the main cause of premature and preventable deaths in Malaysia. Based on the information from the World Health Organization (WHO) report on Global Tobacco 2017 (WHO 2017), tobacco is the largest problem worldwide as it has killed more than seven million every year. The Clinical Practice Guidelines of the Ministry of Health 2016 (MOH 2016), estimated that 20,000 deaths in Malaysia were attributed to smoking annually. Additionally, there was approximately 22.8% male smokers aged 15 years and above and 1.1% of female smokers in 2015 (Ibrahim et al. 2016).
Even though many strategies have been highlighted through the implementation of anti-smoking programmes, the prevalence of smoking is still high with no significant reduction shown. The Malaysian government has played an excellent role in reducing the number of smokers in the country. However, without cooperation from those smokers, all the agenda that had been planned to combat smoking in Malaysia cannot be fulfilled. Awareness of the hazards of smoking should be inculcated and cultured in every Malaysian to prevent the smoking habit. Wee et al. (2016) stated that there are limited studies on the effective strategy to reduce the number of smokers in Malaysia. Thus, this research is relevant and beneficial to get the informative input or views from the healthcare providers on the current anti-smoking campaign and the functionality of smoking cessation clinics. The relevant recommendations by the respondents would be beneficial in improving the current anti-smoking campaign to be more effective and comprehensive. The reasons behind the refusal of smokers in seeking help from the quit smoking service need to be elaborated and explained.
The outcome of this study also can help improving the anti-smoking campaign in Malaysia and offer a positive impact. It is important to make sure that the efforts and contributions of the healthcare providers in helping the target individuals are successfully and able to contribute to the betterment of health and human.
The main aim of this study was to identify the main factors in the challenges of anti-smoking campaigns by interviewing a few healthcare providers who were directly involved with smokers in Kuantan.
MATERIALS AND METHODS
This was a qualitative research study using face-to-face semi structured bilingual interviews to explore the factors behind the challenges of anti-smoking campaigns from the perspective of healthcare providers. This study involved three primary health clinics around Kuantan that were Health Clinic Bandar Kuantan, Health Clinic Beserah and Health Clinic Jaya Gading. In this study, the type of sampling used was purposive sampling. This sampling was based on the predetermined criteria, where: healthcare providers who were closely involved in Smoking Cessation Clinics; able to understand the Malay and English; and willing to participate voluntarily. Consent from respondent was obtained before interview session started. The samples of the study were five healthcare providers recruited from primary health clinics which provide smoking cessation services. Questionnaires that related to anti-smoking campaign and smoking cessation clinic were developed in dual languages, which were Malay and English during interview sessions. The questionnaires were checked by the content expert and members in order to improve the validity.
There were four elements of trustworthiness, which were credibility, transferability, dependability and confirmability which were taken into account for this qualitative research. A few steps were taken such as (i) credibility: to ensure richness of data by appropriate sampling of respondents selected, duration of each session was limited to one hour , data saturation and team checking (expert and members); (ii) dependability to ensure that the finding of the study was consistent even when it was repeated as all the transcriptions from audio to text were cross-checked several times; (iii) transferability by ensuring the findings of this study were capable to be generalised to other contexts; (iv) confirmability was done by measuring through proper audio recording and data checking by external members. Thematic analysis was used for the data interpretation. It involves coding process to establish a meaningful pattern. The interviews were conducted and the recordings were then listened and examined for transcription. It was being listened and read a few times to obtain the information clearly and get the initial idea.
The duration of study was three months from the early April to the end of June 2018. This study was approved by the Medical Research Ethics Committee (MREC), National Medical Research Register (NMRR)-NMRR-18-122-39714 (IIR).
RESULTS
A total of consented five healthcare provides at selected health centre were interviewed (Table 1). During the interview, the researchers found that there were issues or contributing factors raised by the healthcare provider that affected the smoking cessation campaign and the effectiveness of the cessation clinic. The factors were divided into three parts which were smoker, structural and planning.
Part 1: Smoker
i) Low understanding of Standard Operating Procedure (SOP) from smokers.
Three respondents mentioned client dissatisfaction.
“…we follow our procedure (to provide medication)” (Medical Officer, Health Clinic Bandar Kuantan).
“The clients are expected to obtain the medication on the first appointment. They are reluctant to attend the counseling session. Sometimes we will conduct counseling on the first and second appointment, on the third appointment, then we will start giving medication. But the client refused to follow our procedure and SOP.” (Medical Assistant, Health Clinic Beserah).
“The clients will experience demotivation and feel that the doctor is not fully focusing on them.” (Medical Officer, Health Clinic Bandar Kuantan).
Some clients refused to follow the standard of procedure (SOP) of the Smoking Cessation Clinics and were expected to have the medication as soon as they registered. Respondents shared that the SOP affected their motivation badly and felt that healthcare providers were not focused on the treatment. This could probably appear from the failure to explain the procedure or flow process thoroughly.
ii) Low commitment
The problem of absenteeism was raised in the appointment session. Four respondents mentioned that clients were not ready as they were being forced to join the Smoking Cessation Clinics, with the lacking of the motivation and support.
“Their mental state is not strong enough for them to stop smoking. Usually, they failed because of their mental state that is unprepared or not ready, and they join the Smoking Cessation Clinic because being asked by other people.” (Medical Officer, Health Clinic Bandar Kuantan).
“Come (to the Smoking Cessation Clinic) unwillingly and maybe being advised by the doctor… they attend a few early appointments and then absent.” (Medical Assistant, Health Clinic Beserah).
“Family support is important. (They) actually being forced (to join the Smoking Cessation Clinic), they are unwilling. Their wives complained about and then they decided to register for the Smoking Cessation Clinic just to make their wife quiet...” (Medical Assistant, Health Clinic Jaya Gading).
iii) Easily influence from the public
The respondents shared that influence from surroundings contributed to the failure of anti-smoking campaigns. Few clients from the clinic would smoke once they gathered with their friends.
“The clients did not smoke when they were alone and at home, however, when going with friends, they will smoke.” (Medical Officer, Health Clinic Bandar Kuantan)
“…they have the courage and motivation to quit. But, their friends will make them down…and then they will start (smoke) again.” (Medical Assistant, Health Clinic Jaya Gading)
“…I also conducted this programme (Smoking Cessation Clinic) for some of the staffs…” (Medical Assistant, Health Clinic Bandar Kuantan).
Habitual culture norm in the society on smoking also contributes to the failure.
Part II: Structural Factor
Multi-disciplinary tasks of healthcare providers cause low focus on patients who are smokers.
From the interview sessions, four respondents had emphasised on the time-limit session with smokers.
“…from my observation, actually we (health care providers) have a very limited time… (we still need to) review the outpatient clients, it is not that we (people who are in charge of the Smoking Cessation Clinic) can stop doing other work and focusing on Smoking Cessation Clinic only…for myself, I really have a limited time…I had to touch and go only (in reviewing clients of the Smoking Cessation Clinic), it is not what I want but I had to touch and go.” (Medical Officer, Health Clinic Bandar Kuantan).
“…my appointment slot is very limited. So I have to ask (the clients) whether they willing to stop or not.” (Medical Assistant, Health Clinic Bandar Kuantan).
“One of the issues is the client is working at the time of appointment as the clinic is running during the office hours.” (Medical Assistant, Health Clinic Beserah).
According to the respondents above, they also had to focus on other disciplines, therefore could only have limited attention on the Smoking Cessation Clinic. Due to manpower issue, time spent on clients was very limited and as smoking cessation needs more time for counselling, the process will be disrupted.
Part III : Planning
i) Inadequate publicity strategy
There were three participants who commented on the efficiency of current promotions and the widespread nature of the campaign.
“Based on my observation, the promotion is limited and not effective even there is promotion on television, on the cigarette boxes, but still transaction related to the cigarette happened. They only will stop smoking when ill and no budget.” (Medical Assistant, Health Clinic Bandar Kuantan).
“…(there is promotion) but it is not really widespread…” (Medical Officer, Health Clinic Beserah).
“We had made a banner to promote quitting smoking, however, it seems like not to have any participation (from people)…” (Medical Assistant, Health Clinic Jaya Gading).
Respondents believed that the current promotion on anti-smoking campaign was limited, ineffective and not widely spread to the community. According to the respondents, even though banners were displayed but participation from the public was scant. Furthermore, banners were only restricted within primary clinic surroundings only.
DISCUSSION
The knowledge obtained from the investigation cessation barriers, awareness and measures as challenges to enhance the anti-smoking literature. The finding was reviewed and compared against the available literature to find similarities and differences.
Media and communication were an effective medium in spreading the information to the public regarding the health issues. However, the issue of smoking in this country was considered high. The health care providers claimed that they have used many strategies to discourage smoking behaviour, but they were doubtful with the implication of their actions (Khalaf et al. 2017). It is necessary to identify the specific technique and medium to use according to the target population, so that the information and message were delivered well, and have a clear impact. Through interviews, we found that the promotion of smoking cessation is localized and not comprehensive. Therefore, aligned with the previous study, the is a need of technique to ensure the information about anti-smoking and the available facilities will reach the community effectively.
Clients are the important persons involved in Smoking Cessation Clinics. According to the healthcare provider, most of the smokers misunderstand the SOP resulting negative perception on the treatment given. Supported by Collins et al. 2018, concluded their research that most of the homeless smokers were disappointed with the smoking cessation implementation that had been established. From these reviews, it can be understood that the client needs to understand the process of the treatment and the provider shall explain the process to the client effectively. The factors must be identified in order to reduce the failure of the anti-smoking campaign conducted.
In primary health clinics, there were a lot of patients. The health care providers need to divide their time wisely so that they can fulfill the appointments that have been set for each patient. This problem also occurred in the Smoking Cessation Clinics as the health care providers that handled this service also have to review other patients. The Smoking Cessation Clinics have taken measures in providing a specific time to run the Smoking Cessation Clinics. For instance, the Smoking Cessation Clinic in Health Clinic Bandar Kuantan allocated Wednesday and Thursday from 2 pm to 5 pm specifically to meet the clients that join the quit smoking treatment. The finding was similar to Prabhu et al. (2017), that lack of time was mentioned as the main barriers in giving treatment to the anti-smoking clients. Besides that, there was a problem related to time of the appointment as the clients were working in that hour. Thus, employers can play their roles in encouraging smoking cessation among staffs to make sure the health of the workers and optimal workplace productivity (Olumide & Owoaje 2017).
Addiction barrier, internal barrier and external barrier were being reported as refusal factors to stop smoking (Nurulfarahin et al. 2018). The external barrier was explained as difficulty in finding an individual who was able to assist the smoker to stop, lack of encouragement from family, friends and health professional in quitting. It was consistent with the finding of this study, wherein negative influence was one of the challenges to the clients in maintaining abstinent.
Most of the respondents were aware that motivation and support from family members and the people surrounding were more than crucial to encourage the smokers successfully stop smoking. Most of the smokers recommended the support groups to help in preventing smoking relapse (Onezi et al. 2018). The support person carried the responsibility to motivate and assist the smokers to move forward in quitting. The close persons, including family members and friends were the most powerful resources to encourage and help the smokers to quit smoking. It was noted that daily engagement and encouragement were able to motivate and increase the confidence level to quit smoking. Hence, support and motivation were really important to every smoker to fulfill the follow up appointment and continue the treatments to quit.
Based on the results, the author has proposed a few strategies to improvise current approaches to reduce the number of smokers which are improvements in the variation of publicity strategies, law enforcement and providing incentives to smokers who successfully quit smoking.
Information on government/NGO activities, facilities and treatment shall be disseminated by proper promotion. Therefore, the messages will be well spread out and reach the public effectively. Promotions can be online or offline. Information must be successfully received by the public so that the mass can understand and accept it positively. It is necessary to identify the specific techniques and mediums to use according to the target population, so that information and messages delivered would have a great impact (Hafifi et al. 2017). There are several types of smoking cessation strategies which will be generally categorised into three aspects; self-encouragement to quit, medication replacement therapy and counseling therapy that involve peer group or professional consultant and lastly combination of medication with counseling. During counseling therapy, many approaches can be done such as alarming the smokers on the dangers of smoking and to encourage them to replace smoking with other beneficial activities. In 2003, WHO established six policies known as MPOWER to decrease tobacco use and encourage smoking cessation worldwide. MPOWER stands for-Monitor tobacco use and prevention policies, Protect people from tobacco smoke, Offer help to quit tobacco use, Warn about the dangers of tobacco, Enforce bans on tobacco advertising promotion and sponsorship, and Raise taxes on tobacco. Based on the MPOWER, smoking cessation strategies will be under the category of Offer help to quit tobacco use and Warn about the dangers of tobacco policies. The strategies for smoking cessation under Offer help to quit tobacco use could be like advertisements on mass media, internet coaching, medication and others while the smoking cessation strategies under Warn about the dangers of tobacco could be pictorial warning labels and quit smoking policy.
Increasing taxes on cigarettes is one of the most cost-effective programmes to reduce the amount of cigarette packs sold every day. Moreover, this step will prevent youngsters from buying cigarettes. In addition, the World Bank Group’s Global Tobacco Control has become a reference for other countries in designing tobacco taxes by making a special module for tobacco taxation to strengthen their taxes on tobacco policies. Based on the report of The World Bank 2017 (WHO 2017), tobacco tax is a programme that will decrease amount of smoker and increase domestic resources in the country. So, a country will get more resources for investment as a huge amount of money has been used for health problems caused by smoking.
Effective law enforcement will contribute to the success of the campaign. The law will involve multiple parties related to the smoking cessation such as manufacturers, higher authorities, seller and smokers. The law will complement the anti-smoking programme that been published or conducted from the relevant organization. Thirty-two countries in the world had join the laws that establish smoke free workplaces and public areas from 2007 until 2012. Based on the report of WHO in 2017 (WHO 2017), middle income countries participated well rather than high-income countries and the lowest response was from low income countries. The policies that have been revised to promote smoke free areas include increasing taxes of cigarettes, prohibiting smoking in hospitals and workplace areas, and the registration and licensing of tobacco and marketing standards for cigarettes.
This recommendation was highlighted by respondents to enhance motivation from the participants. Appreciation for those who have successfully stopped smoking is a good idea that can make clients feel significant and motivated to continue abstinence. According to Cahill et al. (2015), incentives such as material and financial gains were widely used to encourage or reinforce behavior changes as well as smoking cessation. Examples of incentives that have been offered are prize draws, vouchers and cash payments. It has been shown that incentives given could improve long term smoking abstinence. The rate of smoking abstinence with the incentive programmes was higher than the normal care programme. Besides that, the financial reward-based programme is more interesting to smokers than the deposit based programme. The reward based programme is conducted by paying successful participants. Meanwhile, a deposit based programme means to take a deposit from the participants and reward will be given once the person quit. The individual oriented incentive programmes were mentioned as more effective than group oriented programmes (Ibrahim et al. 2016). Hence, to give incentives or appreciation to the smokers that quit is relevant and can be applied.
CONCLUSION
The results of this study are useful, wherein the information generated, helps to make the campaign stop smoking more efficient and the process more organized and efficient. As healthcare providers are professionals, their input needs to be taken into account in order to provide the optimum service and cost effective.
ACKNOWLEDGEMENT
The authors would like to thank the health institution and personnel who contributed to this article.