Prevalence and Factors Associated With Attempts to Quit and Smoking Cessation in Malaysia

Measures

A prevalidated questionnaire was used to collect data on sociodemographic background, awareness and usage of “e-cigarettes,” cigarette smoking status, exposure to “e-cigarette” smoke/vapor, exposure to e-cigarettes promotion and anti-smoking campaign, and perception of “e-cigarettes.”

The dependent variables were smoking cessation and attempt to quit smoking. Smoking cessation was assessed among ever smokers and defined as smoked more than 100 sticks in their lifetime but did not smoke in the past 30 days. Those who have ceased smoking are hereafter referred to as former smokers. Attempt to quit was assessed among current smokers and defined as smoked more than 100 sticks of cigarettes in their lifetime, at least once during the past 30 days, and have attempted to quit at least once during the past 12 months.

Independent variables were social demographic variables and nicotine addiction. The social demographic variables were gender, ethnicity (Malay, Chinese, Indian, and others), education attainment (no formal education, completed primary education, completed secondary school, and completed university/college), age group (15-24 years old, 25-44 years old, 45-64 years old, and 65+ years old), locality (urban, rural), marital status (single, widow/widower, separated, and married), and occupation (government servant, private sector employee, self-employed, and others). Nicotine addiction was measured using the Fagerstrom Test for Nicotine Dependence, which consisted of 6 items, whose total score ranged from 0 to 10. Nicotine addiction was further categorized into “no to low addiction” (scores from 0-4) or “moderate to high addiction” (scores from 5-10).

Statistical Analysis

Data were cleaned prior to analysis. Descriptive statistic was used to describe the social demographic distribution of the respondents. Pearson’s χ² analysis was used to test associations between attempt to quit smoking among current smokers and smoking cessation and the independent variables. Univariate associations with P value ≤.25 were included in multivariable analysis. Two separate multivariable logistic regression analyses were carried out to determine independent variables associated with attempt to quit smoking among current smokers and smoking cessation (current/former). The final models were assessed by the Hosmer-Lemeshow goodness-of-fit test, which showed P values of .167 (former smokers) and .321 (attempt to quit), indicating that both models were fit. All statistical analyses were performed at significance level (α) of .05 using SPSS statistics software version 22.

Factors Associated With Attempt to Quit Smoking Among Current Smokers

In line with previous studies,^9,15 our study also found that smokers with lower nicotine addiction are more likely to make an attempt to quit smoking. Respondents with moderate to high dependency might encounter more severe withdrawal symptoms including irritability, frustration, anger, anxiety, increased appetite, and difficulty concentrating, since their last quit attempt, therefore making quitting difficult. ¹⁶

Consistent with previous studies among current smokers in Thailand, ¹⁷ Bangladesh, ¹⁰ and the United States, ¹³ our study revealed that younger aged respondents were more likely to make an attempt to quit smoking. Shorter duration of smoking and lower addiction to nicotine might be the plausible reasons why younger smokers are more likely to attempt quitting compared with older smokers.

Although there were significant associations between both marital status and education level with quitting attempt in univariate analysis, the associations diminished after adjustment for other variables. Contrary to general belief that higher educated smokers are more likely to attempt and to quit smoking due to higher awareness of smoking hazards. As for marital status, married smokers are expected to be more motivated to quit smoking because they have better social support and prioritize family expenses and therefore have less disposable income to support a smoking habit. More in-depth qualitative future studies are necessary to elucidate the effect of education and marital status on attempt to quit.

Factors Associated With Smoking Cessation

Former smokers were more likely to be of older age; this is in agreement with findings by Goren et al ¹³ (among US adults), Li et al ¹⁸ (among adult smokers in Malaysia and Thailand) in the International Tobacco Control study, among adults smokers in Romania ¹⁹ as well as Jampaklay and colleagues ¹⁷ in their longitudinal study on smoking cessation among adult Thai smokers. There are several possible reasons for this. First, older smokers are more likely to have made more quit attempts than younger smokers simply because they have lived longer and hence they have had more chances to become smoke-free. Second, this could also be due to different mortality rates between smokers and former smokers (continuing smokers are more likely to die at a younger age and therefore those who quit outlive them into older age). Third, older smokers are more likely to have smoking-related health conditions; therefore, they tend to make more visits to health care facilities due to this, and thus are more likely to have received advice to cease smoking by health care personnel. However, we did not investigate the age at which respondents quit smoking. Future studies are strongly suggested to include age at smoking cessation to confirm this.

Similar to findings from a systematic review by Vangeli et al, ²⁰ our study revealed no significant association between gender and smoking cessation after adjusting for confounders. However, this was contradictory to a study in Korea, which reported female smokers were more likely to successfully quit smoking due to pregnancy and childcare responsibilities. ¹¹ A possible explanation for the lack of association is the relatively low number of female smokers in this study. Therefore, we suggest a longitudinal study focused on smoking women of childbearing age during pregnancy and after delivery to examine the effect of pregnancy and delivery on smoking cessation.

In line with a previous study in Korea, ¹¹ we found that respondents with tertiary education were more likely to cease smoking. However, a study by Jampaklay et al ¹⁷ reported no significant association between education attainment and smoking cessation. Our findings suggested that respondents with high education level have greater knowledge of the dangers of smoking. ²¹ These perceptions are the main driving force of smoking cessation, as posited by the health belief model. ²² The likelihood of smoking cessation among smokers with higher education is high as they are more likely to work and stay in smoke-less environments surrounded by family members, peers, or colleagues who are nonsmokers and do not view smoking as a norm. ²³ This increases the success rate of quit attempts among this group due to reduced exposure to smoking cues. Besides, smokers with higher educational attainment tend to have greater economic resource and psychological support in their endeavors to quit smoking compared with those with lower education. Furthermore, smokers with higher education and less financial constraints can afford to purchase additional effective cessation aids. Having more psychological resources, this group of smokers is also more resilient to psychological stresses as shown in previous studies^17,24; and therefore, they have better capability to cope with withdrawal syndromes to further encourage their quit attempts.

Our finding that married respondents were more likely to cease smoking is consistent with studies from developed and developing countries, which documented that the cessation rate is most likely reflecting the social influence within marriage. ²⁵ Wives in Western countries have a powerful influence on their husbands’ behaviors (eg, in encouraging smoking cessation). ²⁵ This is best explained by the “marriage protection” and “marriage selection” theories. ²⁶ According to the marriage protection theory, marriage has a positive association with beneficial health effects. From the Asian cultural perspective, the family is an important institution. ²⁷ Married respondents are believed to have better economic and social support from their spouses. This consequently enhances their motivation to quit smoking. The marriage selection theory hypothesizes that healthier individuals are likely to marry and to stay married. Those who are married are more intent on living a healthy lifestyle and are willing to take initiatives to quit negative habits.

Limitations

There are some notable limitations in our study. First, several variables explored in previous studies that were associated with attempt to quit and smoking cessation were not investigated in this current study, these include: knowledge of health hazard of smoking, attitude toward health smoking, stress level, self-efficacy, motivational to quit smoking, free smoking policies at home, ²⁸ working areas, ²⁹ and medical condition of respondents and their family. Second, quit attempt was measured verbally and is thus subject to recall bias, particularly if the quit attempt only lasted a short duration or occurred a long time ago. Third, smoking status, smoking cessation, and attempt to quit were self-reported; therefore, there might be response bias. Research has shown that people tend to overreport socially desirable behaviors, and inversely, underreport socially undesirable behaviors. ³⁰ Fourth, the duration of smoking cessation was not investigated in detail; therefore, this might affect the analysis of the association between age group and smoking cessation. However, the representativeness of the study sample enables inference of these findings to the general Malaysian population. Also, the response rate was high, and use of the face-to-face interview method assured the completeness and quality of responses.