Barriers to Cigarette Smoking Cessation in Pakistan: Evidence from Qualitative Analysis

Heated tobacco products- well known or well understood? A national cross-sectional study on knowledge, attitudes and usage in Pakistan

BACKGROUND

Heated tobacco products (HTPs) are reshaping the tobacco industry and just recently, a plan was sought to regularize HTPs in Pakistan. Pakistan provides an intriguing case study in this context, as tobacco use is deeply ingrained in public use. To ensure that future evidence-based policy recommendations are grounded in the public's knowledge, attitudes, and usage of HTPs, a nationwide survey must be conducted.

METHODS

A cross-sectional study was conducted using an online-based questionnaire nationwide in Pakistan. The questionnaire was validated and distributed through convenience sampling. The questionnaire assessed participants' knowledge, attitudes, and usage of HTPs. Descriptive statistics was used to describe participants' response and linear regression was performed at a p-value of < 0.05 using SPSS version 26.

RESULTS

In our sample of 1195 respondents (mean age of 33 years, 41.8% males and 58.2% females), 54.7% had previously heard about HTPs and 16.9% reported using HTPs at least once. Additionally, 38.24% were unsure of the legality of HTP use. Those with monthly household incomes of PKR 100,000 to 500,000, were more likely to have higher knowledge scores (OR:1.80[1.07-3.04]). On the other hand, males (OR:0.70 [0.55-0.89]) and respondents from Balochistan (OR:0.40 [0.22-0.71]) were more likely to have lower knowledge scores. The strongest motivators were the enjoyability of HTPs (55.73%) and usage as a cigarette alternative (54.64%), while the strongest deterrents were the negative health effects (82.68%) and potential for addiction (81.01%).

CONCLUSION

Our study underscores the need for awareness campaigns and interventions concerning HTPs, given prevalent preconceived notions and mixed attitudes among respondents. It was found that women and households with higher incomes scored higher on knowledge. Subjective enjoyment and a substitute for cigarettes were important motivators, but the most mentioned deterrents were the possibility of addiction and the detrimental effects on health. These insights form the basis for informed policy making for non-cigarette tobacco products.

Barriers to seeking tobacco cessation services: a qualitative assessment of university students' needs in Qatar

The prevalence of tobacco use in the Middle East is alarmingly high, especially among university students; most users initiate tobacco use during adolescence and young adulthood. Evidence-based cessation services can be beneficial when quitting tobacco use; however, these services are underutilized. This study aimed to explore the barriers preventing university students in Qatar from seeking tobacco cessation services. Semi-structured interviews were conducted with 20 Qatar University students who are current or former tobacco users (n = 18/2); most current cigarette smokers were also waterpipe users. The interviews were transcribed verbatim, coded, and analyzed using thematic analysis. The major barriers to seeking tobacco cessation services included misconceptions regarding nicotine addiction, negative perceptions of the cessation services' effectiveness, self-efficacy regarding the ability to quit without seeking cessation services, concerns and preferences regarding practitioners' characteristics at clinics, masculine culture that discourages men from seeking cessation help, social stigma around women who use tobacco in Arab culture, and a lack of time to visit cessation clinics. Our findings address gaps in the literature regarding the individual and sociocultural barriers to seeking tobacco cessation among youth in Qatar. A better understanding of these barriers can facilitate successful promotion of tobacco cessation services and enhance cessation-seeking behaviors.

Clinical study protocol on electronic cigarettes and nicotine pouches for smoking cessation in Pakistan: a randomized controlled trial

BACKGROUND

Pakistan is one of most vulnerable low- and middle-income countries with 29 million adult active tobacco users. Smoking cessation services are lacking as the tobacco control initiatives have largely failed to address the smoking endemic. Over the last 5 years, Pakistan has witnessed the use of innovative tobacco harm reduction (THR) products such as e-cigarettes and nicotine pouches. However, their use remains limited. THR products are imported legally as consumer goods and are taxable. The lack of sufficient data for THR and its application is a challenge in gauging their effectiveness in assisting smokers quit combustible smoking. Evidence-based studies can help in measuring the effectiveness of e-cigarettes and nicotine pouches as smoking cessation aids.

METHOD

Keeping in view the study objectives, a sample size of 600 participants will be sufficient to assess the effectiveness of e-cigarettes and nicotine pouches for smoking cessation in Pakistan. Of these, 200 participants each will receive e-cigarettes and nicotine pouches along with basic care counselling, while the remaining 200 participants will only receive basic care counselling for 48 weeks. The association of participants' characteristics with smoking and health status will be based on the bivariate and multivariate analysis. The simple t-test and variance analysis will assess the differences in intervention indicators between the control and treatment groups. For the inferential analysis, the average treatment impact will be based on the quasi-experimental techniques such as difference in difference (DID) or propensity score matching (PMS).

DISCUSSION

The study will evaluate the participants at the baseline as they decide the quit date. After every 12 weeks, a follow-up survey with the participants will be conducted. Results are anticipated to inform the public, decision-makers, and researchers about the effects of using e-cigarettes and nicotine pouches in the short- and medium-term periods. Critically, the potential of e-cigarettes and other alternative nicotine delivery systems as smoking cessation aid will be assessed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05715164 . Registered on February 6, 2023.

PROTOCOL VERSION

Protocol version 1.0, 14-12-2022 Trial in progress and not yet recruiting participants. Estimated primary data collection date-April 2024.

Public Health Practitioners’ Knowledge towards Nicotine and Other Cigarette Components on Various Human Diseases in Pakistan: A Contribution to Smoking Cessation Policies

Smoking cessation seems to be a weak link in the struggle against tobacco epidemic in Pakistan. Awareness regarding nicotine is lacking not only in the general population but also among public health practitioners. This lack of knowledge is one of the key barriers to bringing down the prevalence of smoking. Using primary survey data and nonparametric econometric techniques, this study assesses the knowledge of nicotine and harm reduction among public health practitioners in Pakistan. Results indicate physicians have misconceptions about nicotine. The majority of the medical professionals associate nicotine use with birth defects, cancer, cardiovascular illness, and chronic obstructive pulmonary disease (COPD). More than two-thirds of doctors (70%) strongly agreed and 17.9% somewhat agreed with the statement that nicotine causes cancer. This study suggests physicians need to be better informed about the fact that nicotine in tobacco products is addictive while chemicals, particularly those causing combustion, are the primary risk sources for tobacco-related illnesses. Misconceptions regarding nicotine can be quickly remedied with communication interventions. This study also suggests that alternative nicotine delivery systems can help smoking cessation and reduce the consumption of combustible tobacco in Pakistan.

Effect of socioeconomic status on smoking cessation behavior in selected African countries: Secondary analysis of Global Adult Tobacco Survey data (2014–2018)

Introduction

Tobacco use remains a global public health challenge. While studies report that smoking cessation reduces the risk of cancer and other NCDs, evidence is scarce in African region on socio-economic determinants of smoking cessation behavior. This study examined the socio-economic differentials of smoking cessation behavior among smokers in four African countries.

Methods

The study was conducted through secondary analysis of Global Adult Tobacco Survey (GATS) data from four African countries (Ethiopia, Kenya, Senegal and Tanzania). Smoking cessation behavior was assessed using two variables i) intention to quit smoking in next 12 months and ii) previous quit attempts made within 12 months preceding the survey. The weighted percentages for intention to quit smoking and previous quit attempts were computed. The adjusted odds ratios were computed using multinomial logistic regression to identify the association between socio-economic factors and smoking cessation behavior.

Results

Across the four countries studied, the previous quit attempts among smokers were in the range of 39.6% to 53.7%. Around 7.6% to 15.8% of the smokers tried to quit with an assistance. In Ethiopia over 76.5% of current smokers reported no intention to quit in next 12 months after survey, whereas the same was 50.4% in Senegal. While country specific differences were observed, females, those belonging to the poorest wealth index, unemployed and those without any formal education reported significantly lower odds of previous quit attempts or having an intention to quit smoking.

Conclusion

The socio-economic vulnerabilities were found to compromise smoking cessation behavior among the smokers in countries studied. Targeted interventions, adherence to smokefree laws, and provision of cessation support are essential to improve quit rates and mitigate tobacco risks among socio-economically vulnerable population.

Smoking cessation interventions in South Asian Region: a systematic scoping review

Background

Cigarette smoking is one of the most preventable causes of morbidities and mortalities. Since 2005, the World Health Organization Framework Convention for Tobacco Control (WHO-FCTC) provides an efficient strategic plan for tobacco control across the world. Many countries in the world have successfully reduced the prevalence of cigarette smoking. However, in developing countries, the prevalence of cigarette smoking is mounting which signifies a need of prompt attention. This scoping review aims to explore the extent and nature of Smoking Cessation (SmC) interventions and associated factors in South Asian Region (SAR) by systematically reviewing available recently published and unpublished literature.

Methods

The Joanna Briggs Institute (JBI) framework frames the conduct of this scoping review.

PubMed, EBSCO CINAHL Complete, Cochrane Library, ProQuest Dissertation and Theses, and local websites as well as other sources of grey literature were searched for relevant literature. In total, 573 literature sources were screened. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram, finally, 48 data sources were included for data extraction and analysis.

We analyzed the extracted SmC interventions through the FCTC. Factors that affect smoking cessation interventions will be extracted through manual content analysis.

Results

Regarding FCTC recommended smoking cessation strategies (articles), most of the articles were either neglected or addressed in a discordant way by various anti-smoking groups in SAR. Key barriers that hamper the effectiveness of smoking cessation interventions included lack of awareness, poor implementation of anti-smoking laws, and socio-cultural acceptance of tobacco use. Conversely, increased levels of awareness, through different mediums, related to smoking harms and benefits of quitting, effective implementation of anti-smoking laws, smoking cessation trained healthcare professionals, support systems, and reluctance in the community to cigarette smoking were identified as facilitators to smoking cessation interventions.

Conclusion

The ignored or uncoordinated FCTC’s directions on smoking cessation strategies have resulted in continued increasing prevalence of cigarette smoking in developing countries, especially SAR. The findings of this review highlight the need for refocusing the smoking cessation strategies in SAR.

Strengths

The review was conducted by a team of expert comprising information specialists, and senior professors bringing rich experience in systematic and scoping reviews. Every effort was made to include all available literature sources addressing cigarette SmC and associated factors in SAR. The review findings signal the need and direction for more SmC efforts in SAR which may contribute to development of effective policies and guidelines for the control of smoking prevalence.

Limitations

Despite efforts, potentially relevant records may have been missed due to unpublished or inaccessible articles, unintended selection bias, or those published in local languages, etc. Moreover, the exclusion of literature on under 18 participants and mentally ill smokers may limit the generalizability of findings.