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Predictors of Smoking Cessation in an Incentive-based Community Intervention Volume 21, No. 2- 2000
Abstract The Quit and Win Challenge, an incentive-based intervention, was implemented
in two counties in Eastern Ontario to encourage adult smokers to quit
smoking. Participants (n = 231) were compared with adult smokers
selected at random (n = 385) from a larger, four-county area. Baseline
characteristics were assessed by telephone interview, including socio-demographic
and smoking-related factors. Follow-up interviews were also conducted
by telephone. Initial and follow-up response rates were high (over 84%)
in both groups. Compared with the random survey group, Quit and Win participants
tended to be younger, more educated, employed and heavier smokers, with
fewer friends or co-workers who smoked. After one year, 19.5% of them
reported that they were smoke-free, whereas less than 1% of the random
group had achieved cessation. This translates into an impact rate of 0.17%,
affecting 1 in 588 adult smokers. With the exception of the smokers' baseline
"stage of change," none of the socio-demographic or smoking factors was
predictive of cessation. We conclude that this intervention achieved only
limited success and attracted certain sectors of the community disproportionately,
i.e. smokers who were highly motivated to quit. We argue that increased
access to proven cessation therapies would improve the impact of such
interventions.
In Canada, over 41,000 deaths are attributed to tobacco use annually, and cigarette smoking remains the leading cause of preventable illness and premature death.1 Causal associations have been established between cigarette smoking and many diseases, including respiratory and coronary heart disease, and lung and other cancers.2-7 Population-based smoking cessation programs have the potential to play an important role in the prevention of these diseases. Guidelines for the provision of public health programs and services require that boards of health in Ontario ensure the availability of smoking cessation programs in the communities that they serve.8 In accordance with these guidelines, health units in Eastern Ontario are involved in a variety of cessation activities.9 In the past, this included the implementation of the incentive-based Quit & Win Challenge within the general adult population. This program was a variation of an intervention developed in Minnesota,10 in which smokers pledged to quit smoking in exchange for the chance to win prizes. Other tobacco control activities offered by the health units included the distribution of educational materials packaged in a folder called the Quit Kit. Quit and Win contests and Quit Kits are examples of "minimal intervention strategies" for smoking cessation.11 They have been developed and implemented because up to 90% of smokers who quit can be expected to do so on their own, rather than through participation in an organized smoking cessation program.11,12 From the perspective of public health, minimal intervention strategies are quite important because, in general, limited public resources are available for more individualized smoking cessation programs in Canada.6,9,10 We had the opportunity to recruit and then follow a sample of adult smokers from Eastern Ontario who had been exposed to these specific smoking cessation interventions. At the same time, a reference population of adult smokers was selected by a random telephone survey from the same geographic area. Initial investigation of this cohort involved an analysis of progression through the stages of change13-15 within these groups of smokers.16 We then conducted a descriptive epidemiologic study with the following goals.
Methods Setting The study was conducted between 1995 and 1996 within four counties in Eastern Ontario having a combined population of approximately 306,000. About two thirds of the population resided in an urban area, and the first language of 92% of residents was English. The median household income in 1991 was about $44,000, and the overall rate of unemployment was 8.6%.17 The Minimal Intervention The Quit and Win Challenge was an incentive-based program that enrolled adult smokers who pledged to quit smoking for a designated period of time. In exchange, they were entered into a lottery with a cash prize of $1,000 and secondary prizes of lesser values. The initiative was promoted through the local print and radio media, as well as through the distribution of leaflets. Contest entry forms included a description of official rules and were available in local newspapers and at health unit locations. A contest winner, who was required to be smoke-free in the month leading up to the prize ceremony, was selected by random draw approximately three months after the contest was initiated. As described in the contest rules, the winner was asked to provide the name of a "buddy" to be contacted to verify his or her smoke-free status. Those who enrolled in the contest were also given the educational Quit Kit, which contained a letter of encouragement, information on cessation methods, a list of local cessation programs, helpful tips on maintaining a smoke-free status and a refrigerator magnet with the telephone number of a health unit information line. Overview of Study Design The two groups of adult smokers were identified, contacted by telephone and recruited for study. The intervention group consisted of 231 Quit & Win Challenge participants from two of the four Eastern Ontario counties (Frontenac, Lennox & Addington). Smokers selected by random telephone survey (n = 385) came from these regions as well as two neighbouring counties (Hastings, Prince Edward). Baseline telephone interviews were conducted in order to document socio-demographic characteristics and a variety of smoking indicators. Follow-up telephone interviews were conducted after one year in order to re-examine smoking behaviours. All indicators of smoking behaviours were self-reported, and there was no opportunity for biochemical validation of these self-reports. Descriptive and etiologic analyses were used to describe the intervention group at baseline, quantify associations between baseline characteristics and smoking cessation after one year and compare the intervention group with the smokers selected at random. Eligibility Criteria/Recruitment Subjects in the intervention group met each of the following criteria: 1) residents of Eastern Ontario; 2) aged 18 or older; 3) daily smokers, consuming a minimum average of 10 cigarettes per day; and 4) entered the Quit and Win contest in January 1995. Upon entry they filled in a ballot with identifying information. All members of this group were subsequently contacted by telephone and, if they consented, recruited to the study. Members of the random smoker group had the following characteristics: 1) residents of Eastern Ontario; 2) aged 18 or older; and 3) daily smokers, consuming a minimum average of 10 cigarettes per day. The group was identified by direct telephone contact in January and February 1995 using a random selection process (available from the corresponding author upon request), and those who met the study criteria were asked to participate. Variables Assessed at Baseline In both groups, socio-demographic characteristics and smoking indicators were examined at baseline. Variables assessed included known predictors of smoking cessation in adult populations: age and sex,12,18-21 smoking history (duration, frequency, previous quit attempts),2,18-23 socio-economic status (education, employment status and occupation),12,24,25 other smoking variables (the presence or absence of other smokers in the household, whether friends and co-workers smoked)18-20,24 and intention to quit smoking, as indicated by one of the stages of change.13-15 The baseline questionnaire was developed from questions in existing surveys. Questions about smoking history and current smoking patterns were based on the Ontario Health Survey26 and a current review paper.27 Socio-demographic variables were based on questions suggested by Dillman.28 Occupations were coded using the Statistics Canada Census coding manual29 and were classified according to the Pineo-Porter classification of occupational status.30 Intention to quit smoking was measured using the transtheoretical (Stages of Change) model developed by Prochaska and DiClemente.15 Follow-up Follow-up telephone interviews after one year were used to assess continuous abstinence from cigarette smoking in the six months prior to interview. This very rigid outcome was chosen rather than a point prevalence measure because the program organizers had stated, a priori, that the intervention was developed to help daily smokers to quit smoking completely. Data Collection The telephone surveys were designed using the principles outlined by Dillman.28 The baseline and follow-up surveys were pilot tested with a convenience sample of peers and revised on the basis of their feedback. Four interviewers collected data from each of the two groups and at follow-up. All variables were pre-coded. Responses were entered into a computerized database manager and then checked for accuracy. Statistical Analysis Response rates (number of completed interviews/best estimate of smokers eligible for interview) were calculated for each group at baseline and at follow-up. Descriptive statistics (frequencies, chi-squared tests, t-tests) were used to describe each group and to compare the two groups at baseline by age and sex, socio-economic indicators, prior smoking history and other smoking variables. Logistic regression analyses were conducted to estimate the strength and statistical significance of associations between baseline factors and smoking cessation after one year. Bivariate odds ratios and associated 95% confidence intervals were produced. Multiple logistic regression was then used to refine the odds ratio estimates while simultaneously adjusting for the influence of other variables. Etiologic analyses were limited to members of the intervention (Quit and Win) group. Statistical analyses were conducted using SAS31 and EGRET.32 Results Response Response rates at baseline were high in both the intervention (97.6%, n = 231) and random survey (92.8%, n = 385) groups of adult smokers. Of those recruited at baseline, 86.5% (n = 200) of the intervention group were re-contacted successfully after one year using a follow-up telephone call, and 84.4% (n = 325) of the random survey group were re-contacted. Baseline Data Members of the intervention group were predominantly female and, compared with the random survey group, were younger, more highly educated, more likely to be employed and more likely to be working as a semi-professional or professional (Table 1). In the intervention group, 73% began smoking as teenagers, and 77% had smoked for more than 10 years; they smoked more often but had been smoking for fewer years than subjects in the comparison group. During the previous year, 42% of the intervention group had made at least one quit attempt, one third (35%) lived in a household with at least one other smoker and 57% reported that at least half of their friends also smoked; however, they had fewer friends or co-workers who smoked than did the random survey group and more often worked in a smoke-free environment.
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In order to be eligible to win the Quit and Win contest, respondents had to be smoke-free in the month before its conclusion (March 1995). As a result, a very high proportion (87%) were actively trying to quit at the time of the baseline interview. Thus they were more likely to be in the action or preparation stages of change. Factors Associated with Cessation (Intervention Group) Bivariate analyses were carried out to examine baseline variables and their association with smoking cessation after one year. These analyses were limited to members of the intervention group, since only 1% of the random survey group (n = 4) had achieved cessation after one year. One in five (19.5%) of the 200 smokers who were re-contacted after one year had quit smoking. However, there was no evidence of strong or statistically significant associations between socio-demographic factors and cessation, nor was there evidence of strong associations between baseline smoking indicators and cessation. The one exception to this was "motivation to quit," as measured by stage of change. Those in the action stage at baseline were six times more likely to have quit than those in all other stages combined, although this finding was of borderline significance. Multiple logistic regression analyses confirmed these basic findings (Table 2) and, as a result, no models were produced that included more than one explanatory variable. |
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Discussion When compared with the random sample of adult smokers, the composition of the group of smokers enrolled in the Quit and Win intervention was different with respect to several salient characteristics. Consistent with the findings of Cummings et al.,33 contestants were on average younger, heavier smokers, better educated and more likely to be employed than non-participants. There was also a significant difference between the two groups with respect to a smoke-free workplace, although this difference is largely due to the inclusion of the "not applicable" responses as a category. This category included subjects who either had no workplace (i.e. were retired, homemakers or unemployed) or had an atypical workplace (e.g. were bus drivers). When the analysis was conducted only for subjects who were employed or were students (66% of subjects), no difference was found between the two groups with respect to this variable. Curiously enough, a small number of subjects in the intervention group were not in the action stage of the Stages of Change model. Baseline interviews with subjects were conducted after the contest deadline. Thus it is possible that some subjects entered the contest with the intention of quitting, but were somehow discouraged during the short time period between contest entry and the baseline interview. One interpretation of the findings is that systematic differences exist between smokers who choose to participate in these interventions and smokers who do not. For example, our study showed that the intervention did not reach older and retired people or entice them to enter, nor did it well represent smokers with lower socio-economic status. This may indicate different levels of motivation to quit smoking, or it may reflect the methods employed to advertise the contest and the varying exposures that different social groups had to the advertising. The contest was advertised through direct contact with workplaces, in newspapers and on specific radio stations. People employed outside the home and those in certain occupations may have had more exposure to these messages and greater opportunity to sign up for the contest because of their physical proximity to health unit locations. One-year follow-up data available from the intervention group of smokers showed that, even in this highly motivated group, only about 20% were abstinent; moreover, this is likely an overestimate. The smoking status of individuals was based on self-reported information obtained during a telephone call, and biochemical validation of these reports was not feasible. Further, participants were aware that they were providing information to a research study being conducted under the auspices of a public health unit. We expect that this may have led to some false reports of smoking cessation because of the need of some people to provide a socially acceptable response, particularly as they had declared their intention to quit smoking to a health agency in a very public format. Evaluations of contests similar to this particular Quit and Win program, which have also used sustained cessation as an end point, have reported quit rates ranging from 13% to 37%, with a mean value of 23% for community settings.34 The 20% rate of cessation achieved in Eastern Ontario is consistent with these results. The best available estimate of adult smokers in the four counties who were eligible for contest entry is 28,900,26 and 239 of these people entered the Quit and Win program. This participation rate of 0.83% is slightly lower than those reported for contests held in other communities.34 When the participation rate is combined with the cessation rate into a single measure of impact,34,35 the program was successful for 0.17% of the smoking population. Expressed in another manner, if we assume a causal relation between entry into the contest and sustained cessation, we can extrapolate that 1 in every 588 smokers in the community was led to quit because of the contest. We consider this rate of impact to be quite low in practice. This type of information is useful as a benchmark that can assist in setting priorities for future community-based tobacco control initiatives. One of the most striking observations in the present study was that strong and statistically significant associations were not identified between baseline variables and one-year smoking cessation within the Quit and Win intervention group. This was true of a number of categories of potential predictors, including socio-demographic factors (age group, sex, education, employment), smoking history (duration, consumption) and the presence of smokers in various social environments (household, friends, co-workers). Arguably, the one exception to this trend was that a person's motivation to quit, as indicated by categorization according to the Stages of Change model,13-15 showed a strong (albeit not statistically significant) association with one-year cessation. Although these findings are corroborated by some existing literature,23,33,36,37 they are not consistent with other investigations. For example, in a number of studies18,20,21,38 those in higher age groups were more likely to quit successfully. Other demographic factors, such as sex (men being more likely to quit) and marital status (married or common-law partnerships as a positive factor) have also emerged as possible predictors.25,38 Cigarette consumption and number of previous quit attempts are also associated statistically with cessation. Subjects who made fewer previous quit attempts were more likely to quit in some investigations.20,21,38 As well, success rates have been better among heavy consumers of cigarettes than among moderate ones,20,21 although converse results39 have been reported. The presence of social support from friends, family or co-workers also appears to contribute to cessation.20,21 The results of this study have implications for prevention. First, public health and other community-based agencies must recognize that Quit and Win interventions can achieve only limited success in reaching and affecting certain sectors of society. This is of particular concern because the groups with lower rates of participation (older people, those of lower socio-economic status) are especially vulnerable to chronic disease and mortality, in general, and smoking-related illness, in particular.40-42 Quit and Win interventions represent one of many different options for communities embarking upon smoking cessation campaigns. Unless special efforts are made to target the particularly vulnerable sub-sectors of the adult smoking population in these contests, the latter are unlikely to respond to such efforts. Alternatively, such groups may be better served by other population-based approaches, such as price increases (which are beyond local control in Ontario) or promotion of more individualized support combined with subsidized antidepressant (bupropion) treatments43 and/or nicotine replacement therapies.44 Our data suggest that once smokers have enrolled in a Quit and Win intervention, no other factors appear to influence the success of the cessation effort, but the person's underlying motivation to quit may be an important factor. This supports the need to provide general rather than targeted advice and support to these people in their efforts. The 20% success rate achieved in our study is quite typical and demonstrates the difficulty that even highly motivated smokers face. The consistency of cessation rates across different socio-demographic strata reinforces the idea that social and behavioural support offered in home and work situations may play some role in cessation, but is often insufficient, alone, to achieve cessation. Despite this fact, it is also important to recognize that Quit and Win participants achieved cessation rates that were as much as 20 times higher than those observed in general populations of smokers. It is highly probable that this could be further increased if proven therapies and professional support were made available at little or no cost to these highly motivated individuals. Without these, one can expect to have only a marginal influence on general smoking rates using incentive-based initiatives alone. The limitations of this descriptive study must be emphasized. Our study population consisted of selected adult smokers in a four-county area of Eastern Ontario. The findings may not be generalizable to larger communities or those with a different demographic structure. Further, they may not represent the potential for Quit and Win interventions that are conducted on a larger scale or in settings where cigarette prices are more prohibitive or cessation therapies more readily available to the average consumer. Our sample of random smokers may have been biased toward subpopulations that are more likely to be at home, and the disparities between them and the intervention group may have been exaggerated because of this. Finally, our study did not assess rigorously the role of social support and related factors, which are more difficult to quantify than the basic measures that were assessed. We therefore were unable to account for these factors as predictors of cessation, and this is an acknowledged limitation of our study.
We thank the following individuals who made important contributions to this project: Dr John Hoey, Dr Jamie Myles (statistical advice); Caulette McBride (Kingston, Frontenac and Lennox & Addington Health Unit); Karen Fitchett, Cathy Myles, Cindy McKegney, Mary Jean Shortt (data collection); Dr Lynn Noseworthy, Nicole McKinnon, Carolyn Case (Hastings and Prince Edward Counties Health Unit). Sources of financial support for this study were the National Health Research and Development Program, Health Canada (Project Grant No 6606-5669-800); Kingston, Frontenac and Lennox & Addington/Queen's University Teaching Health Unit; and the Ontario Ministry of Health (Career Scientist Fellowship support to Dr Pickett).
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Inequalities in health: the Black report. Middlesex: Penguin, 1982. 41. Marmot MG. Social inequalities in mortality: the social environment. In: Wilkinson RG, ed. Class and health: research and longitudinal data. London: Tavistock; 1986;21-33. 42. Marmot MG, Davey Smith G. Stansfeld S, Patel C, North J. Health inequalities among British civil servants: the Whitehall II study. Lancet 1991;337:1387-93. 43. Jorenby DE, Leischow SJ, Nides MA, Rennard SI, Johnston JA, Hughes AR, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 1999;340:685-91. 44. Tonnesen P, Norregaard J, Simonsen K, Sawe U. A double-blind trial of a 16-hour transdermal nicotine patch in smoking cessation. N Engl J Med 1991;324:311-5.
Author References Namrata Bains, Department of Community Health and Epidemiology, Queen's University; and Health Information Partnership, Eastern Ontario Region, Kingston, Ontario William Pickett, Department of Community Health and Epidemiology, Queen's University; and Ontario Tobacco Research Unit, Toronto, Ontario Brian Laundry, Hastings & Prince Edward Counties Health Unit, Belleville, Ontario Darlene Mecredy, Kingston, Frontenac and Lennox & Addington Teaching Health Unit, Kingston, Ontario Correspondence: Ms Namrata Bains, Health Information Partnership, Eastern Ontario Region, 221 Portsmouth Road, Kingston, Ontario K7M 1V5; Fax: (613) 549-7896; E-mail: nbains@hip.on.ca [Previous][Table of Contents [Next]
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