Exploration of tobacco-quitting experiences and self-help strategies among former and current tobacco users in India: a qualitative study

■ Introduction

The tobacco epidemic is unequivocally one of the  most serious public health crises the world has ever faced [1]. Over 7 million deaths are caused by direct tobacco use and 1.2 million deaths by second-hand smoke [2]. Around 80-90% of oral cancers are directly attributable to tobacco use [3]. According to the Global Adult Tobacco Survey conducted in 2016-2017, tobacco is consumed by 28.6% of the total population of India of which smoking tobacco is consumed by 10.7% and smokeless tobacco by 21.4%. With the increased usage of smokeless tobacco, there is a higher prevalence of oral cancer in India [4]. Recognising the importance of tobacco cessation, 13 tobacco cessation clinics (TCCs) were started in 2002 in India with the objective to evolve cessation strategies for smokers and smokeless tobacco users, to gain experience in tobacco cessation interventions and to evaluate the feasibility of scaling up these strate­gies [5]. Different methods have been used for smoking cessation, which include quitting without assistance such as cold turkey or cutting down then quitting, Nicotine Replacement Therapy (NRT) or antidepressants coupled with behavioural counselling. Despite the availability of numerous agents for tobacco cessation, a high level of cooperation, motivation, and compliance is required for tobacco users to quit.
Nicotine replacement therapy, bupropion, and varenicline are the primary medications for tobacco cessation. It is essential to combine behavioural interventions with pharmacologic therapy to increase smoking cessation success rates [6]. There is an increase in the usage of non-cigarette or alternative tobacco products such as hookahs/waterpipes, smokeless tobacco, and electronic cigarettes and herbal cigarettes among youth these days [7].
Qualitative studies on tobacco quitting experiences are few and not many studies on self-help strategies are available in the literature. We made the deliberate decision to conduct a qualitative study to effectively capture the underlying beliefs, values, feelings and motivations that drive participant behaviour [8]. Qualitative research could also aid the development of theories relating to people and their perception of health risks [9]. It could enhance our knowledge about the extent and nature of quitters’ dependence on nicotine prior to attempts to stop and indicate the extent to which such people are persistent in their efforts to quit tobacco. Various self-help strategies are used by tobacco users to quit tobacco and nicotine addiction but success varies from person to person, hence this study aims to record various experiences of tobacco users and their different self-help strategies.

■ Material and methods

Study design

This is the Interpretative Phenomenological Analysis using an interview guide to record current or former tobacco-user study participants’ tobacco- quitting experiences. The phenomenological approach explores their feelings and experiences and finds shared patterns rather than individual characteristics.

Study setting

This study was conducted in Chennai, Tamil Nadu, India from October to December 2022. Chennai [former Madras] is a megacity in India that is populated by more than ten million people.

Sample

Fifty study participants visiting a tobacco- cessation clinic in Chennai were selected using convenience sampling. Sample size was determined based on theoretical data saturation. The study population includes former and current tobacco users aged 18-74 years with at least one failed quit attempt who were willing to share their experience. A person who had been smoking for at least 6 months and was a smoker at the time of the study was defined as a current smoker in line with the WHO criteria. A person who had smoked for at least 6 months and had not smoked for at least 3 months before the study was regarded as a former smoker.

Data collection

A semi-structured interview guide with open questions was developed with the help of pre­vious studies and with experts’ opinions; the data were collected through semi-structured In-Depth Inter­views (IDIs). Demographic data was collected and nicotine dependence was recorded using the Fagerstörm Test for Nicotine Dependence. The interviews were audio recorded and written notes were taken. The interview was conducted in Tamil and lasted around 30-40 min. The participants were labelled alphanumerically like P1, P2, P3… P50. The participants were asked to record their experience of tobacco quitting and self-help strategies. Data collection stopped when data saturation was achieved.

Interview guide

1. Have you ever tried to quit tobacco usage before?
2. How was your tobacco quitting experience?
3. What are the things that helped you to quit tobacco?
4. How beneficial was the material/method used for quitting tobacco?
5. Why did you resume tobacco usage after stopping?
6. What difficulties/problem you faced during quitting?
7. How do you think tobacco usage affected your health?

Data analysis

The data was analysed using Braun and Clarke’s six-phase framework of thematic analysis, gene­rating initial codes, searching for themes, reviewing themes, defining themes and write-up. Thematic analysis (TA) is a method for identifying, analysing, and interpreting patterns of meaning (‘themes’) within qualitative data. Themes provide a framework for organising and reporting the researcher’s analytic observations [10].
The collected data was transcribed within 24 hours of the interview by a transcriptionist and translated into English language by listening to the audio recordings to conduct a thematic analysis. Data were analysed concurrently to determine the data saturation.

Ethical considerations

Ethical approval was obtained from IERB committee from Tamil Nadu Government Dental College and Hospital. Participants were provided with information sheet and informed consent was obtained. Study participants have been assured that confidentiality of the information will be maintained.

■ Results

The demographic data of fifty participants were shown in Table I. The analysis of transcripts from the interviews revealed themes and subthemes as shown in Table II.

Theme 1. Ease of Quitting

Quitting tobacco is a journey towards choosing life. Various quitting experiences of former and current tobacco users were explored and divided into following subthemes – Burden-free, Slow and Steady, Difficult.
I felt no difficulties in quitting as I left the habit by my choice. (P37)
It was difficult initially to control myself from usage, but later tried to quit slowly over a period of time and now stopped completely. (P27)
It’s difficult for me to quit, tried to stop once for a week but again started as I felt I will die if I don’t use it. (P22)

Theme 2. Barriers to Quitting

Almost all tobacco users want to quit the habit at one point in life but there are many psychosocial barriers that lead to failure. We must therefore take an in-depth look to understand the reasons contributing to failures in tobacco cessation and so various subthemes identified include Nicotine addiction, Temptation and Social acceptability.
Mind is difficult to control, I feel its compulsory, if not nothing seems right. (P39)
I couldn’t control seeing other people using in front of me. (P8)
I felt lonely during quitting as those around did not include me so I resumed usage. (P1)

Theme 3. Self-Help Strategies for Quitting Tobacco

Many tobacco users try to use alternative material to quit tobacco or reduce tobacco usage. Many self-help materials were listed – various self-help strategies that were beneficial includes chewing gum, mouth fresheners, chocolate, peanuts/cereals, fruits/vegetables and seeds and nuts.
I tried to use boomer (chewing gum) every day and also used tic tac each day which helped me to stop the habit slowly. (P36)
I used kopikko chocolate around 5 pieces per day it was quite helpful to quit the habit. (P2)
I used to chew raw rice and aniseed; it was helpful for me to quit betel nut. (P38)
I used to chew ginger which reduced my craving for tobacco. (P23)

Theme 4. Reasons for Relapse

Many people want to quit but not all are successful as there is relapse, which is a relevant problem. Main reasons for relapse were divided in the peer- pressure, stressbuster and sense-of-something- missing subthemes.
Due to family tension, problem and fight in the family I got depressed and was stressed and started using cigarettes to relax. (P36)
Due to peer pressure and socially, I again started the habit. (P22)
I feel tense if I don’t use itself. To feel better, I started using again. (P44)

Theme 5. Motivation to Quit

All participants agreed that the right motivation plays an important role in the causing behaviour change that led them to quit the habit. How­ever, participants had different motivations to quit, which was classified into life events, health-issues, family- need and financial-cost subthemes.
As I am getting married next month, I was determined to quit the habit; my motivation is the main driver of my success. (P43)
I have stopped using tobacco due to my health issues. (P25)
I had quit the habit, as my daughter asked me not to use as she even felt embarrassed about me taking her to school. (P38)
I feel happy now after quitting the habit of cigarette usage as it was extra money I was spending. (P46)

Theme 6. Health Concerns

Many participants knew about the health risk associated with usage of tobacco products. Those health concerns were divided into dental-issue, neurological-damage and respiratory-problem sub­themes.
Due to usage of mawa1 all my teeth got stained, I felt sensitivity and pain on eating food due to attrition of many teeth. (P40)
I was using cigarette for past 12 years, which caused me considerable nervous damage. I feel lazy and my hands start trembling sometimes. (P1)
While I was using cigarette, I got cold often and also had wheezing problem, so I decided to quit the habit. (P6)

■ Discussion

The present study explored various tobacco users’ quitting experiences, different applied self-help strategies, reasons for relapse, psychosocial barriers and their perceptions of health risks.

Ease of quitting

The first theme of the journey towards quitting was easy and burden free for a few tobacco users as they were determined to quit whereas a few other participants felt they could slowly and steadily quit the habit as in the “transtheoretical model” [11]. It is worth emphasising the fact that, in our study, the process of tobacco cessation reported by the participants was closer to that captured by the transtheoretical model of health-behaviour change rather than to the PRIME Theory as explained by study conducted by Buczkowski et al. [12] on modes of quitting. This revealed that, when it comes to modes of quitting, the majority of smokers intent on giving up succeeded because they acted on an impulse, without prior preparation for smoking cessation. However, this is not in line with our study, which revealed that participants stopped tobacco usage in a planned manner, gradually decreasing usage. In the journey towards quitting, study findings showed few participants were highly-dependent tobacco users as they felt usage of tobacco was a compulsive behaviour. This is in line with study conducted by Roditis et al. [13], which explored perception about addiction among adolescents also revealed as dependence or compulsory behaviour as one of main causes of addiction.

Barriers to Quitting

Our study findings revealed that the major barriers to quitting are nicotine addiction, temptation and social acceptability. The findings of our study are in line with study conducted by Chean et al. [8] in which major barriers were lifestyle factors like temptation, nicotine addiction, withdrawal symptoms, sociocultural norms and peer pressure.

Self-Help Strategies for Quitting Tobacco

The next theme is Self-Help Strategies for Quitting Tobacco used by tobacco users to quit the habit. This is the first of its kind and there were no previous studies that explored various tobacco-quitting self-help strategies and the degree of benefit of each strategy. Self-help strategies were mainly used to reduce tobacco usage and divert the mind with a substitute whenever they felt like using, which in turn helped them to quit tobacco. Among various self-help strategies, chewing gum (Centre Fresh, Boomer, Orbit) was most frequently chosen by tobacco users. Next in line as beneficial for quitting was chocolate like Pass Pass Pulse, peanuts, fruits and vegetables and cereals (raw rice).

Reasons for relapse

The finding from our study revealed few reasons for relapse that were in line with the study conducted by Buczkowski et al. [12], which explored reasons like smoking a cigarette to reduce stress, the need to experience the pleasure associated with smoking and the smoking environment both at home and at work. Similarly, in our study we found that stress-busting was the main reason for relapse. The next reason for relapse is peers and friends or just social acceptability. Another is sense of something missing, where the participants felt the lack of pleasure connected with tobacco usage.

Motivation to quit

The findings from our study are in line with study conducted by Smith [14], which that explored stories of successful quitting. According to Smith, the main motivation for quitting was participants identifying an existential threat as many wanted to live a healthy life until old age, which is similar in our study as many participants were motivated to quit due to health issues and health awareness. When success stories of quitting were explored by Smith [14], it was revealed that prior experiences of quitting motivated smokers, which is line with our study – failed attempts to quit motivated participants as they eventually became more determined. Their own determination to quit made them successful quitters.

Health concerns

Participants also assessed their own health-risk perceptions with respect to tobacco consumption. This is not in line with the study conducted by Mohammadnezhad et al. [15], which revealed many participants did not feel tobacco usage affects their health whereas few participants were uncertain about relationship between tobacco usage and health while only few felt tobacco usage causing adverse health effects. But our study revealed many were aware of the adverse effects of tobacco and assessed their own health risk perception with health concerns related to dental issues, neurological damage and respiratory problems.
Similarly, a study conducted by Wang et al. [16] also recorded ex-smokers’ own experiences with smoking cessation. Results from this study pointed towards a combination of pressures from several factors – the fear of diseases, legislation, taking advice from health care personnel, views of children and grandchildren and providing a new identity as an ex-smoker, which are in line with our study. Many participants had successful tobacco cessation stories with various supporting factors, including family pressure, their own determination, health issues and tobacco-cessation counselling. The study conducted by Amato et al. [17] recorded a range of motivating experiences among a population of treatment- seeking young e-cigarette users. The most common reasons were health, financial cost, freedom from addiction and social influence. The most of the reasons for quitting were similar and in line with our study; participants were motivated to quit for health reasons, financial reasons and personal determination (except for the social influence, which was the main reason for relapse in our study).
Limitations. Men were almost exclusively the participants of the study; most used smokeless tobacco, largely due to the increased usage of smokeless tobacco in India along with higher prevalence of usage among men compared to women. There is a possibility of selection bias due to the use of convenience sampling. This could potentially result in difficulty in comprehending the various paths to quitting by gender. The sample obtained through convenience sampling may not be representative of the entire population, leading to an incomplete understanding of different genders’ quitting patterns.

■ Conclusions

This study explored the lived experiences of quitting tobacco users. Quitting tobacco is a challenging but rewarding experience. The various motives included life events, health concerns, financial aspects and family needs. Self-help strategies in quitting included chewing gum, mouth fresheners and chocolate. Apart from addiction and temptation, one of the barriers to quitting was social acceptability. The main reason for relapse was stress and peer pressure. Different people have different experiences. Success stories offer inspiration and insights for quitting, recognising that it is a unique journey with no one-size-fits-all approach. Professional guidance with a tailored approach based on individual specific circumstances will make quitting more effective and sustainable.

■ Recommendations

Understanding these experiences it will be helpful in designing and implementing social, structural, psychological and culturally competent interventions. Quitting tobacco is normally a complex and gradual process with associated psychosocial aspects and we, as health professionals, could use these quitters’ positive experiences to support and educate tobacco users and motivate them by behavioural counselling.

■ Relevance

By exploring tobacco quitting experiences and understanding the forms of quitting and reasons for relapse, implementing awareness towards quitting will be facilitated. Exploration of these experiences will also provide inputs to Tobacco Control Programs and subsequently curb tobacco-related morbidity and mortality.

Conflict of interest/Konflikt interesów

None declared./Nie występuje.

Financial support/Finansowanie

None declared./Nie zadeklarowano.

Ethics/Etyka

The study was approved by the Bioethics Committee of the Tamil Nadu Government Dental College and Hospital, IERB Reference No: 2/ERB/2022.
Badanie uzyskało zgodę Komisji Bioetycznej Tamil Nadu Government Dental College and Hospital IERB Reference No: 2 /ERB/2022.
The work described in this article has been carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) on medical research involving human subjects, Uniform Requirements for manuscripts submitted to biomedical journals and the ethical principles defined in the Farmington Consensus of 1997.
Treści przedstawione w pracy są zgodne z zasadami Deklaracji Helsińskiej odnoszącymi się do badań z udziałem ludzi, ujednoliconymi wymaganiami dla czasopism biomedycznych oraz z zasadami etycznymi określonymi w Porozumieniu z Farmington w 1997 roku.

References/Piśmiennictwo