415 Tob Control: first published as 10.1136/tc.2003.006460 on 24 November 2004. Downloaded from
RESEARCH PAPER Which smokers use the smoking cessation Quitline in Hong Kong, and how effective is the Quitline? A S M Abdullah, T-H Lam, S S C Chan, A J Hedley ......
Tobacco Control 2004;13:415–421. doi: 10.1136/tc.2003.006460
Objective: To describe the characteristics of the Chinese subjects who utilised the first telephone smoking cessation service in Hong Kong, and to evaluate its effectiveness. Methods: The Quitline provided Hong Kong residents with free telephone smoking cessation services which was publicised through a press conference, media reports, pamphlets, and posters at public and private hospitals and clinics. Callers who completed an initial interview from 13 December 2000 to 31 See end of article for May 2002 were included. Smokers were interviewed using a structured record sheet and provided with authors’ affiliations ...... stage matched counselling. A follow up interview was carried out after six months. Analysis was conducted by intention-to-treat. Correspondence to: Results: Of the 1120 callers who completed initial assessments, 1047 were current smokers and 872 Professor Tai-Hing Lam, Department of Community consented to follow ups. Compared to the general smoking population, the Quitline attracted more of Medicine, The University of those who were female, younger, single, unemployed, higher educated, smoking more than 20 cigarettes Hong Kong, 5/F per day, and those with quitting experience. At six months, 12% (95% confidence interval 10% to 15%) of Academic Block, New the participants reported that they had not smoked a cigarette for the past seven days. A stepwise logistic Medical Complex, 21 Sassoon Road, Hong Kong regression model showed that the use of nicotine replacement therapy at the present attempt to quit, SAR; [email protected]. having made one or more serious attempts to quit in the past, perceiving less difficulties in quitting, and hk smoking the first cigarette at age 15 years or above were significant predictors of quitting. Received 20 October 2003 Conclusion: This first Quitline in Asia appears to be acceptable to Chinese smokers, with quit rate Accepted 14 July 2004 comparable to those of better funded Quitlines in the West. A low cost Quitline is a promising model for ...... smoking cessation services in the East.
smoking cessation among Quitline callers, and compared the
moking is the major preventable cause of death in Hong http://tobaccocontrol.bmj.com/ Kong, leading to about 6000 deaths annually and service’s quit rate with Quitlines in the West. accounting for about one fifth of all deaths.1 Quitting S 2 smoking has significant health benefits, and effective METHODS strategies are available to support quitting.34 Among the Quitline programme many services that are available to support smoking cessa- The Quitline was operated as a pilot programme by the tion, Quitline services (telephone based services with Department of Community Medicine and Nursing Studies of smokers’ direct access to smoking cessation counsellors) the University of Hong Kong in collaboration with Hong were reported to be effective in the USA,5–7 the UK,89 and Kong Council on Smoking and Health. The Quitline was Australia.10 11 Quitlines can deliver cessation services to those publicised, with a small budget, through press conference, who need help at convenient times and with less resources media reports, pamphlets, posters at public and private than other methods. The telephone format encourages people hospitals and clinics, and through the website of the Hong
who are reluctant to obtain help from usual services to seek Kong Council on Smoking and Health. Free services were on September 24, 2021 by guest. Protected copyright. service,12 13 as soon as they make decision to seek help. There available for 38 hours per week (Monday to Friday from 2 pm is evidence that telephone based counselling is helpful to the to 8 pm and Saturdays from 10 am to 6 pm) by trained general smoking population who want to receive direct bilingual (English and Chinese) counsellors. Smokers were advice or counselling but try to avoid face-to-face contact.314 interviewed using a structured record sheet, and were However, a major criticism is that Quitline services rely on provided with stage matched counselling16 using a structured callers to be proactive. protocol with each session lasting for about 20 minutes. The Hong Kong Special Administrative Region (HKSAR), Callers who provided mailing addresses also received cessa- the most westernised and economically advanced city in tion related materials by post. China, has a population of 6.5 million, 95% of whom are ethnic Chinese. In 1998, there were 0.8 million daily Subjects smokers—about 15% of the population aged 15 years or The potential subjects were current smokers who called the above.15 Before the Quitline was established in December Quitline from 13 December 2000 to 31 May 2002 and 2000, no telephone based smoking cessation service was completed an initial assessment about their smoking status available in Hong Kong or in mainland China. and intention to quit. In this report we included those There is a lack of smoking cessation services in the Asia- smokers who wanted to receive counselling regardless of Pacific region, particularly in China with more than 300 their intention to quit, and who gave verbal consent and million smokers. Moreover, information on the predictors of provided a contact telephone number for a follow up (fig 1). quitting among Quitline callers is lacking around the world. Ethical approval for this study was obtained from the ethics This paper describes the characteristics of the smokers who committee of the Faculty of Medicine, the University of Hong used the Hong Kong Quitline. We also examined predictors of Kong.
www.tobaccocontrol.com 416 Abdullah, Lam, Chan, et al Tob Control: first published as 10.1136/tc.2003.006460 on 24 November 2004. Downloaded from
Figure 1 Flowchart for subject Callers (n = 5554) recruitment.
Did not complete initial assessment (n = 4206) Completed initial (Reasons: called during non-operation hours and assessment did not leave contact telephone numbers, (n = 1348) general enquiry not related to smoking cessation)
Smoker (n = 1120) Non-smoker (n = 228)
Gave verbal consent and Refused to give consent/did not provided contact telephone provide contact telephone number (n = 872) number (n = 248)
Follow up at 6 months (75% of the randomly selected participants, n = 654)
Data collection validation, because biochemical tests are considered unin- The record sheet gathered participants’ demographic infor- formative in low intensity interventions5 such as this Quitline mation (sex, age, marital status, educational attainment, and we expected very few would turn up for validation. occupation, and personal and household monthly income), smoking history (smoking status, other household members’ Analysis smoking status, the age that the participant started smoking The data were analysed using SPSS for Windows version regularly, and the average number of cigarettes smoked per 11.0. The difference between smokers who called the Quitline http://tobaccocontrol.bmj.com/ day), nicotine dependence level (using the six question and the general smoking population in Hong Kong and the Fagerstrom tolerance questionnaire17), quitting history characteristics of quitters and non-quitters were compared by (whether the participant had ever seriously tried to stop x2 tests. The variables that were significant in the univariate smoking, the number of serious attempts, and the longest analysis were tested by forward stepwise logistic regression to duration of not smoking during the latest attempt), and identify predictors for quitting and to estimate adjusted odds intention to quit based on the Prochaska’s model.16 ratios and 95% confidence intervals (CI). We used an To assess respondent’s perceived risk of tobacco use, we intention-to-treat analysis (that is, all cases analysis) to asked two questions: ‘‘Do you think smoking is harmful to assess the quit rate. Follow up variables with missing data health?’’ and ‘‘Do you think second hand smoking is harmful were set to their baseline values. We also repeated the to health?’’ We also asked whether subjects used any form of analysis on predictors for quitting by including only those nicotine replacement therapy (NRT) in the current quitting whose outcome data were available at follow up. A
attempt. Adherence to stage matched counselling recom- probability value of p , 0.05 (two tailed) was considered on September 24, 2021 by guest. Protected copyright. mendations was assessed by asking: ‘‘Did you completely significant. Since the results were similar in the two analyses follow the counselling advice as recommended by counsel- (that is, by intention-to-treat and by including only those lors?’’ All the response categories above were yes or no. with outcome data), we only reported results based on the To compare the characteristics of the Quitline callers with intention-to-treat analysis. those of the general population, we used data from the 2000 Smoking cessation was measured by asking subjects Thematic Household Survey (THS)18 of the Government whether they had smoked any cigarette during the past Census and Statistics Department, which collected informa- seven days at the six month follow up interview (point tion on cigarette smoking patterns and other social informa- prevalence quit rate).2 Those who answered ‘‘no’’ were tion on the general population aged 15 or above from October defined as quitters without any biochemical validation. All to November 2000. Systematic random sampling was used subjects who could not be contacted at follow up were and 11 779 persons were interviewed; of these, 14.4% (1692) considered to have continued smoking. For comparison with were current smokers (daily and occasional smokers). We other studies, we reported a number of outcomes (analysed compared our sample with these current smokers, who both by intention-to-treat and otherwise), ranging from a 24 should be representative of those in the general population. hour quit rate to six months continuous quit rate.
Follow up assessment RESULTS A follow up interview was carried out at six months for a 75% Users of Quitline (654/872) random sample. We could not follow up all Of the 5554 calls received by the Quitline over the study participants because of resource limitations. We did not period, 3% were repeat calls, 5% were calls enquiring about invite those smokers who reported cessation for biochemical the nature of the Quitline service, 68% were calls received
www.tobaccocontrol.com Quitline in Hong Kong 417 Tob Control: first published as 10.1136/tc.2003.006460 on 24 November 2004. Downloaded from
pre-contemplation stage, 52% in the contemplation stage, Table 1 Demographic and smoking characteristics of 22% in the preparation stage, and 7% were in the action current smokers who completed initial assessments for stage. the Quitline` compared to all smokers from the Thematic Of the 1065 current smokers, 13 were aged 14 or below and Household Survey (THS), Hong Kong five were non-Chinese, and were excluded from this analysis. Quitline (%) THS (%) Compared to the general population, there were significantly n = 1047 n = 1692 more people in our 1047 smokers who were female, younger, Demographics never married, unemployed, with lower household income or Sex* n = 1040 n = 1692 with secondary or higher education, daily smokers, who Male 77.9 84.1 consumed more than 20 cigarettes daily or had tried to quit in Female 22.1 15.9 the past (p , 0.01) (table 1). Age* n = 1047 n = 1692 15–19 4.5 3.1 Of the 1120 smoker callers who completed initial assess- 20–29 25.3 17.0 ment, 248 did not consent to be followed up or did not 30–39 28.9 23.1 provide a contact telephone number, leaving a total of 872 40–49 22.3 24.0 smokers of which 75% (654/872) were available for further 50–59 12.7 14.9 60+ 6.3 18.0 analysis (fig 1). Of the 654 smokers, 76% were male, 56% Education attainment* n = 997 n = 1692 were married or co-habiting, and 86% had received secondary No schooling/primary or below 15.3 30.6 school education or above. The 30 day average daily Secondary/matriculation 74.0 60.2 consumption was 20 cigarettes. The mean Fagerstrom score Tertiary or above 10.6 9.2 was 4.8 (range 0–10). Marital status* n = 1003 n = 1692 Never married 38.3 25.8 Married 57.0 67.1 Smoking status at six months Divorced/separated/widowed 4.7 7.2 Table 2 shows that, of the 384 smokers (59%; 384/654) who Employment status* n = 984 n = 1663 Employed 71.5 74.5 were successfully followed up, the point prevalence quit rate Unemployed 14.9 6.7 at six months was 20% (95% CI 16% to 25%). By using Students 2.5 1.5 intention-to-treat analysis, the point prevalence quit rate was Retired persons 6.1 13.3 12% (95% CI 10% to 15%). The continuous abstinence rate Homemakers 4.9 4.0 Personal monthly income n = 981 n = 1677 was 7% (95% CI 5% to 10%) among those who were followed Less than HK$9999 47.2 48.7 up and 4% (95% CI 3% to 6%) by intention-to-treat. HK$10000 or above 52.8 51.3 Considering a broader measure of any positive action taken Household monthly income* n = 959 n = 1676 towards quitting (not smoking at follow up, having quit for Less than HK$19999 65.5 41.8 at least a day, or having reduced cigarette consumption by at HK$20000 or above 34.5 58.2 Tobacco use related1 least 50%), 73% (95% CI 68% to 77%) had made a positive Daily smokers* (%) 99.6 86.1 behavioural change towards smoking cessation at the six Daily consumption of cigarettes* n = 1038 n = 1457 month follow up. By using intention-to-treat analysis, 43% 1–10 23.5 44.8 (95% CI 39% to 47%) had made a positive behavioural 11–20 49.5 45.4 change. 21–30 16.1 6.5 http://tobaccocontrol.bmj.com/ 31+ 10.9 3.4 Age started smoking regularly* n = 1039 n = 1457 Predictors of quitting ,10 years old 1.5 3.2 10–19 66.5 62.5 Table 3 shows that eight factors significantly predicted 20–29 28.5 30.8 smoking cessation (based on the seven day point prevalence 30+ 3.5 3.6 quit rate at six months by intention to treat analysis). Of Tried to quit smoking in the past* n = 1043 n = 1457 these significant factors that were tested by stepwise logistic Yes 76.7 41.8 No 23.3 58.2 regression, adherence to counselling recommendations, use of NRT at the present attempt to quit, having made one or Percentage may be greater or less than 100% due to the rounding of more serious attempts to quit in the past, smoking 10 or less figures; US$1 = HK$7.8. cigarettes per day, smoking the first cigarette at age 15 or *Denotes that the Quitline smokers were significantly different from the above, and being aged over 50 years were the six significant smokers in the THS (p,0.01).