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Predictors of the participation of smoking parents in a proactive telephone-based smoking cessation program
Addictive Behaviors 31 (2006) 1731 – 1743
Predictors of the participation of smoking parents in a proactive telephone-based smoking cessation program Yim Wah Mak a,*, Alice Yuen Loke b, Tai Hing Lam c, Abu Saleh Abdullah d a
Department of Nursing Studies, The University of Hong Kong, Hong Kong, China b School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China c Department of Community Medicine, The University of Hong Kong, Hong Kong, China d International Health Department, Boston University, USA
Abstract Objective: The objective of this study is to identify the predictors of participation by smoking parents in a proactive telephone-based smoking cessation program. Methods: The smoking parents of young children from a birth cohort were interviewed and invited to take part in a telephone-based smoking cessation program. The characteristics of the parents and the predictors of participation were analyzed by chi-square test and by logistic regression. Results: A total of 952 (82.9%) out of the 1149 smoking parents who were interviewed agreed to participate in the smoking cessation program. The analysis showed that the predictors of participation in a pro-active smoking cessation program are being from a middle-income household, being currently employed, having recently had a medical consultation or been hospitalized, being at the stage of contemplating a change in behavior, and perceiving the importance of quitting smoking. Conclusions: Recruitment approaches should be refined according to the identified factors to target those who might decline an invitation to participate in a smoking cessation program. D 2005 Elsevier Ltd. All rights reserved. Keywords: Participation predictors; Smoking parents; Smoking cessation program
* Corresponding author. Tel.: +852 2819 2628; fax: +852 2872 6079. E-mail address: [email protected] (Y.W. Mak). 0306-4603/$ - see front matter D 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2005.12.018
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1. Introduction Young children with smoking parents are vulnerable to health risks from passive smoking (DiFranza & Lew, 1996). Studies have shown that the health of children is adversely affected by passive smoking at home (Lam, Chung, Betson, Wong, & Hedley, 1998). If the smoking parents of young children could quit smoking, their children would be at a reduced risk of smoking-related morbidity and mortality due to exposure to passive smoking or active smoking in later life. Thus, an effective smoking cessation program for smoking parents of young children could have a major impact on the health of both the parents and their children (Cook & Strachan, 1999; Godtfredsen, Holst, Prescott, Vestbo, & Osler, 2002; Mclaughlin, Hrubec, Blot, & Fraumeni, 1995). Researchers and clinicians alike have faced difficulties in their attempts to reach out and help smokers who choose not to take part in smoking cessation programs. As a matter of fact, smoking cessation intervention studies often only reach those smokers who are breadyQ to participate in such programs or are at the bcontemplationQ or bactionQ stage of quitting (Orleans et al., 1998; Zhu et al., 1996). Genuine efforts to recruit those who refuse or are not ready to take part in intervention studies are imperative if clinicians are eager to reach these smokers who might otherwise be excluded from such studies. Knowledge about the characteristics of smokers and the predictors of their participation in smoking cessation interventions would provide clinicians with the information they need to develop strategies to recruit smokers to participate in interventions or to re-design interventions so that they will be acceptable to the target population. It is expected that information on non-participating smokers will further strengthen the generality of the results of the study, the feasibility of interventions, and the external validity of the recruiting and sample selection processes as well as of the interventions themselves (Glasgow, Mccaul, & Fisher, 1993; Wilson, 1990). Reports of intervention studies among smokers have focused mainly on the effects of interventions on those who participated in the intervention studies. Although many of these reports specify the rates of participation in their programs, not many have examined the factors that influence smokers to participate or refuse to participate in such programs. The few studies that have reported on the characteristics of the participants and non-participants in smoking cessation programs have been conducted in workplaces (Cummings, Hellmann, & Emont, 1988); and among secondary school students (Hublet, Maes, & Csincsak, 2002). Predictors of non-participation in smoking cessation programs indicate those who have a lower level of literacy, do not regularly utilize health care services, and who belong to a lower income group (Ahluwalia et al., 2002). Men in full-time employment and those with relatively high annual household incomes are also less likely to take part in smoking cessation programs (Kviz, Crittenden, & Warnecke, 1992). A study on the cessation of smoking conducted among low-income women in a community primary care setting identified a higher intention to quit and lower self-efficacy in doing so as predictors of participation (Pohl, Martinelli, & Antonakos, 1998).
2. Studies targeted at smoking parents A meta-analysis was conducted of intervention studies on reducing the degree to which young children are exposed to environmental tobacco smoke that targeted smoking parents or the children’s family and school environment (Roseby et al., 2003). These intervention studies were conducted in child
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health clinics, asthma clinics, schools, or homes. Although all of the studies reported a reduction in children exposed to environment tobacco smoke among those who took part in the studies, none revealed details about the backgrounds of non-participating parents/families. This is a limitation found in most intervention studies for smokers. Smoking parents may differ as to whether or not they are willing to take part in smoking cessation programs or intervention studies. Besides investigating the characteristics of the parents as predictors of participation, it is also necessary to determine whether predictors of the participation of smoking parents in smoking cessation programs could include the presence of respiratory symptoms in their young children and whether or not their children utilize medical services.
3. Strategies to recruit smoking parents into intervention programs A well-designed smoking cessation intervention is of limited use if it cannot capture the interest of the target audience and persuade them to participate in the programs. Effective strategies to recruit participants into smoking cessation programs are those that appeal to smokers and are receptive to their concerns. Understanding the characteristics of these non-participating smokers and their reasons for not taking part in smoking cessation programs will be helpful in the planning of recruitment strategies to increase rates of participation in such programs. Most smoking cessation intervention studies adopt the reactive approach, in which most participating smokers present themselves in clinics and are breadyQ to take action to quit smoking (Lichtenstein, Glasgow, Lando, OssipKlein, & Boles, 1996). Strategies to maximize the participation of smoking parents using bproactiveQ interventions need to be designed if clinicians and researchers are determined to reach such people. Telephone-based counseling as an intervention is accessible to most in countries where a telephone is common in all households, and has become a popular mode for providing counseling on the cessation of smoking (Curry, McBride, Grothaus, Louie, & Wagner, 1995; Hennrikus et al., 2002; Lam, Leung, & Ho, 2001). The study presented here is part of a smoking cessation program for smoking parents using a telephone-based proactive intervention in an attempt to reach those who otherwise would not have presented themselves to clinics or health settings to quit smoking.
4. Study aims and objectives This is a report to identify the characteristics of smoking parents with young children who choose or do not choose to participate, and to identify the predictors of their participation in a proactive telephonebased smoking cessation program.
5. Study methods In 1997, a Birth Cohort Study was conducted in the months of April and May by the Department of Community Medicine of the University of Hong Kong and the Maternal and Child Health Center (MCHC) in Hong Kong (Lam et al., 2001). A total of 8327 births took place during that period, and the Birth Cohort Study gathered information from the mothers of the newborns about the parents’ smoking
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status. Two thousand seven hundred and thirty-three smoking fathers and 230 smoking mothers were identified. All of these parents were contacted at intervals when the babies were at birth, 3 months, 9 months, and 18 months of age. At the end of an 18-month follow-up period, a total of 2311 smoking parents remained in the sample pool. In the period June 2001 to July 2003, these 2311 smoking parents were again contacted for a telephone interview to reassess their current smoking status. Those parents who continued smoking or who had recently quit for less than six months were considered eligible for inclusion in a randomized controlled trial of telephone-based counseling on smoking cessation. Other criteria were that the smoking parents must live in Hong Kong and with their children for not less than five days a week. Verbal informed consent was granted through the telephone interview. Those smoking parents who gave their consent to participate in the study would be randomly allocated into the intervention group, in which they would receive printed self-help materials and telephone smoking cessation counseling sessions; whereas the control group would receive printed self-help materials only. A structured questionnaire was used for the telephone interview. The questionnaire solicited information on the demographic characteristics of the smoking parents; their smoking history; current smoking status and behavior, including their Fagestrom’s nicotine dependency level (Fagerstrom & Schneider, 1989); previous attempts to quit and their self-efficacy on how successful they were in doing so; the stage of behavioral change at which they are in, according to the Transtheoretical model of behavioral change (Prochaska & DiClemente, 1983); and the health of the smoking parents and that of their child. This report serves two purposes. It is to compare the characteristics of smoking parents with young children who choose to take part in a telephone-based smoking cessation program with those who choose not to do so, and to identify the predictors of their participation. It would be useful to consider these characteristics and predictors of participation when developing approaches to recruit participants in smoking cessation intervention activities targeted at smoking parents. Second, the result will give information on the acceptability to smoking parents of a free offer of participation in a proactive telephone-based smoking cessation program.
6. Ethical considerations Prior to carrying out the study, ethical approval for the study was obtained from the Ethics Committee of The Hong Kong Polytechnic University, and from the Maternal and Child Care Centre. All parents were invited to take part on voluntary basis. They were informed of the purpose of the study and had the right to withdrawal at any time. It was clearly stated that their decision on whether or not to participate in the study would not affect the care they received in the clinic. They were also explained that any personal information collected during the study would remain confidential.
7. Data management Participants were defined as parents who completed the telephone interview and consented to participate in the smoking cessation telephone-based counseling program. The characteristics of the participants versus those of the non-participants were compared using a Chi-square test for bivariate
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analysis. A stepwise logistic regression analysis was used to identify the predictive factors of participation.
8. Results A total of 1420 out of the 2311 smoking parents contacted were considered eligible, while the remaining 891 parents were excluded for any one of the following reasons: some could not be recontacted because of an invalid telephone number (n = 510), some denied ever having smoked (n = 23), some reported that they had quit smoking for more than 6 months (n = 159), some no longer resided in Hong Kong (n = 141),were separated or divorced and not living with the index child (n = 50), or were Table 1 Socio-demographic characteristics of smoking parents: the participants and non-participants in a proactive telephone-based smoking cessation program (N = 1149a) Characteristics
Non-participants (N = 197)
Participants (N = 952)
Demographics:
n
%
N
%
18 179
9.1 90.9
149 803
15.7 84.3
4 56 107 27
2.0 28.9 55.2 13.9
23 306 518 102
2.4 32.2 54.6 10.7
42 129 22
21.8 66.8 11.4
181 704 66
19.0 74.0 6.9
194 3
98.5 1.5
930 22
97.7 2.3
76 92 19
40.6 49.2 10.2
364 478 92
39.0 51.2 9.9
175 19
90.2 9.8
898 46
95.1 4.9
40 87 46
23.1 50.3 26.6
143 606 159
15.7 66.7 17.5
Gender Mother Father Age 18–25 26–35 36–45 46 or above Educational attainment Primary or below Secondary Matriculation or above Marital status Married Divorced/separated Number of children under 12 1 2 z3 Employment status Currently employedb Unemployed Monthly household incomec HK$9999 or less HK$10,000–29,999 HK$30,000 or above
The total percentage may be more or less than 100 due to the rounding off of the figures. p value: *V 0.05; **b0.01,***b 0.001. a The total number is not equal to 1149 because of missing data of up to 5.9%. b Includes parents who are currently employed, housewives, and full-time students. c US$1 = HK$7.8.
Value for v 2 tests (df) 5.58* (1) 2.11 (3)
5.90* (2)
0.48 (1) 2.79 (2)
7.24** (1) 17.12*** (2)
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deceased (n = 8). Of the 1420 eligible parents that were approached, 1149 (80.9%) completed the initial telephone interview, and 271 refused to answer questions on the initial contact. Of the 1149 smoking parents that were interviewed, 952 (82.9%) indicated a willingness to participate in the trial, and 197 refused. The reasons given by the non-participants for not taking part in the smoking cessation intervention program were: three-quarters (n = 150, 76.1%) simply indicated that they had no interest in quitting smoking at this point, 6.6% (n = 13) did not have the time to take part, another 6.6% (n = 13) believed that they could quit smoking by themselves, and 3% (n = 6) did not want to try again because they had previously been unsuccessful at quitting. The remaining 15 (7.6%) smoking parents did not see a need to quit smoking. Table 1 shows the socio-demographic characteristics of the 1149 smoking parents who completed the telephone interviews (167 mothers and 982 fathers). Of these parents, 952 (82.9%) agreed to take part in
Table 2 Smoking behavior of parents who participated or declined to participate in a proactive telephone-based smoking cessation program (N = 1149a) Smoking behavior
Smoking status Daily smoker Occasional smoker Recent quitter b 6 months Daily cigarette consumption in the past 1 month 10 or less 11–20 21+ Nicotine dependency levelb Low Moderate Severe Years of smoking 1–10 11–20 21–30 31 or more Living with other smoker in the same household Yes No Smoke at home Yes No
Value for v 2 tests (df)
Non-participants (N = 197)
Participants (N = 952)
N
%
n
%
186 7 4
94.4 3.6 2.0
880 29 43
92.4 3.0 4.5
96 79 17
50.0 41.1 8.9
388 447 82
42.3 48.7 8.9
121 40 33
62.4 20.6 17.0
532 241 174
56.2 25.4 18.4
15 90 67 21
7.8 46.6 34.7 10.9
83 450 335 73
8.8 47.8 35.6 7.8
45 150
23.1 76.9
293 637
31.5 68.5
159 35
82.0 18.0
808 133
85.9 14.1
2.72 (2)
4.09 (2)
2.77 (2)
2.17 (3)
5.45* (1) 1.94 (1)
The total percentage may be more or less than 100 due to the rounding off of the figures. p value: *b 0.05; **b 0.01,***b0.001. a The total number is not equal to 1149 because of missing data of up to 3.5%. b The nicotine dependence level was measured using a Fagestrom scale. The scale is divided into 3 levels: low (score 0–3), moderate (score 4–5) and severe (score = 6–10).
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the telephone-based smoking cessation program; 149 (15.7%) of whom were mothers and 803 (84.3%) of whom were fathers. The participants and non-participants in this proactive telephone-based smoking cessation program did not differ in age, marital status, and number of children under the age of 12. However, a significantly higher proportion of mothers than fathers agreed to take part in the program ( p b 0.05). The participants were more likely to have attained a secondary school education than a primary school level or matriculation and above ( p = 0.05). In addition they were more likely to be currently employed (95.1% vs. 90.2%, p b 0.01), and at the middle range in terms of monthly household income (66.7% vs. 50.3%; p b 0.001). In smoking behavior, the participants and non-participants were similar in smoking status, daily cigarette consumption, level of nicotine dependency, numbers of years they had smoked, and their preference for smoking at home (Table 2). However, participants were more likely to have another smoker(s) living in the same household (31.5% vs. 23.1%; p b 0.05). The comparison between the participants and non-participants demonstrated differences in their previous history of quitting and their self-efficacy of success in doing so (Table 3). The participants were Table 3 Previous history of quitting, self-efficacy in quitting smoking, and willingness to participate a proactive telephone-based smoking cessation program (N = 1149a) Previous attempts at quitting and related variables
Ever attempted quitting No Attempted Length of period of abstinence in the last quitting attemptb One month or less More than a month Stage of change Pre-contemplation Contemplation Preparation Action Self perceptions of quitting smoking: Importance of quitting+ (mean = 61) Less important More important Difficulty in quitting++ (mean = 58) Less difficult More difficult Confidence in quitting+++ (mean = 50) Less confident More confident
Non-participants (N = 197)
Participants (N = 952)
n
%
N
%
89 107
45.4 54.6
267 685
28.0 72.0
57 47
54.8 45.2
379 293
56.4 43.6
179 9 3 5
91.3 4.6 1.5 2.6
646 218 39 49
67.9 22.9 4.1 5.1
22.9*** (1) 0.09 (1) 45.3*** (3)
66.2*** (1) 138 36
80.1 19.9
439 493
47.1 52.9
98 80
55.1 44.9
421 512
45.1 54.9
109 58
65.3 34.7
579 341
62.9 37.1
The total percentage may be more or less than 100 due to the rounding off of the figures. These variables were classified as more versus less by placing the division at the mean value. p value: *b 0.05; **b0.01,***b 0.001. a The total number is not equal to 1149 because of missing data of up to 6.6%. b This question was only for those parents who had attempted to quit smoking in the past. +/++/+++
Value for v 2 tests (df)
5.93* (1) 0.33 (1)
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more likely than the non-participants to have previously attempted to quit (72.0% vs. 54.6%; p b 0.001); less to be in the pre-contemplation stage (67.9% vs. 91.3%) with p V 0.001 according to Prochaska’s stage of behavioral change. The participants were also more likely to perceive the importance of quitting (52.9% vs. 19.9%; p b 0.001) and to consider it more difficult to quit (54.9% vs. 44.9%; p b 0.05). The participants and non-participants did not differ on the length of time that had managed to abstain in their last attempt to quit and in their confidence in being able to quit. Table 4 compares the health of the participants and non-participants in the past six months. The participants and non-participants did not differ in their self-perceived health status. Participants were more likely to report frequent coughing in the morning (14.2% vs. 8.6%; p b 0.05), frequent asthmatic symptoms (6% vs. 2%; p b 0.05), and were more likely to have had medical problems that required Table 4 Smoking parents’ health condition and their willingness to participate a proactive telephone-based smoking cessation program (N = 1149a) Health condition of parent smokers
Health status in the past 3 months Good or very good Poor or very poor Throat frequently sore or throat feels uncomfortable Yes No Frequent coughing in the morning after waking up Yes No Frequent coughing in the day time or night time Yes No Frequently need to expel phlegm in the morning after waking up Yes No Frequently need to expel phlegm in the day time or night time Yes No Frequently experience asthmatic conditions in lung or chest Yes No Frequently experience running nose or nasal congestion Yes No Had medical problem that required regular follow-up/hospitalization in the past 6 months Yes No
Non-participants (N = 197)
Participants (N = 952)
n
%
(n)
%
189 6
96.9 3.1
896 52
94.5 5.5
12 185
6.1 93.9
89 863
9.3 90.7
17 180
8.6 91.4
135 817
14.2 85.8
10 187
5.1 94.9
63 884
6.7 93.3
52 145
26.4 73.6
277 675
29.1 70.9
16 180
8.2 91.8
109 838
11.5 88.5
4 193
2.0 98.0
57 895
6.0 94.0
27 169
13.8 86.2
133 815
14.0 86.0
p-value for v 2 tests (df) 1.94 (1) 2.16 (1) 4.38* (1) 0.68 (1) 0.58 (1) 1.87 (1) 5.08* (1) 0.01 (1) 9.65**
22 174
11.2 88.8
The total percentage may be more or less than 100 due to the rounding off of the figures. p value: *b 0.05; **b 0.01,***b0.001. a The total number is not equal to 1149 because of missing data of up to 0.6%.
197 749
20.8 79.2
(1)
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Table 5 Summary of the logistic regression model (forward stepwise) of predictors of participation in a proactive telephone-based smoking cessation program Independent variables
Adjusted ORa( 95% CI )
p value
1.82 (1.10–3.01) 0.81 (0.46–1.44)
b 0.001 b 0.05 0.48
2.97 (1.33–6.61) 2.12 (1.24–3.65)
b 0.01 b 0.01
3.22 (1.55–6.65) 1.39 (0.40–4.79) 1.20 (0.45–3.23)
b 0.05 b 0.005 0.61 0.72
b
Monthly household income (referent = HK$9999 or less) HK$10,000–29,999 HK$30,000 or above Occupational status (referent = unemployed) Currently employed Had medical problem requiring follow up for intervention/was admitted to hospital in the past 6 months Stage of quitting (referent = pre-contemplation stage) Contemplation stage Preparation stage Action stage Perceived importance of quitting (referent = less important) More important 2 log likelihood Model chi-square (df = 9) P Overall rate of correct classification
3.72 (2.38–5.82) 749.34 106.42 .000 85.1%
b 0.001
OR = odds ratio; CI = confidence interval. a Adjusted for all the significant variables in the bivariate analysis. b US$1 = HK$7.8.
follow-up and hospitalization in the last six months (20.8% vs. 11.2%, p b 0.01). Smoking parents were also asked to report on the health of their index children by responding to the same health-related questions. There were no statistically significant differences in the children’s health status between the participants and non-participants. All of the characteristics that were found to have a statistically significant difference between the participants and non-participants in the previous analysis were included in the forward stepwise logistic regression analysis to identify the predictive factors of participation in the telephone-based smoking cessation program (Table 5). The results showed that the following were the predictors of participation by smoking parents in the telephone-based smoking cessation program: being in the middle class with a monthly household income of HK$10,000–29,999 (US$1282–3846) (OR = 1.82; 95% CI: 1.10–3.01; p b 0.05), being currently employed (OR = 2.97; 95% CI: 1.33–6.61; p b 0.01), having had medical problems that required follow-up or having been hospitalized in the last six months (OR = 2.12, 95% CI: 1.24–3.65; p b 0.01), being at the stage of contemplating quitting (OR = 3.22, 95% CI: 1.55–6.65; p b 0.005), and perceiving it to be important to quit smoking (OR = 3.72; 95% CI: 2.38–5.82; p b 0.001).
9. Discussion This report compared the characteristics of participating and non-participating smoking parents with young children, and the predictors of their participation in a proactive telephone-based smoking cessation program. Among the 1149 smoking parents who completed the initial telephone interviews,
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82.9% (n = 952) agreed to take part in the telephone-based smoking cessation program that was offered. This high proportion of positive responses suggests that telephone interview is a feasible and proactive way of recruiting smokers to join smoking cessation programs. This approach maximizes the possible contact with smokers, and provides researchers and clinicians with easier access to a large number of smokers, including many of those who would not have been reached, to persuade them to become engaged in smoking cessation activities. This is an important finding, particularly when most of the studies that have adopted face-to-face interventions have had limited access to dbusyT smokers, which has hindered participation (Woods et al., 2002). The majority of the intervention trials targeting smoking parents did not give enough details on the rate of participation (Chilmonczyk, Palomaki, Knight, Williams, & Haddow, 1992; Groner, Ahijevych, Grossman, & Rich, 2000; Mcintosh, Clark, & Howatt, 1994). In previous studies, a high participation rate (95%) was obtained from smoking mothers of newborn babies in a maternity care setting (Woodward, Owen, Grgurinovich, Griffith, & Linke, 1987) or among the smoking parents with sick babies (71.2–77.2%) (Irvine et al., 1997; Wakefield et al., 2000). The participation rate (82.9%) in this study indicated that smoking parents are receptive to dproactiveT telephone-based interventions; higher than the 67% participation rate in a study in which the subjects were recruited using financial incentives (Hovell et al., 2000). The participation rate is also higher than the 56% in a prospective cohort study on a smoking cessation intervention for parents with children who have been hospitalized for respiratory illness (Winickoff, Hibberd, Case, Sinha, & Rigotti, 2001). The results showed that the smoking parents who were willing to participate were more likely to be the mothers; to be employed; and to be from families with a household income ranging from HK$10,000–29,999 (approx. US$1282–3846) than from those with a lower or higher family income. Participants were also more likely to be living with other smokers; to have previously attempted to quit smoking before, to not be at the pre-contemplation stage of quitting; to feel that it is important to quit smoking, and to perceive that it is difficult to do so. They also coughed more frequently and had health problems that required medical consultations or hospitalization in the last six months. This indicated that smoking parents were more ready to relate the need to quit smoking to their own health problems. However, the failure to find evidence that the parents’ decision to participate in a smoking cessation program was related to their fear of the effects of smoking on their child’s health is disappointing. This finding indicates that it is necessary to educate smoking parents about the hazards posed by second-hand smoking on the health of their young children. The smoking mothers in the present study were more likely to take part in the smoking cessation program than the smoking fathers. This is not surprising, since mothers tend to be the main caretaker of their children and they may be more aware of the need to provide a bsmoke-freeQ environment. This is in line with the result of a community study that found that female smokers were more likely take part in smoking cessation interventions (Woods et al., 2002) and speculated that availability of time was a contributing factor in participation. However, in our study, parents who are currently employed were more likely to take part in a smoking cessation program. Perhaps working parents are less likely to be available to attend a face-to-face smoking cessation intervention program (Winickoff et al., 2001), and considered this proactive telephone-based intervention to be a viable option for them. The same community-based study found that higher household income is predictive of participation in a smoking cessation program (Kviz et al., 1992), which differed from the finding in this study. Since it is unclear whether socio-economic status is a predictor of participation, further population-based investigations on participation are needed.
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It was interesting in this study to find that smoking parents who live with another smoker in the family were more likely to take part in the cessation program. This is a factor that no previous studies have identified. It is uncertain if the presence of another smoker in the family led to greater concern about the negative consequences of smoking on the family member’s health. Further studies are needed to explore this phenomenon. The results of this study support the findings of previous studies that smoking parents with young children who perceive there to be benefits from quitting (Hublet et al., 2002), and those who are breadyQ to take action to quit smoking will take part in smoking cessation programs (Ahluwalia et al., 2002; Cummings et al., 1988; Hublet et al., 2002; Pohl et al., 1998; Woods et al., 2002). Those smokers with health problems that required medical attention were also more likely to participate a smoking cessation intervention (Cummings et al., 1988). It is disappointing to note that this study did not find any relationship between a child’s health and his/ her parents’ decision to participate in a smoking cessation program. This implies that a child’s health needs do not translate into better awareness on the part of the parents to follow good health practices nor have any influence on their decision to quit smoking. Although it was reported that parents of sick children are knowledgeable about the signs and symptoms of an illness (Daly, Selvius, & Lindgren, 1997), they do not seem to be aware of the risk factors. Health education efforts for smoking parents should focus on increasing their awareness of environmental exposure to tobacco as a risk to their children’s health and to motivate changes in behavior. 10. Conclusion This study fills the gap in reporting the characteristics of smoking parents with young children who choose to participate and not to participate in a telephone-based smoking cessation program, and the predictive factors of their participation. Information regarding the predictors of participation in smoking cessation programs is useful for clinicians who are interested in recruiting smokers to participate in their smoking cessation programs or intervention studies. Future reports of intervention studies should also include information on the participants as well as the non-participants, to limit the bias of self-selection. A proactive telephone approach to maximizing the recruitment of smoking parents into smoking cessation programs is feasible. Professionals may refine their subject recruitment approach to target those who are less likely to take part in smoking cessation programs. Health professionals should develop telephone-based smoking cessation interventions to maximize their contact with smoking parents, so as to help the parents and protect the children. More effective strategies should be developed to recruit smoking parents in the lower and upper socio-economic classes, who are unemployed, who have no manifested health symptoms or problems, who do not realize the importance of quitting, and who are at the pre-contemplation stage of quitting. References Ahluwalia, J. S., Richter, K., Mayo, M. S., Ahluwalia, H. K., Choi, W. S., Schmelzle, K. H., et al. (2002). African American smokers interested and eligible for a smoking cessation clinical trial: Predictors of not returning for randomization. Annals of Epidemiology, 12, 206 – 212.
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Predictors of the participation of smoking parents in a proactive telephone-based smoking cessation program Yim Wah Mak a,*, Alice Yuen Loke b, Tai Hing Lam c, Abu Saleh Abdullah d a
Department of Nursing Studies, The University of Hong Kong, Hong Kong, China b School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China c Department of Community Medicine, The University of Hong Kong, Hong Kong, China d International Health Department, Boston University, USA
Abstract Objective: The objective of this study is to identify the predictors of participation by smoking parents in a proactive telephone-based smoking cessation program. Methods: The smoking parents of young children from a birth cohort were interviewed and invited to take part in a telephone-based smoking cessation program. The characteristics of the parents and the predictors of participation were analyzed by chi-square test and by logistic regression. Results: A total of 952 (82.9%) out of the 1149 smoking parents who were interviewed agreed to participate in the smoking cessation program. The analysis showed that the predictors of participation in a pro-active smoking cessation program are being from a middle-income household, being currently employed, having recently had a medical consultation or been hospitalized, being at the stage of contemplating a change in behavior, and perceiving the importance of quitting smoking. Conclusions: Recruitment approaches should be refined according to the identified factors to target those who might decline an invitation to participate in a smoking cessation program. D 2005 Elsevier Ltd. All rights reserved. Keywords: Participation predictors; Smoking parents; Smoking cessation program
* Corresponding author. Tel.: +852 2819 2628; fax: +852 2872 6079. E-mail address: [email protected] (Y.W. Mak). 0306-4603/$ - see front matter D 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2005.12.018
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1. Introduction Young children with smoking parents are vulnerable to health risks from passive smoking (DiFranza & Lew, 1996). Studies have shown that the health of children is adversely affected by passive smoking at home (Lam, Chung, Betson, Wong, & Hedley, 1998). If the smoking parents of young children could quit smoking, their children would be at a reduced risk of smoking-related morbidity and mortality due to exposure to passive smoking or active smoking in later life. Thus, an effective smoking cessation program for smoking parents of young children could have a major impact on the health of both the parents and their children (Cook & Strachan, 1999; Godtfredsen, Holst, Prescott, Vestbo, & Osler, 2002; Mclaughlin, Hrubec, Blot, & Fraumeni, 1995). Researchers and clinicians alike have faced difficulties in their attempts to reach out and help smokers who choose not to take part in smoking cessation programs. As a matter of fact, smoking cessation intervention studies often only reach those smokers who are breadyQ to participate in such programs or are at the bcontemplationQ or bactionQ stage of quitting (Orleans et al., 1998; Zhu et al., 1996). Genuine efforts to recruit those who refuse or are not ready to take part in intervention studies are imperative if clinicians are eager to reach these smokers who might otherwise be excluded from such studies. Knowledge about the characteristics of smokers and the predictors of their participation in smoking cessation interventions would provide clinicians with the information they need to develop strategies to recruit smokers to participate in interventions or to re-design interventions so that they will be acceptable to the target population. It is expected that information on non-participating smokers will further strengthen the generality of the results of the study, the feasibility of interventions, and the external validity of the recruiting and sample selection processes as well as of the interventions themselves (Glasgow, Mccaul, & Fisher, 1993; Wilson, 1990). Reports of intervention studies among smokers have focused mainly on the effects of interventions on those who participated in the intervention studies. Although many of these reports specify the rates of participation in their programs, not many have examined the factors that influence smokers to participate or refuse to participate in such programs. The few studies that have reported on the characteristics of the participants and non-participants in smoking cessation programs have been conducted in workplaces (Cummings, Hellmann, & Emont, 1988); and among secondary school students (Hublet, Maes, & Csincsak, 2002). Predictors of non-participation in smoking cessation programs indicate those who have a lower level of literacy, do not regularly utilize health care services, and who belong to a lower income group (Ahluwalia et al., 2002). Men in full-time employment and those with relatively high annual household incomes are also less likely to take part in smoking cessation programs (Kviz, Crittenden, & Warnecke, 1992). A study on the cessation of smoking conducted among low-income women in a community primary care setting identified a higher intention to quit and lower self-efficacy in doing so as predictors of participation (Pohl, Martinelli, & Antonakos, 1998).
2. Studies targeted at smoking parents A meta-analysis was conducted of intervention studies on reducing the degree to which young children are exposed to environmental tobacco smoke that targeted smoking parents or the children’s family and school environment (Roseby et al., 2003). These intervention studies were conducted in child
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health clinics, asthma clinics, schools, or homes. Although all of the studies reported a reduction in children exposed to environment tobacco smoke among those who took part in the studies, none revealed details about the backgrounds of non-participating parents/families. This is a limitation found in most intervention studies for smokers. Smoking parents may differ as to whether or not they are willing to take part in smoking cessation programs or intervention studies. Besides investigating the characteristics of the parents as predictors of participation, it is also necessary to determine whether predictors of the participation of smoking parents in smoking cessation programs could include the presence of respiratory symptoms in their young children and whether or not their children utilize medical services.
3. Strategies to recruit smoking parents into intervention programs A well-designed smoking cessation intervention is of limited use if it cannot capture the interest of the target audience and persuade them to participate in the programs. Effective strategies to recruit participants into smoking cessation programs are those that appeal to smokers and are receptive to their concerns. Understanding the characteristics of these non-participating smokers and their reasons for not taking part in smoking cessation programs will be helpful in the planning of recruitment strategies to increase rates of participation in such programs. Most smoking cessation intervention studies adopt the reactive approach, in which most participating smokers present themselves in clinics and are breadyQ to take action to quit smoking (Lichtenstein, Glasgow, Lando, OssipKlein, & Boles, 1996). Strategies to maximize the participation of smoking parents using bproactiveQ interventions need to be designed if clinicians and researchers are determined to reach such people. Telephone-based counseling as an intervention is accessible to most in countries where a telephone is common in all households, and has become a popular mode for providing counseling on the cessation of smoking (Curry, McBride, Grothaus, Louie, & Wagner, 1995; Hennrikus et al., 2002; Lam, Leung, & Ho, 2001). The study presented here is part of a smoking cessation program for smoking parents using a telephone-based proactive intervention in an attempt to reach those who otherwise would not have presented themselves to clinics or health settings to quit smoking.
4. Study aims and objectives This is a report to identify the characteristics of smoking parents with young children who choose or do not choose to participate, and to identify the predictors of their participation in a proactive telephonebased smoking cessation program.
5. Study methods In 1997, a Birth Cohort Study was conducted in the months of April and May by the Department of Community Medicine of the University of Hong Kong and the Maternal and Child Health Center (MCHC) in Hong Kong (Lam et al., 2001). A total of 8327 births took place during that period, and the Birth Cohort Study gathered information from the mothers of the newborns about the parents’ smoking
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status. Two thousand seven hundred and thirty-three smoking fathers and 230 smoking mothers were identified. All of these parents were contacted at intervals when the babies were at birth, 3 months, 9 months, and 18 months of age. At the end of an 18-month follow-up period, a total of 2311 smoking parents remained in the sample pool. In the period June 2001 to July 2003, these 2311 smoking parents were again contacted for a telephone interview to reassess their current smoking status. Those parents who continued smoking or who had recently quit for less than six months were considered eligible for inclusion in a randomized controlled trial of telephone-based counseling on smoking cessation. Other criteria were that the smoking parents must live in Hong Kong and with their children for not less than five days a week. Verbal informed consent was granted through the telephone interview. Those smoking parents who gave their consent to participate in the study would be randomly allocated into the intervention group, in which they would receive printed self-help materials and telephone smoking cessation counseling sessions; whereas the control group would receive printed self-help materials only. A structured questionnaire was used for the telephone interview. The questionnaire solicited information on the demographic characteristics of the smoking parents; their smoking history; current smoking status and behavior, including their Fagestrom’s nicotine dependency level (Fagerstrom & Schneider, 1989); previous attempts to quit and their self-efficacy on how successful they were in doing so; the stage of behavioral change at which they are in, according to the Transtheoretical model of behavioral change (Prochaska & DiClemente, 1983); and the health of the smoking parents and that of their child. This report serves two purposes. It is to compare the characteristics of smoking parents with young children who choose to take part in a telephone-based smoking cessation program with those who choose not to do so, and to identify the predictors of their participation. It would be useful to consider these characteristics and predictors of participation when developing approaches to recruit participants in smoking cessation intervention activities targeted at smoking parents. Second, the result will give information on the acceptability to smoking parents of a free offer of participation in a proactive telephone-based smoking cessation program.
6. Ethical considerations Prior to carrying out the study, ethical approval for the study was obtained from the Ethics Committee of The Hong Kong Polytechnic University, and from the Maternal and Child Care Centre. All parents were invited to take part on voluntary basis. They were informed of the purpose of the study and had the right to withdrawal at any time. It was clearly stated that their decision on whether or not to participate in the study would not affect the care they received in the clinic. They were also explained that any personal information collected during the study would remain confidential.
7. Data management Participants were defined as parents who completed the telephone interview and consented to participate in the smoking cessation telephone-based counseling program. The characteristics of the participants versus those of the non-participants were compared using a Chi-square test for bivariate
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analysis. A stepwise logistic regression analysis was used to identify the predictive factors of participation.
8. Results A total of 1420 out of the 2311 smoking parents contacted were considered eligible, while the remaining 891 parents were excluded for any one of the following reasons: some could not be recontacted because of an invalid telephone number (n = 510), some denied ever having smoked (n = 23), some reported that they had quit smoking for more than 6 months (n = 159), some no longer resided in Hong Kong (n = 141),were separated or divorced and not living with the index child (n = 50), or were Table 1 Socio-demographic characteristics of smoking parents: the participants and non-participants in a proactive telephone-based smoking cessation program (N = 1149a) Characteristics
Non-participants (N = 197)
Participants (N = 952)
Demographics:
n
%
N
%
18 179
9.1 90.9
149 803
15.7 84.3
4 56 107 27
2.0 28.9 55.2 13.9
23 306 518 102
2.4 32.2 54.6 10.7
42 129 22
21.8 66.8 11.4
181 704 66
19.0 74.0 6.9
194 3
98.5 1.5
930 22
97.7 2.3
76 92 19
40.6 49.2 10.2
364 478 92
39.0 51.2 9.9
175 19
90.2 9.8
898 46
95.1 4.9
40 87 46
23.1 50.3 26.6
143 606 159
15.7 66.7 17.5
Gender Mother Father Age 18–25 26–35 36–45 46 or above Educational attainment Primary or below Secondary Matriculation or above Marital status Married Divorced/separated Number of children under 12 1 2 z3 Employment status Currently employedb Unemployed Monthly household incomec HK$9999 or less HK$10,000–29,999 HK$30,000 or above
The total percentage may be more or less than 100 due to the rounding off of the figures. p value: *V 0.05; **b0.01,***b 0.001. a The total number is not equal to 1149 because of missing data of up to 5.9%. b Includes parents who are currently employed, housewives, and full-time students. c US$1 = HK$7.8.
Value for v 2 tests (df) 5.58* (1) 2.11 (3)
5.90* (2)
0.48 (1) 2.79 (2)
7.24** (1) 17.12*** (2)
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deceased (n = 8). Of the 1420 eligible parents that were approached, 1149 (80.9%) completed the initial telephone interview, and 271 refused to answer questions on the initial contact. Of the 1149 smoking parents that were interviewed, 952 (82.9%) indicated a willingness to participate in the trial, and 197 refused. The reasons given by the non-participants for not taking part in the smoking cessation intervention program were: three-quarters (n = 150, 76.1%) simply indicated that they had no interest in quitting smoking at this point, 6.6% (n = 13) did not have the time to take part, another 6.6% (n = 13) believed that they could quit smoking by themselves, and 3% (n = 6) did not want to try again because they had previously been unsuccessful at quitting. The remaining 15 (7.6%) smoking parents did not see a need to quit smoking. Table 1 shows the socio-demographic characteristics of the 1149 smoking parents who completed the telephone interviews (167 mothers and 982 fathers). Of these parents, 952 (82.9%) agreed to take part in
Table 2 Smoking behavior of parents who participated or declined to participate in a proactive telephone-based smoking cessation program (N = 1149a) Smoking behavior
Smoking status Daily smoker Occasional smoker Recent quitter b 6 months Daily cigarette consumption in the past 1 month 10 or less 11–20 21+ Nicotine dependency levelb Low Moderate Severe Years of smoking 1–10 11–20 21–30 31 or more Living with other smoker in the same household Yes No Smoke at home Yes No
Value for v 2 tests (df)
Non-participants (N = 197)
Participants (N = 952)
N
%
n
%
186 7 4
94.4 3.6 2.0
880 29 43
92.4 3.0 4.5
96 79 17
50.0 41.1 8.9
388 447 82
42.3 48.7 8.9
121 40 33
62.4 20.6 17.0
532 241 174
56.2 25.4 18.4
15 90 67 21
7.8 46.6 34.7 10.9
83 450 335 73
8.8 47.8 35.6 7.8
45 150
23.1 76.9
293 637
31.5 68.5
159 35
82.0 18.0
808 133
85.9 14.1
2.72 (2)
4.09 (2)
2.77 (2)
2.17 (3)
5.45* (1) 1.94 (1)
The total percentage may be more or less than 100 due to the rounding off of the figures. p value: *b 0.05; **b 0.01,***b0.001. a The total number is not equal to 1149 because of missing data of up to 3.5%. b The nicotine dependence level was measured using a Fagestrom scale. The scale is divided into 3 levels: low (score 0–3), moderate (score 4–5) and severe (score = 6–10).
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the telephone-based smoking cessation program; 149 (15.7%) of whom were mothers and 803 (84.3%) of whom were fathers. The participants and non-participants in this proactive telephone-based smoking cessation program did not differ in age, marital status, and number of children under the age of 12. However, a significantly higher proportion of mothers than fathers agreed to take part in the program ( p b 0.05). The participants were more likely to have attained a secondary school education than a primary school level or matriculation and above ( p = 0.05). In addition they were more likely to be currently employed (95.1% vs. 90.2%, p b 0.01), and at the middle range in terms of monthly household income (66.7% vs. 50.3%; p b 0.001). In smoking behavior, the participants and non-participants were similar in smoking status, daily cigarette consumption, level of nicotine dependency, numbers of years they had smoked, and their preference for smoking at home (Table 2). However, participants were more likely to have another smoker(s) living in the same household (31.5% vs. 23.1%; p b 0.05). The comparison between the participants and non-participants demonstrated differences in their previous history of quitting and their self-efficacy of success in doing so (Table 3). The participants were Table 3 Previous history of quitting, self-efficacy in quitting smoking, and willingness to participate a proactive telephone-based smoking cessation program (N = 1149a) Previous attempts at quitting and related variables
Ever attempted quitting No Attempted Length of period of abstinence in the last quitting attemptb One month or less More than a month Stage of change Pre-contemplation Contemplation Preparation Action Self perceptions of quitting smoking: Importance of quitting+ (mean = 61) Less important More important Difficulty in quitting++ (mean = 58) Less difficult More difficult Confidence in quitting+++ (mean = 50) Less confident More confident
Non-participants (N = 197)
Participants (N = 952)
n
%
N
%
89 107
45.4 54.6
267 685
28.0 72.0
57 47
54.8 45.2
379 293
56.4 43.6
179 9 3 5
91.3 4.6 1.5 2.6
646 218 39 49
67.9 22.9 4.1 5.1
22.9*** (1) 0.09 (1) 45.3*** (3)
66.2*** (1) 138 36
80.1 19.9
439 493
47.1 52.9
98 80
55.1 44.9
421 512
45.1 54.9
109 58
65.3 34.7
579 341
62.9 37.1
The total percentage may be more or less than 100 due to the rounding off of the figures. These variables were classified as more versus less by placing the division at the mean value. p value: *b 0.05; **b0.01,***b 0.001. a The total number is not equal to 1149 because of missing data of up to 6.6%. b This question was only for those parents who had attempted to quit smoking in the past. +/++/+++
Value for v 2 tests (df)
5.93* (1) 0.33 (1)
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more likely than the non-participants to have previously attempted to quit (72.0% vs. 54.6%; p b 0.001); less to be in the pre-contemplation stage (67.9% vs. 91.3%) with p V 0.001 according to Prochaska’s stage of behavioral change. The participants were also more likely to perceive the importance of quitting (52.9% vs. 19.9%; p b 0.001) and to consider it more difficult to quit (54.9% vs. 44.9%; p b 0.05). The participants and non-participants did not differ on the length of time that had managed to abstain in their last attempt to quit and in their confidence in being able to quit. Table 4 compares the health of the participants and non-participants in the past six months. The participants and non-participants did not differ in their self-perceived health status. Participants were more likely to report frequent coughing in the morning (14.2% vs. 8.6%; p b 0.05), frequent asthmatic symptoms (6% vs. 2%; p b 0.05), and were more likely to have had medical problems that required Table 4 Smoking parents’ health condition and their willingness to participate a proactive telephone-based smoking cessation program (N = 1149a) Health condition of parent smokers
Health status in the past 3 months Good or very good Poor or very poor Throat frequently sore or throat feels uncomfortable Yes No Frequent coughing in the morning after waking up Yes No Frequent coughing in the day time or night time Yes No Frequently need to expel phlegm in the morning after waking up Yes No Frequently need to expel phlegm in the day time or night time Yes No Frequently experience asthmatic conditions in lung or chest Yes No Frequently experience running nose or nasal congestion Yes No Had medical problem that required regular follow-up/hospitalization in the past 6 months Yes No
Non-participants (N = 197)
Participants (N = 952)
n
%
(n)
%
189 6
96.9 3.1
896 52
94.5 5.5
12 185
6.1 93.9
89 863
9.3 90.7
17 180
8.6 91.4
135 817
14.2 85.8
10 187
5.1 94.9
63 884
6.7 93.3
52 145
26.4 73.6
277 675
29.1 70.9
16 180
8.2 91.8
109 838
11.5 88.5
4 193
2.0 98.0
57 895
6.0 94.0
27 169
13.8 86.2
133 815
14.0 86.0
p-value for v 2 tests (df) 1.94 (1) 2.16 (1) 4.38* (1) 0.68 (1) 0.58 (1) 1.87 (1) 5.08* (1) 0.01 (1) 9.65**
22 174
11.2 88.8
The total percentage may be more or less than 100 due to the rounding off of the figures. p value: *b 0.05; **b 0.01,***b0.001. a The total number is not equal to 1149 because of missing data of up to 0.6%.
197 749
20.8 79.2
(1)
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1739
Table 5 Summary of the logistic regression model (forward stepwise) of predictors of participation in a proactive telephone-based smoking cessation program Independent variables
Adjusted ORa( 95% CI )
p value
1.82 (1.10–3.01) 0.81 (0.46–1.44)
b 0.001 b 0.05 0.48
2.97 (1.33–6.61) 2.12 (1.24–3.65)
b 0.01 b 0.01
3.22 (1.55–6.65) 1.39 (0.40–4.79) 1.20 (0.45–3.23)
b 0.05 b 0.005 0.61 0.72
b
Monthly household income (referent = HK$9999 or less) HK$10,000–29,999 HK$30,000 or above Occupational status (referent = unemployed) Currently employed Had medical problem requiring follow up for intervention/was admitted to hospital in the past 6 months Stage of quitting (referent = pre-contemplation stage) Contemplation stage Preparation stage Action stage Perceived importance of quitting (referent = less important) More important 2 log likelihood Model chi-square (df = 9) P Overall rate of correct classification
3.72 (2.38–5.82) 749.34 106.42 .000 85.1%
b 0.001
OR = odds ratio; CI = confidence interval. a Adjusted for all the significant variables in the bivariate analysis. b US$1 = HK$7.8.
follow-up and hospitalization in the last six months (20.8% vs. 11.2%, p b 0.01). Smoking parents were also asked to report on the health of their index children by responding to the same health-related questions. There were no statistically significant differences in the children’s health status between the participants and non-participants. All of the characteristics that were found to have a statistically significant difference between the participants and non-participants in the previous analysis were included in the forward stepwise logistic regression analysis to identify the predictive factors of participation in the telephone-based smoking cessation program (Table 5). The results showed that the following were the predictors of participation by smoking parents in the telephone-based smoking cessation program: being in the middle class with a monthly household income of HK$10,000–29,999 (US$1282–3846) (OR = 1.82; 95% CI: 1.10–3.01; p b 0.05), being currently employed (OR = 2.97; 95% CI: 1.33–6.61; p b 0.01), having had medical problems that required follow-up or having been hospitalized in the last six months (OR = 2.12, 95% CI: 1.24–3.65; p b 0.01), being at the stage of contemplating quitting (OR = 3.22, 95% CI: 1.55–6.65; p b 0.005), and perceiving it to be important to quit smoking (OR = 3.72; 95% CI: 2.38–5.82; p b 0.001).
9. Discussion This report compared the characteristics of participating and non-participating smoking parents with young children, and the predictors of their participation in a proactive telephone-based smoking cessation program. Among the 1149 smoking parents who completed the initial telephone interviews,
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82.9% (n = 952) agreed to take part in the telephone-based smoking cessation program that was offered. This high proportion of positive responses suggests that telephone interview is a feasible and proactive way of recruiting smokers to join smoking cessation programs. This approach maximizes the possible contact with smokers, and provides researchers and clinicians with easier access to a large number of smokers, including many of those who would not have been reached, to persuade them to become engaged in smoking cessation activities. This is an important finding, particularly when most of the studies that have adopted face-to-face interventions have had limited access to dbusyT smokers, which has hindered participation (Woods et al., 2002). The majority of the intervention trials targeting smoking parents did not give enough details on the rate of participation (Chilmonczyk, Palomaki, Knight, Williams, & Haddow, 1992; Groner, Ahijevych, Grossman, & Rich, 2000; Mcintosh, Clark, & Howatt, 1994). In previous studies, a high participation rate (95%) was obtained from smoking mothers of newborn babies in a maternity care setting (Woodward, Owen, Grgurinovich, Griffith, & Linke, 1987) or among the smoking parents with sick babies (71.2–77.2%) (Irvine et al., 1997; Wakefield et al., 2000). The participation rate (82.9%) in this study indicated that smoking parents are receptive to dproactiveT telephone-based interventions; higher than the 67% participation rate in a study in which the subjects were recruited using financial incentives (Hovell et al., 2000). The participation rate is also higher than the 56% in a prospective cohort study on a smoking cessation intervention for parents with children who have been hospitalized for respiratory illness (Winickoff, Hibberd, Case, Sinha, & Rigotti, 2001). The results showed that the smoking parents who were willing to participate were more likely to be the mothers; to be employed; and to be from families with a household income ranging from HK$10,000–29,999 (approx. US$1282–3846) than from those with a lower or higher family income. Participants were also more likely to be living with other smokers; to have previously attempted to quit smoking before, to not be at the pre-contemplation stage of quitting; to feel that it is important to quit smoking, and to perceive that it is difficult to do so. They also coughed more frequently and had health problems that required medical consultations or hospitalization in the last six months. This indicated that smoking parents were more ready to relate the need to quit smoking to their own health problems. However, the failure to find evidence that the parents’ decision to participate in a smoking cessation program was related to their fear of the effects of smoking on their child’s health is disappointing. This finding indicates that it is necessary to educate smoking parents about the hazards posed by second-hand smoking on the health of their young children. The smoking mothers in the present study were more likely to take part in the smoking cessation program than the smoking fathers. This is not surprising, since mothers tend to be the main caretaker of their children and they may be more aware of the need to provide a bsmoke-freeQ environment. This is in line with the result of a community study that found that female smokers were more likely take part in smoking cessation interventions (Woods et al., 2002) and speculated that availability of time was a contributing factor in participation. However, in our study, parents who are currently employed were more likely to take part in a smoking cessation program. Perhaps working parents are less likely to be available to attend a face-to-face smoking cessation intervention program (Winickoff et al., 2001), and considered this proactive telephone-based intervention to be a viable option for them. The same community-based study found that higher household income is predictive of participation in a smoking cessation program (Kviz et al., 1992), which differed from the finding in this study. Since it is unclear whether socio-economic status is a predictor of participation, further population-based investigations on participation are needed.
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It was interesting in this study to find that smoking parents who live with another smoker in the family were more likely to take part in the cessation program. This is a factor that no previous studies have identified. It is uncertain if the presence of another smoker in the family led to greater concern about the negative consequences of smoking on the family member’s health. Further studies are needed to explore this phenomenon. The results of this study support the findings of previous studies that smoking parents with young children who perceive there to be benefits from quitting (Hublet et al., 2002), and those who are breadyQ to take action to quit smoking will take part in smoking cessation programs (Ahluwalia et al., 2002; Cummings et al., 1988; Hublet et al., 2002; Pohl et al., 1998; Woods et al., 2002). Those smokers with health problems that required medical attention were also more likely to participate a smoking cessation intervention (Cummings et al., 1988). It is disappointing to note that this study did not find any relationship between a child’s health and his/ her parents’ decision to participate in a smoking cessation program. This implies that a child’s health needs do not translate into better awareness on the part of the parents to follow good health practices nor have any influence on their decision to quit smoking. Although it was reported that parents of sick children are knowledgeable about the signs and symptoms of an illness (Daly, Selvius, & Lindgren, 1997), they do not seem to be aware of the risk factors. Health education efforts for smoking parents should focus on increasing their awareness of environmental exposure to tobacco as a risk to their children’s health and to motivate changes in behavior. 10. Conclusion This study fills the gap in reporting the characteristics of smoking parents with young children who choose to participate and not to participate in a telephone-based smoking cessation program, and the predictive factors of their participation. Information regarding the predictors of participation in smoking cessation programs is useful for clinicians who are interested in recruiting smokers to participate in their smoking cessation programs or intervention studies. Future reports of intervention studies should also include information on the participants as well as the non-participants, to limit the bias of self-selection. A proactive telephone approach to maximizing the recruitment of smoking parents into smoking cessation programs is feasible. Professionals may refine their subject recruitment approach to target those who are less likely to take part in smoking cessation programs. Health professionals should develop telephone-based smoking cessation interventions to maximize their contact with smoking parents, so as to help the parents and protect the children. More effective strategies should be developed to recruit smoking parents in the lower and upper socio-economic classes, who are unemployed, who have no manifested health symptoms or problems, who do not realize the importance of quitting, and who are at the pre-contemplation stage of quitting. References Ahluwalia, J. S., Richter, K., Mayo, M. S., Ahluwalia, H. K., Choi, W. S., Schmelzle, K. H., et al. (2002). African American smokers interested and eligible for a smoking cessation clinical trial: Predictors of not returning for randomization. Annals of Epidemiology, 12, 206 – 212.
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