The Effectiveness Of Group Counseling Module In Smoking Cessation Program

THE EFFECTIVENESS OF GROUP COUNSELING MODULE IN SMOKING CESSATION PROGRAM : QUANTITATIVE AND QUALITATIVE APPROACHES Rohani Ismail 1 , Syed Aljunid 2 , Khalib Abd Latip1,Wan Sharifa Ezat Wan Puteh 1 1 Department of Community Health, Faculty of Medicine Universiti Kebangsaan Malaysia 2 United Nations University-International Institute For Global Health, Kuala Lumpur Malaysia 3 RD MCTC CONFERENCE 8-9 AUGUST 2009

INTRODUCTION The onset of tobacco use typically occurs during childhood or adolescence. The Third National Health Mobidity Survey in 2006 reported that the national prevalence of current smoking increase among adolescents age 13 to 17 years old [13(3.5%), 14 (6.0%), 15 (8.7%), 16 (12.0%), 17 (15.5%)]. Strong positive correlation between the age of starting experiment with cigarette smoking and the probability of becoming a regular smoker (Conrad et al., 1992)

PROBLEM STATEMENT Smoking being a health problem especially among the adolescents and its continuation throughout adulthood, thus it is important to formulate preventive and cessation programs at addressing this particular age group. Intervention via group counseling may proof to be one of the effective methods for helping adolescent for quitting smoking. Group counseling is especially suited for adolescents because it gives them a place to express conflicting feelings, to explore self doubts, and to come to the realization that they share these concerns with their peers (Gerald C, 2000). Although school counselors are assumed to have sufficient skills in managing counseling sessions among students, the structured method tailored for smoking cessation program is underprovided. This present research was design to address the aspects mentioned above

GENERAL OBJECTIVE To measure the effectiveness of smoking cessation program using quantitative and qualitative methods Specific Objectives To study the smokers characteristics in intervention and nonintervention group To measure quit rate of smoking before and after the intervention program 3. To predict quit smoking among adolescents 4. To identify the strengths and weaknesses of the program

Measurements Quantitative Self report (questionnaire) - Smoking previous 7 days Cotinine in urine - GCMS (Gass Chromatography Mass Spectrometry) Carbon monoxide exhale - Carbon monoxide analyzer Qualitative Guidelines questionnaire (in depth interviews)

Operational Definition Adolescents smoking – respondents 14 years old smoking at least one day during 30 days prior to the study (GYTS, WHO) confirmed by self reported and carbon monoxide exhaled. Intervention group – adolescents received group counseling on smoking cessation by trained counselors for a period of four months Non intervention group – did not receive any counseling but the respondents were subjected to the regular smoking cessation activities organized by their respective schools Group counseling – a group of adolescents (not more than 10 adolescents) received counseling based on module developed Counselor – full time school counselor, qualified in Degree in Counseling and Psychology with one year experience in counseling field.

Intention to stop smoking – adolescents have intention to stop smoking in stage of contemplation, preparation and action Contemplation – thinking about quitting Preparation – seriously thinking about quitting Action – seriously thinking and high motivation in quitting. Level of addiction – based on Modified Fagerstrom Test for Nicotine Tolerance comprise of six questions

Quit rate – stop smoking in 7 day point prevalence by self reported (questionnaire), verified by cotinine in urine and carbon monoxide exhaled at 4, 8 and 12 months post baseline. - cotinine < 99.99ng/ML - carbon monoxide < 6 ppm Effectiveness of intervention – increase of quit rate at 4, 8 and 12 months post baseline.

METHODOLOGY Purposive sampling was conducted to choose Gombak and Hulu Langat district 24 schools randomly selected in two districts. All form two students go through a screening process to identify the smoker who had an intention to stop smoking. The research pass through 3 phases :

Measure of knowledge and attitude (4 month after intervention) Measure knowledge and attitude 4 month post baseline Measure knowledge and attitude - 8 month post baseline. Final follow up Measure knowledge and attitude – 8 month without intervention ( 12 month post baseline) Final follow up Measure knowledge and attitude – 12 month post baseline Measure knowledge and attitude - 4 month without intervention. (8 month post baseline) 4 month intervention 4 month 4 month MODULE DEVELOPMENT BY RESEARCH TEAM and PRE TESTED SCREENING PROCESS (smoking at least one day past 30 days an intention to stop at contemplation, preparation and action stage ) (N = 346) INTERVENTION GROUP (n=158) NON INTERVENTION GROUP (n = 188) Measure of quit rate (8 moths post baseline) Measure of quit rate (4 moths post baseline) PHASE 1 PHASE 2 PHASE 3 Program evaluation (in depth interview among counselors) STUDY FLOW Measure of quit rate (12 moths post baseline) Group counseling intervention Usual practice

Program Evaluation Qualitative method strength and weaknesses of the program activities implemented in non intervention schools - in-depth interview - Involved 10 counselors – justified on the consensus information Interviews was recorded on tape and transcribed The transcripts were manually analyzed - theme and keywords

1 2 3 4 5 6 7 8 9* 10 11 12 13 14 15* 16 17 18 19 20 21 22 23 *24 1 st session = Iice breaking (4 h) 2 nd session = Brain storming (4 h) 3 rd session = Decision making (2 h) 4 th session = Decision making (2 h) 5 th session = Decision making ( 2 h) 1 st ses. 2 nd ses. 3 rd & 4 th ses. 5 th ses. 7 th ses. 8 th ses. 9 th ses. 10 th ses. 6 th session = Managing withdrawal symptom 1 (4 h) session = Managing withdrawal symptom 2 (2 h) 8 th session = Managing daily activities (2 h) 9 th session = Reflection Activities (2 h) 10 th session = Outdoor activities (3 days 2 nights) COUNSELLING SESSION WEEK 1 st MODULE = PREPARATION TO STOP SMOKING (1 st ,2 nd session) 2 nd MODULE = DECISION MAKING (3 rd ,4 th ,5 th session) 3 rd MODULE = MANAGING WITHDRAWAL SYMPTOM (6 th ,7 th session) 4 th MODULE = REMAINING CESSATION STATUS ( 8 th ,9 th ,10 th session) 6 th ses. JULY 2005 OCTOBER 2005

Figure 1 : Respondents d istribution by gender (n= 346)

Figure 2 : Respondents d istribution by ethnics (n= 346)

Figure 3 : Initiation age of start smoking

Figure 4 : Stage of changes quitting smoking

Figure 5 : Number of cigarettes

Figure 6 : Number of smoking day

Table 1 : Baseline characteristic of study group PARAMETER IG (n= 158) NIG (n= 188) P value Male Female 143 (90.5) 15 ( 9.5) 158 (84.0) 30 (16.0) 0.075 Malay Chinese India 153 (96.8) 2 (1.3) 3 (1.9) 179 (95.2) 3 (1.5) 6 (3.2) 0.425 Initiation age of smoking < 7-9 years 10-11 years 12-13 years 14 years 12 (7.6) 25 (15.8) 91 (57.6) 30 (19.0) 19 (10.2) 34 (18.2) 87 (46.5) 47 (25.1) 0.222

PARAMETER IG (n= 158) NIG (n= 188) P value Number of cigarettes 1 stick 2-5 sticks >6 sticks 80 (50.6) 63 (39.9) 15 ( 9.5) 114 (61.0) 59 (31.6) 14 (7.5) 0.156 Number of days smoking 1-5 days 6-19 days 20-30 days 53 (38.1) 55 (39.6) 31 (22.3) 83 (52.5) 55 (34.6) 21 (13.2) 0.027

PARAMETER IG (n= 158) NIG (n= 188) P value Stage of changes Contemplation Preparation Action 66 (41.8) 37 (23.4) 55 (34.8) 73 (38.8) 49 (26.1) 66 (35.1) 0.807 Fagerstrom Scale Less addicted Moderate addicted High addicted 138 (87.3) 18 (11.4) 2 (1.3) 161 (85.6) 21 (11.2) 6 (3.2) 0.494

Table 4 : Smoking quit rate among intervention and non intervention group * P < 0.005 Intervention (n = 158) Non intervention (n = 188) Chi square test 4 months post baseline 71 (44.9) 60 (31.9) 6.19 (0.01)* 8 months post baseline 33 (20.9) 45 (23.9) 0.46 (0.50) 12 months post baseline 29 (18.4) 49 (26.1) 2.92 (0.09)

Table 5 : Predictors on quit smoking Factors Wald Adjusted odds ratio 95% CI P value Sex Male Female 7.54 2.67 1.32 – 5.36 0.006* Received counseling Yes No 6.49 2.00 1.17 – 3.40 0.01* Intention to stop smoking Action Contemplation 8.31 2.36 1.31 – 4.24 0.00* Parent smoking Yes No 4.31 1.68 1.03 – 2.74 0.04*

Strength of the program i) Improved respondents personality - improved students’ discipline - improved academic achievement - highly motivated to stop smoking ii) Enhanced cohesiveness between respondents and counselors - maintain good relationship

iii) Positive knowledge delivery on smoking cessation - valuable information on smoking cessation to counselors as well as to respondents iv) Creation of awareness about the harmful effects of smoking habit - posters and movie related to smoking diseases contribute high impact to students v) Being a counselor-friendly module - easy-follow module, informatics and comprehensive. - easy access module for counselor in student assessment

Weaknesses of the program i) Time constraints - program begin at mid of the year - increase counselor workload at year-end. - students commit with exam and school holiday ii) Lack of commitment from school administrators - counseling during teaching hours was unfavorable

Quantitatively, The quit rate at four months after intervention was determined higher in the IG as compared to the NIG. - due to counseling and developing motivation from the intervention after 8 and 12 month follow up relapse among adolescents behavior of smoking. - due to inconsistence monitoring Qualitatively - Improved personality of respondents, enhanced cohesiveness between respondents and counselors, positive inputs on smoking cessation, creation of awareness about the harmful, effects of smoking habit, being a counselor-friend module The strength of the module was affected by: Time limitation and commitment from school counselor. DISCUSSION

Conclusion The module is effective in encouraging respondents to quit smoking only in the short term. Therefore the duration of intervention should be extended to ensure the quit rate among adolescents sustain in the long term. Qualitative study identified more of the strength factors mentioned as compared to the weaknesses of the program

References Conrad, K.M., Flay, B. R. & Hill, D. 1992. Why children start smoking cigarette: predictors of onset. Br J Addiction . 87 : 1711-1724. . Hashami Bohari (1998). Keberkesanan Pakej Pendidikan Kesihatan untuk Modifikasi Tingkahlaku Merokok. Gerald Corey. 2000. Theory and Practice of Group Counseling . 5th edition. Brooks/Cole Thomson Learning. USA Lee Pi Hsia., Wu Der Min, Lai Hsiang Ru, Chu Naing-Feng. 2007. The impacts of a school wide no smoking strategy and classroom-based smoking prevention curriculum on the smoking behavior of junior high school students. Addictive Bahavior 32 . 2099 – 2107 Nagmeldien Ahmed M. Magzoub, Mohamed Izham Mohamed Ibrahim.2009. Health promotion Initiatives : Smoking Cessation Program and Weight Management. Penerbitan USM. Pulau Pinang . James D. S dan Joseph R. D. 2003. Tobacco Control for Clinicians Who Treat Adolescents. CA Cancer Journal Clin 53: 102-123. O’Connel DL, Alexander HM, Dobson AJ et al. 1981. Cigarette smoking and drug use in school students 111. Factors associated with smoking. Int. J .Epid . 110 : 221-231. Global Youth Tobacco Survey Malaysia report. NCDC, MOH National Health Morbidity Survey 2006. MOH

Acknowledgement Ministry of Health Ministry of Education National Poison Centre Pejabat Pelajaran Daerah Hulu Langat Pejabat Pelajaran Derah Gombak MCTC

Research Team Prof. Dr Syed Mohamed Aljunid P.M Dr Khalib Abd latip Dr. Sharifah Ezat En. Razak Lajis Dr Maizurah Omar P.M Dr. Foong Kin Prof Dr. Hashami Bohari Dr. Nor Saleha Ibrahim Tamin Dr. Nik Rubiah binti Nik Abdul Rasid Pn Ivy Ho Siew Yoon Pn Salamatussaadah En. Ahmad Fadli En Ahamad Fuad Cik Azlina Adnan En David a/l Samanasu Dr Taniza Toha Dr. Zabani Darus Dr Aminah Kassim En Lim Beng Kung Cik Salina binti Nen Cik Normah Che Din Rohani Ismail

The Effectiveness Of Group Counseling Module In Smoking Cessation Program

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