Nurse-Led Gender-Specific Smoking Cessation for Hong Kong Female Smokers

1. A nurse-led gender-specific smoking cessation program for female smokers: A successful experience in Hong Kong Sophia Chan PhD, MEd, MPH, RN, RSCN, FFPH, FAAN Professor & Head School of Nursing, The University of Hong Kong Email: nssophia@hku.hk Conference on Public Health and Preventive Medicine 6-7 Nov 2010

2. Team members • Research team: • Prof. Tai-hing Lam1, Dr. Doris Leung2, Ms. Idy Fu2, Ms. Zoe Wan2 • Nurse Counselors: • Ms. Anita Chan2, Ms. Helen Poon2 Note: 1. Department of Community Medicine, School of Public Health, LKS Faculty of Medicine, The University of Hong Kong 2. School of Nursing, LKS Faculty of Medicine, The University of Hong Kong

3. Acknowledgments • Funding Source: • Health Care and Promotion Fund (Ref. no. 19050504) • The Hong Kong Council on Smoking and Health (COSH) • Women Against Tobacco Taskforce (WATT) includes: • The Family Planning Association of Hong Kong • Hong Kong Outlying Islands Women’s Association Ltd • Hong Kong Federation of Women

4. Introduction • Women comprise about 20% of the world's more than 1 billion smokers. • Although the smoking prevalence in Asia is relatively low, the epidemic of tobacco use among women is increasing • In Hong Kong, the prevalence of female smokers (3.6%) remained similar in decades while that of male smokers has significantly reduced. References: Social Surveys Section. (2008). Thematic Household Survey, Report No.36: Pattern of Smoking. Hong Kong: Census and Statistics Department. Ma, S. (2010). Affluence prompts more women in China to light up. CMAJ :182 (12), E557-E558.

5. Background • In Hong Kong, the prevalence of female smokers ( around 4%) remained similar in decades while that of male smokers has significantly reduced. Figure 1: The smoking prevalence of male and female smokers from 1982 to 2008. 圖 表1 : 在1982年至2008年間，男性及女性之吸煙比率。 Reference: 1. Social Surveys Section. (2008). Thematic Household Survey, Report No.36: Pattern of Smoking. Hong Kong: Census and Statistics Department.

6. Introduction • Well-recognized hazards of smoking Reference: American Thoracic Society (1996). Cigarette smoking and health. Am. J. Respir. Crit. Care Med, 153: 866-878.

7. Specific hazards of smoking to woman’s health Reproduction system Menstrual symptoms and disturbance Increase chance of infertility Higher risk of cervical cancer Miscarriage Retarded fetal growth Sudden infant death Preterm delivery References: Lam TH, Ho SY, Hedley AJ, Mak KH, Peto R. (2001). Mortality and smoking in Hong Kong: case-control study of all adult deaths in 1998. British Medical Journal, 323, 1-6.

8. Women are the new target of tobacco companies • To attract female to smoke, tobacco products were packaged as slim, slender, trendy, light etc. Photos extracted from http://www.victoriawissa.com/print.html

9. A recent migration of tobacco advertisement to movies in Hong Kong

10. “She inhales not smoke but solitude”“He exhales not smoke but romance”

11. Woman smoking: A more complicated addiction • Cigarettes filled many roles for women who smoke • Smoking is helpful in: • reducing negative moods • enhancing positive moods • Managing the stress of daily life • Managing appetite and weight gain

12. Gender plays a part in smoking and quitting • Previous studies showed that women had greater difficultyand lower confidencein quitting smoking and less responsiveto nicotine replacement therapy (Abdullah 2006; Chan 2009). • Other studies suggested that stress, anxiety may keep women smoking, and they have a 25% lower success rate on quitting (than men) (Shiffman 2009). • Comparing to male, less female smokers sought help for quitting smoking. • These data showed an urgent need to develop a gender-specific smoking cessation service targeting the needs of women smokers. References: Abdullah ASM, Lam TH, Chan SSC, Hedley AJ. Smoking cessation among Chinese young smokers” Does gender and age difference matters and what are the predictors? Addictive Behaviors, 2006;31: 913-921. Social Surveys Section. (2008). Thematic Household Survey, Report No.36: Pattern of Smoking. Hong Kong: Census and Statistics Department.

13. A nurse-led gender specific smoking cessation programme HKU School of Nursing conducted a nurse-led gender specific smoking cessation programme to: • To publicize quitting among women smokers • To encourage and support those who want to quit by providing cessation counseling

14. Project Design- Phase 1 女性反吸煙工作組 Women Against Tobacco Taskforce (WATT) • Women Against Tobacco Taskforce (WATT) was launched in January 2007. • It is a collaboration among local women organizations to promote smoking cessation in the community. • A total of 17 organisations including 22 units are the members of WATT. • The learning needs, knowledge and attitude towards smoking cessation of volunteers and staff from WATT were assessed through questionnaires and focus group interviews.

15. Project Design – Phase 2 • A gender-specific Smoking Cessation Counseling Training Program were designed based on the results from phase I. • 51 staff and volunteers from WATT received the training and they are capable of providing a brief smoking cessation advices to smokers. Training on 23 October 06 Training on 2 November 09

16. Project design – Phase 3 • A smoking cessation hotline has been launched since November 2006. • Experienced nurse counselors provided individual face-to-face or telephone tailor stage-matched smoking cessation counseling for female smokers.

17. Female smokers recruitment Establishment of WATT at 2006 Poster and leaflet Website News report

18. The study protocol Female smoker calls our smoking cessation hotline Eligible smoker is invited to have counseling at HKU / telephone counseling First visit (baseline): i) Simple body check, ii) Assess smoking history and readiness to quit,& iii) setting an individualized quit plan 1-week follow up: Telephone reminder to assess progress, provide further support and boost self-efficacy 1-month follow up: Face-to-face or telephone interview to assess progress and provide further support 3-month follow up: telephone interview 6-month follow up: telephone interview

19. Results • Up to 31 October 2009, we responded to 689 enquiries about smoking and smoking cessation. • 332 female smokers joined our smoking cessation program and eligible for 6-month follow up. 18 (5.4%) 10 (3.0%) 22 (6.6%) 32 (9.6%) 130 (39.2%) 120 (36.1%)

20. Results • Demographics (N = 332):

21. Results • Smoking profile (N = 332):

22. Results • Fagerstrom test for Nicotine dependence (N = 332) 114 (34.3%) 111 (33.4%) 107(32.2%) % of participant

23. Results • Stage of readiness to quit Action 55 (16.6%) Preparation 77 (23.1%) Contemplation 140 (42.2%) 60 (18.1%) Pre-contemplation % of participant

24. Results at 6 month follow up • 6-month follow up (N = 332) • Smoking profile (N = 332, intention-to-treat analysis)

25. Daily cigarette consumption* • Comparing the difference of three baseline characteristics among three group of participants (by ANOVA) • Reducer group had higher cigarette consumption 17.7 ± 9.8 13.7 ± 8.1 11.9 ± 5.8 Number of cigarette (* p-value < 0.001, Turkey test: Reducer > Quitter, Others)

26. Perceived importance of quitting smoking (Scale 0-100)* 89.2 ± 13.1 83.7 ± 17.0 83.8 ± 15.4 Score (* p-value = 0.022, Turkey test: Quitter > Reducer, Others)

27. Perceived confidence on quitting smoking (Scale 0-100)* 63.0 ± 19.9 58.0 ± 21.6 55.6 ± 23.1 Score (* p-value = 0.03, Turkey test: Quitter > Others)

28. Conclusion • The nurse-led gender-specific smoking cessation program had achieved a higher 7-day point prevalence quit rate compared to a local mixed-gender program (27% vs. 22%), and about 25% had reduced smoking. • Our results also highlighted that psychosocial factors such as perceived importance of, and confidence in, quitting are key in achieving complete cessation in female smokers.

29. Conclusion • Although challenges remained regarding recruiting and motivating female smokers to come forward to quit, our program has demonstrated a successful experience in helping female smokers to quit in Hong Kong, and can serve as a model for countries in the region.

30. Conclusion • To echo WHO’s recent theme for World No Tobacco Day “Gender and tobacco with an emphasis on marketing to women”, we should protect women and girl against tobacco industry and help female smokers to quit. Photos extracted from http://www.who.int/tobacco/wntd/2010/en/index.html