Tobacco smoking Cessation: lessons learnt from Chinese and American Health Education Programs.
The tobacco epidemic is one of the biggest public health threats the world has ever faced, killing more than 7 million people a year(1). More than 6 millions of those deaths are the result of direct tobacco use while around 890 000 are as a result of non-smokers being exposed to second-hand smoke(1). The mortality rate of lung cancer is about 23 times higher in current
male smokers and 13 times higher in current female smokers than in lifelong nonsmokers(2). On the basis of current trends it is projected that, 10 million people annually will die prematurely because of tobacco by 2030, two-thirds of these deaths will occur in low- and middle-income countries, and, absent effective global tobacco control, a shocking 1 billion people are projected to die from tobacco use this century(3). In China, tobacco is also one of the major threats to public health. China is the largest consumer of tobacco in the world. The latest available data reveals that the cumulative prevalence of smoking is 27.7% across China. The specific prevalence rates among Chines men is 52.1% while that of women stands at 2.7% among Chinese women(4). The high smoking prevalence improves a high risk of death among smokers. It can be assumed that cigarette smoking is responsible for 7.9 percent of the total premature mortality in China(5). It appears that in many developed countries, the vast majority of smokers begin using tobacco products well before the age of 18 years(6). The prevalence of tobacco using among students age 13–15 years is 8.6%-14.6% in four major provinces in China, while the overall median percent is 18.7 in the world(6). Meanwhile, the data collected in some study provide evidence that second-hand smoke exposure is frequent in public places in China(7).
Smoking harms nearly every organ of the body: causing many diseases especially lung cancer, cardiovascular disease, respiratory disease and reducing the health of smokers in general(8). Tobacco use causes death and disease not only among those who actively smoke but also among those who are exposed to second-hand smoke in indoor environments(7). Second-hand smoke exposure causes heart disease and lung cancer in nonsmoking adults(8). In adults, second-hand smoke causes serious cardiovascular and respiratory diseases, including coronary heart disease and lung cancer. In infants, it causes sudden death. In pregnant women, it causes low birth weight(1).
Treatment for tobacco use and dependence is a critical part of reducing tobacco use, and WHO recommends offering cessation services as part of primary health care(4). However, helping people access cessation support can be a challenge as it requires sustained commitment from governments that often find it difficult to identify sufficient resources for such programs(4). In China, there are three main challenges for tobacco control:
1. Education level.
Education level always influence people’s smoking behavior. Individuals who are less educated, poorer, and employed in stressful jobs are more likely to be heavy smokers and less likely to quit smoking than those with higher income and better education, which was defined as > 9 years of schooling(2).
2. Barriers to implementation of tobacco control policies and accession of smoking cessation resources.
Although there are some regulations on the control of smoking in large cities like Beijing and Shanghai, tobacco control activities at villages were rare and infrequent. Commonly reported activities were smoking cessation-related posters and blackboard bulletins at village gathering places or in village clinics. Pessimism regarding the effectiveness of these activities were widely shared by participants(9).
3. Cigarette Sharing culture
The practices of gifting and sharing cigarettes are well accepted and pervasive across China. Individual cigarettes are generally exchanged on a daily basis whereas gifts of entire packs or cartons are primarily given only during holidays and special occasions(10).
4. The interference of tobacco industry
The tobacco industry is increasingly using domestic and especially international trade litigation as an attempt to block progress on many tobacco control measures, such as smoke-free public places, pictorial health warnings, plain packaging and product regulation(4).
Most tobacco users want to quit smoking, especially if they are aware of the full range of harms caused by tobacco use(4). However, the extremely addictive nature of nicotine makes it difficult for most people to quit without some form of assistance(4). Three tobacco cessation interventions are highly recommended by WHO: Cessation advice in primary health care systems, Quitlines, Pharmacological therapy.
To address the problem of smoking we hereby discuss the efforts that have been put in place in three Chinese regions and America based in universally agreed indicators by the WHO and the United Nations member states. The two interventions are presented hereunder:
1.Text to Quit China: An mHealth Smoking Cessation Trial
The major intervention in this study is 6-week text message–based smoking cessation intervention. Participants were randomly divided into the intervention or control group. Intervention group is the high-frequency text contact (HFTC) group which received one to three messages daily. Control group is the low-frequency text contact (LFTC) group received one weekly message. All the text messages came from a professional American text message library. After translation and adapting to the Chinese context, this library was reviewed by Chinese health communication and tobacco cessation experts. The study assessed smoking status of each group for four times which at 0, 1, 3, and 6 months after intervention.
By considering all nonresponders to be smokers, this study observed high reported quit rates (between 26.7% and 30.5%) at all of the follow-up time points for both HFTC and LFTC groups. However, there is no any difference in quit rates between HFTC and LFTC groups. Excluding those who did not report their smoking status, this study observed significantly greater 7-day point prevalence abstinence in the HFTC group compared with the LFTC group immediately after the intervention (66% vs. 58% for the HFTC and LFTC, respectively p<0.001); 1 month after the intervention (67% vs. 64% for the HFTC and LFTC, respectively; p<0.027); and at 6 months (67% vs. 63% for the HFTC and LFTC, respectively; p <0.032). Meanwhile, in view of the higher opt-out rate in the HFTC group compared with the LFTC group (42.9% and 15.4%, respectively). 2. A Social Network Family-Focused Intervention to Promote Smoking Cessation in Chinese and Vietnamese American Male Smokers: A Feasibility Study This study was a single-group feasibility trail by using a social-network family-focused intervention which was guided by the Social Cognitive Theory, the Transtheoretical Model of Change, and Social Network Theory and was also based on interviews of smoker-family. The study educated both smokers and family members by outreaching two small group education sessions and two individual telephone calls to strengthen progress and provide support. The intervention aimed to improve the smokers and family member's knowledge of tobacco–related health risks, smokers' self-efficacy and intention for quitting smoking, family members' self-efficacy and intention to help their smokers to quit smoking. The study assessed 7-day and 30-day point prevalence smoking abstinence and using condition of smoking cessation resources after the intervention. After the intervention, the 7-day point prevalence abstinence rate was 30.2% and the 30-day abstinence rate was 24.0%. Smokers' reports of making at least one 24-hour quit attempt increased from 22.9% at 3 months prior to the intervention to 59.4% at 3 months post-initiation of the intervention (P < 0.001). Smokers' utilization of any cessation resources (medication, quitline, or physician's advice) increased from 2.1% during the 3 months prior to the initiation of the intervention (as obtained by the baseline survey) to 60.4% at 3 months post-initiation of the intervention (P < 0.001). Assessment 1. The message–based smoking cessation intervention increased the cessation rate obviously. Using mobile technology to provide tobacco cessation advice is highly recommended by WHO. This study promoted a successful smoking cessation text messages library in China. By using message as an intermediary can easily let smokers get smoking-related information. But there is no difference between the intervention group and control group. The reasons might be that all the participants were welling to quit smoking before joining this study. Another weakness of this study is losing of follow-up because too many messages might make people lose their patience. 2. The social-network family-focused intervention was highly successful and acceptable on the smoking cessation. The well trained lay health worker provided a professional counselling which can make participant accept the information easier. The key point of this intervention is the participation of smoker's families. Because of the encouragement and supervision, the smoking cessation among smokers can be more efficient. Work to be done Both these two interventions show that smoking related education among smokers and their families is an effective way to help smokers to quit tobacco use. Government needs to popularizing the using of advanced equipment to provide acceptable assistant to smokers in more area of China. Meanwhile, reinforce spreading smoking related information to non-smokers. So, they provide sustainable support for smokers and keep them insist using smoking cessation resources and quitting smoking goals. If most smokers can improve their awareness of the risk of tobacco smoking, the challenge of implementation of tobacco control policies and cigarette sharing culture will also be solved. Reference 1. Media centre. Tobacco. World Health Organization,. 2. She J, Yang P, Hong Q, Bai C. Lung cancer in China: challenges and interventions. Chest. 2013;143(4):1117-26. 3. Wipfli H, Samet JM. One Hundred Years in the Making: The Global Tobacco Epidemic. Annu Rev Public Health. 2016;37:149-66. 4. World Health Organization. WHO report on the global tobacco epidemic 2015: raising taxes on tobacco. World Health Organization. 2015 Jul 31. 5. 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