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Stages of Change, Smoking Behavior and Acceptability of A Open access Original research BMJ Open: first published as 10.1136/bmjopen-2019-029144 on 8 September 2019. Downloaded from “Stages of change, smoking behavior and acceptability of a textmessaging intervention for tobacco cessation among cigarette, dokha and shishasmokers: A qualitative research study.” Yusra Elhidaia Elobaid, 1 Andrea Leinberger Jabari,2 Aisha Al Hamiz,2 Abdul Rizzak Al Kaddour,3 Sherif Bakir,4 Heba Barazi,5 Elisa Kazim,6 Scott Sherman,7 Raghib Ali2 To cite: Elobaid YE, Jabari AL, ABSTRACT Strengths and limitations of this study Al Hamiz A, et al. “Stages of Objectives To explore: (A) the underlying motivators change, smoking behavior and barriers to smoking cessation among young Arabic ► This study is the first study in the Middle East re- and acceptability of a speaking smokers and (B) to examine the suitability textmessaging intervention gion that explored text messaging intervention’s ac- and preferences for tobacco cessation interventions for tobacco cessation ceptability and feasibility among dokha and shisha (specifically text messages) and study the possibility of among cigarette, dokha and smokers. enrollment methods for a randomised controlled study shishasmokers: A qualitative ► This study assessed tobacco smokers’ preferences using text messages as an intervention for tobacco research study.”. BMJ Open of cessation techniques including re-emerging to- cessation. 2019;9:e029144. doi:10.1136/ bacco use patterns such as dokha and shisha. bmjopen-2019-029144 Design Qualitative research using focus group ► The findings of this study will assist in tailoring and discussions and content analysis. ► Prepublication history for examining the content and acceptability of text mes- Setting(s) Two universities, one of them is the first and this paper is available online. sages to be used in tobacco cessation intervention foremost comprehensive national university in the United http://bmjopen.bmj.com/ To view these files, please visit among young dokha and shisha smokers. the journal online (http:// dx. doi. Arab Emirates (UAE). The third setting is the largest ► Limitations included the small number of focus hospital in the UAE and the flagship institution for the org/ 10. 1136/ bmjopen- 2019- group discussions. 029144). public health system in the emirate of Abu Dhabi. ► Selection bias have been encountered due to the Participants Six focus group discussions with a total of fact that the smokers seen in the healthcare setting Received 15 January 2019 57 participants. Forty-seven men and 10 women. Fifty- (Shaikh Khalifa Medical City) were already experi- Revised 31 July 2019 three of them were current smokers. Accepted 09 August 2019 encing smoking and might have more awareness Results The analysis of six focus groups was carried out. of the smoking negative effects as they have been Main themes arose from the data included: preferences exposed at least once to antismoking awareness ac- for tobacco cessation interventions and acceptability on September 25, 2021 by guest. Protected copyright. tivities by healthcare providers. and feasibility of text messaging as tobacco cessation intervention. Different motives and barriers for quitting smoking including shisha and dokha were explored. Conclusion Interventions using text messaging for Alternative forms of tobacco are well known smoking cessation have not been used in the Middle East to be used in the Middle East (ME) among and they could potentially be effective; however, tailoring younger adults such as ‘shisha’ or ‘water- and closely examining the content and acceptability of text 10–12 messages to be used is important before the conduction pipe’. Another alternative form that has © Author(s) (or their of trials involving their use. Social media is perceived to increasingly gained popularity in the region employer(s)) 2019. Re-use is ‘dokha’ or ‘midwakh’.13–15 Dokha smoking permitted under CC BY-NC. No be more effective and influential, with a higher level of commercial re-use. See rights penetration into communities of young smokers. is not a new phenomenon in the ME region, and permissions. Published by specifically in the United Arab Emirates BMJ. (UAE); Bedouin and sailors in the UAE have For numbered affiliations see INTRODUCTION traditionally used it15; however, this phenom- end of article. Tobacco is a major risk factor for mortality enon is re-emerging with an increased popu- 1 Correspondence to producing 9% of total deaths in the world ; larity among younger adults. Dr Yusra Elhidaia Elobaid; the negative health effects of tobacco and In the UAE, the prevalence of current yusraelobaid@ hotmail. com its alternatives are well documented.2 2–9 tobacco smoking is 20.5%.1 In the UAE, it Elobaid YE, et al. BMJ Open 2019;9:e029144. doi:10.1136/bmjopen-2019-029144 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-029144 on 8 September 2019. Downloaded from was found that dokha smoking has become the second The impact of technology-based cessation interventions popular form of tobacco smoking following cigarettes.16 in the ME where dokha and shisha are more prevalent is Smoking levels in UAE men (mainly cigarette and unknown. New tobacco cessation programmes that aim to midwakh) are about 28.1% and 2.4% in women (WHO).2 support and assist dokha/shisha smokers in their attempt It has been reported by some studies that this trend will to quit tobacco smoking among the UAE population is be transferred to other parts of the world including needed. Europe and USA as a result of the use of technology This study aimed to uncover underlying motivators and globalisation.17 18 As a result of this increasing trend, and barriers to smoking cessation among young Arabic new tobacco cessation interventions tailored for these speaking smokers and to test specific message content for smokers are urgently needed, especially that existing ways clarity and resonance with the intended audience and of helping people to stop tobacco use are perceived by to explore young adults’ preferences of cessation tech- many smokers as very costly or ineffective.19 niques including the use of social media and other new Although many smokers successfully quit unaided, a communication modes. The evidence of the acceptability Cochrane review presented evidence that many smoking and feasibility of text messaging interventions to reduce cessation interventions are effective and increase chances smoking behaviour is well established among cigarettes of successful quitting.20 Many smokers who want to stop smokers. This study is the first study in the ME region smoking engage in quit attempts; however, they are unsuc- that explored this intervention’s acceptability and feasi- cessful in their attempts to quit smoking on their own. bility among dokha and shisha smokers. This study is part Many young UAE smokers are willing to quit but most do of a larger study that aims to investigate the effect of a text not use existing smoking cessation services, such as medi- messaging intervention tailored for cigarette, dokha and cation therapy and counselling.21 A review of studies (n=12 shisha smokers. studies) of mobile phone-based tobacco cessation inter- ventions showed that primarily SMS-based interventions were effective in helping people quit smoking (Relative Risk (RR)=1.67; 95% CI 1.46 to 1.90)), with interven- METHODS tions involving biochemical verification showing the best The study was conducted between October 2016 and June results (RR=1.83, 95% CI 1.54 to 2.19).22 Another review 2017 using focus group discussions.32 Purposive samples of of studies (n=5 studies) conducted by Ybarra et al23 looked participants for focus groups were recruited through New at quit rates across several countries and found that 7-day York University Abu Dhabi, United Arab Emirates University continuous abstinence at 4 weeks post-SMS intervention and Shaikh Khalifa Medical City (SKMC). Six focus group was greater in the intervention versus control participants discussions (57 participants) were moderated by a qualita- (absolute RR=2.34, 95% CI 2.12 to 2.58) after adjusting tive research expert and an observer and used a generated for demographic characteristics. While the reviews of topic guide which explored topics such as tobacco cessation http://bmjopen.bmj.com/ SMS-based smoking cessation interventions were gener- motivators and barriers. ally positive, it is important to note that the content of Text messages were in the Arabic language. The content the messages and frequency is key to the intervention of text message was based on theories of smoking cessa- success. All of the intervention components addressed tion and behaviour change, perspectives on change model, participants’ intention to quit, were highly personalised previous research and qualitative work with smokers.33–36 and linked participants to existing helpline and nicotine Focus group participants were asked to comment on the replacement therapy.24 25 messages clarity, understandability and supportiveness to There is a global recognition of the effectiveness of quit smoking, based on which stage of behaviour change on September 25, 2021 by guest. Protected copyright. mobile phones in the control of non-communicable risk they fall. They were also asked to identify messages that factors including smoking.26 27 The WHO/International were considered potentially problematic. All participants Telecommunication Union (ITU) mHealth Initiative for gave a written informed consent before participating in the NCDs is considering text messages as a cost-effective tech- study. nique that can be widely used to tackle tobacco epidemic Purposeful sampling was used; participants who are worldwide.28 former/current smokers were selected as they can best Previous studies have found that irrespective of income engage in tobacco cessation discussion and answer ques- personalised text messaging programmes can be an tions pertaining to their own experience. effective tool for smoking cessation.29 30 In a randomised The focus group discussions were conducted for control trial in the UK, participants who received 45–60 min.
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