A Comprehensive Community Smoking Prevention And Control Study In Shanghai

Tobacco use has been the most severe public health problem in China. It is estimated that about 13,000 people die of tobacco related diseases everyday. China is the largest tobacco production and consumption country all over the world. The prevalence of tobacco use is 35.8% among population aged 15 years and over according to the behavior supervising results of China in 2002. In addition, 51.9 percent non-smokers suffer from environmental tobacco smoke (ETS) .Although tobacco use is the largest preventable cause of premature death and disability in China, unfortunately, limited tobacco use control laws, policies, control interventions are far from preventing tobacco use in children, adolescents and women, reducing tobacco use in adults and reducing non-smokers' exposure to ETS in China. In selecting and implementing interventions, it is recommended that communities should develop and maintain a comprehensive, multifaceted strategy to reduce exposure to ETS, reduce tobacco use initiation, and increase tobacco use cessation.The present study was designed as a community-based program of tobacco interventions. A matched pair of communities were randomly selected as a demonstration community of tobacco intervention and other one as control. In the intervention communities, comprehensive, multifaceted tobacco control strategies based on an ecological model were employed at individual, group or family, and organizational levels. It was comprehensively implemented in health care system, workplace, school and community-wide settings. The program was focused on two specific types of intervention: (1) tobacco prevention and control in school, (2) smoking cessation intervention intervention in community.Tobacco use prevention and control in school: The objective of this part was to prevent and control the tobacco use in adolescents and to decrease the proportion of attempt smoking. It was designed as quasi-experiment. A middleschool and a primary school were selected both from the intervention and control communities through random sampling. One year tobacco prevention program was implemented in intervention schools.The result of baseline survey showed that the attempt smoking rate was 13.7 percent and the average attempt smoking age was 8.8 years old. 75 percent students had smoking family members and 45 percent students suffered from passiving smoking.The multivariate logistic regression analysis showed that male, classmates who use tobacco were the risk factors related to attempt smoking. The higher in knowledge, attitude score, the least possibility would they attempt smoking.According to the result of baseline survey, the intervention based on ecological theory and stage development theory of organizational change were implemented among students and teaching staffs.The anticipated results were achieved through intervention and the smoking free environment was created. The proportion of "having seen teachers smoking in the last 3 months" decreased from 75 percent in the baseline to 34 percent at the 6-month follow up survey and the proportion of heavy passive smoking rate have been decreased from 15.1 percent to 12.1 percent. As for the knowledge and attitude related to smoking, the intervention also have evident and sustaining impact and only several aspects decreased after half year.The intervention also influenced the smoking behavior among teaching staffs. The smoking rate of male teaching staffs decreased from 56 percent to 38.1 percent while the passive smoking rate decreased from 56.7 percent to 28 percent. Exposure to ETS within school among teaching staffs were also greatly reduced.The qualitative group interview among students and teachers indicated that the nonsmoking environment was built after intervention. The students improved their understanding about the harm of tobacco use and master the skill on rejecting tobacco and avoiding passive smoking. On the other hand, the combination of school activity with community tobacco control action have impact in decreasing ETS within family. Students welcome the activities of tobacco use especially the intuitionistic and reciprocal education method.The smoking cessation intervention in community: this part was designed to study the smoking behavior, quitting intention and related factors among smokers and explore the feasible and effective smoking cessation measure. The study includes two aspects: the study of tobacco use and related knowledge and attitude among smokers as well as the study on exploring the effective quitting method.The cross-sectional study among smokers included the questionnaire survey, the qualitative interview. 969 smokers were surveyed through multi-stage proportional random sampling and the result have showed that nearly half smokers were heavy smokers and 70.8 percent have no intention to quit in following 6 months. Only 7 percent realized that smoking took heavy harm on health and less than 5 percent realized that tobacco use might lead to hypertension or coronary heart disease. 42 percent smokers considered that smoking shouldn't be intervened. The Logistic regression analysis has showed that people who were older than 60 years and suffered from diseases were more likely to quit, whereas 40 to 49 years old people seldom quit.The qualitative interview with 36 smokers showed that social convention and customs have great impact on smoking initiation. Most smokers focused on the "convenience" brought by tobacco and neglected the potential harm of smoking. Their knowledge of smoking harm was usually the external symptom such as cough. Therefore, they have weak intention and confidence to quit. Among the smokers who had made quitting attempt, the most familiar reason was suffering from illness. However, the quitting attempts often lead to relapse when they got well. To the smokers who have intention to quit, they always met great difficulty because of the luck of knowledge and skill on how to quit, more important, the luck of supporting environment.The study on smoking cessation intervention was divided into two parts: to creat the supporting environment in the community and to explore the smoking cessation method.The effort to creat the supporting environment for tobacco control provided the base for behavior change among smokers. To improve the quitting intention among smokers and make smoking free environment in the community, intervention strategies were employed among individual, family,organization and community level. The knowledge and attitude about tobacco control among smokers have also been greatly improved. The proportion of "considering that tobacco use would be heavily harmful to health"has been increased from 2.6 percent to 24.9 percent and the figure of supporting the opinion "smoking is not a good behavior" was raised from 79.4 percent to 91.1 percent. The quitting proportion among smokers was increased from 15.2 percent to 19.4 percent.Based on the finding mentioned in the survey and interview and led by social cognitive theory, a smoking cessation method titled as "I can quit" class was explored. 225 smokers were recruited through social mobilization. After baseline investigation, the current smokers were randomly divided into an intervention group (118 members) and a control group (107 members). Thus, the intervention group received the course and control group received no further specific interventions. All participants were contacted to complete 6-months follow-up questionnaire to assess the intervention result.The 6-month follow up survey showed that the quitting rate in the intervention group were 40.5 percent and much higher than the quitting rate in the control group (5.2 percent) (P<0.01) . The average daily cigarettes consumption was 3.92±5.65 and less than 13.10±6.83 in the control group (P<0.01) The proportion of precontemption ( having no intention to quit in the 6 month) in the intervention group was lower than the control group (19.8% vs. 40.9%). Analysis of covariance was used to analyze the factors influencing the change of daily consumption. The results showed that attending intervention influence the change of daily consumption (F=98.08, P<0.01) and the education background didn't affect the result. The logistic regression analysis showed that intervention was the strongest predictor corresponded to a cluster-adjusted odds ratio of 6.7. The subjects who were older, have optimistic anticipation in the baseline were more likely to quit in the 6 -month follow up survey.The participants were satisfied with the quitting training course. 79.4 percent members thought the training method "excellent" and 20.6 percent considered it to be "good". 74.6 percent of participants expressed they would mobilize other smokers to participate the training course. The qualitative interview with 56 participants showed that the attending the training coursechanged their opinion on smoking. The trainees had the common understanding of the tobacco harm and they moved from "having no intention to quit" to "deciding to quit" stage through intervention. Mastering the quitting skill and improving the self-efficacy on quitting helped the smokers make success in quitting. The training method such as teaching through multimedia, discussion and activity were welcomed by the trainees. The trainees approved most content and proposed their suggestion for improving.