The project had three phases: the first was to build up a network, Women Against Tobacco Taskforce (WATT), with 14 women’s organizations mobilizing the community to support smoking cessation among female smokers, conduct a needs assessment survey to ascertain the learning needs, knowledge, attitudes and practice of tobacco control and smoking cessation, and identify those interested in joining the training program; the second phase was to develop a smoking cessation training curriculum and deliver a workshop for woman volunteers to equip them with knowledge and skills in smoking cessation and build a rapport with WATT members; the third phase was to set up a hotline service to deliver a gender-specific smoking cessation program to female smokers in Hong Kong. To examine the effectiveness of this program, a one-group pre-test and repeated post-test, within subjects design was used.
Female smokers referred by WATT and met the inclusion criteria were invited to participate in this study. The inclusion criteria were (a) female Hong Kong Chinese current smokers, (b) aged 15 years or above, (c) able to speak and understand Cantonese and (d) willing to receive face-to-face or telephone counseling. We excluded those who were participating in other smoking cessation programs or services.
Training and counseling service
Based on the results of the needs assessment survey, we designed a tailor-made smoking cessation counseling training program for the woman volunteers. A one-day workshop for WATT affiliates was organized. The curriculum was specifically designed to recognize the characteristics of women who smoked and to instruct the volunteers in the psychological and behavioral therapies involved in managing them. Throughout the training, a variety of topics were covered, such as how to assess smoking status and stage of readiness to change, nicotine addiction and the provision of brief individualized advice and motivation to promote cessation, using the ‘Five As’ approach, which refers to (1) asking about tobacco use; (2) advising quitting; (3) assessing willingness to quit; (4) assisting in the quit attempt and (5) arranging follow-up. At the end of the program, the volunteers were capable of delivering sound cessation advice for women.
Prior to the intervention, female smokers received brief advice on smoking cessation given by the trained woman volunteers from the WATT. The volunteers were encouraged to raise awareness of the hazards of smoking to women’s health and the importance of smoking cessation, provide brief cessation advice to female smokers according to their needs in their respective communities, and refer them to receive gender-specific smoking cessation intervention
Gender-specific smoking cessation intervention
The intervention was delivered by female registered nurses who had attended a smoking cessation counseling program organized by the School of Nursing at the University of Hong Kong and had been awarded a certificate as a smoking cessation counselor after passing an examination.
During the intervention, the counselor first assessed the subject’s smoking and quitting history, and designed an individualized quit plan for her at the baseline interview. An intervention was then given by the counselor according to the subject’s stage of readiness. In the case of smokers at the pre-contemplation stage, counselors would increase their awareness of the need to quit smoking. For those at the contemplation stage, counselors would motivate them and enhance their confidence in the ability to quit, and reinforce their achievement in previous quit attempts. For those at the preparation stage, counselors would boost their self-efficacy in resisting smoking and discuss possible withdrawal symptoms. The counseling also included an explanation of the adverse effects of smoking on women’s health, identifying the barriers and facilitators to quitting, working with the subject to design an individualized quit plan, and teaching some relapse prevention strategies. In the case of smokers who had a concern about weight gain if they quitted smoking, counselors would correct the myths that smoking can control weight, and at the same time counselors would discuss and advise them about alternative strategies for weight control. Such an intervention was also given to subjects at the one-month follow–up, which aimed to assess the progress of the action plan and the barriers encountered in the behavioral change process, as well as to engage them in that process, enhance their self-efficacy and identify individual barriers and facilitators.
A mechanism was set up to assure the quality of the counseling interventions. First, the research team held regular meetings with the counselors every two months to discuss cases and evaluate the counseling. Second, the nurse counselors audio-taped one session per month and completed a self-assessment form for audit checking purposes. Before audio-taping, participants were well informed and verbal consents were obtained. An experienced nurse supervisor reviewed the audio tapes and completed a performance assessment form for cross-validation.
Demographics and smoking characteristics
Baseline data including demographic and socio-economic characteristics and smoking history were obtained from each subject using a structured questionnaire, administered by a trained female nurse counsellor. The content of the structured questionnaire included smoking related information such as daily cigarette consumption, nicotine dependency assessed by the Fagerstrom test , stage of readiness to quit according to TTM  and previous quit attempts. Moreover, subjects’ psychological perspectives on behavior changes were also investigated by asking their perception on the importance, confidence and difficulty in quitting smoking on a scale of 0 to 100, with higher score indicating more.
Smoking Self-efficacy Questionnaire (SEQ-12)
Subjects’ self-efficacy against tobacco was assessed by using by the SEQ-12 . The SEQ-12 is categorized into two subscales, namely internal stimuli (6 items) and external stimuli (6 items), with total possible scores ranging from 6 to 30 for both internal stimuli and external stimuli. Higher scores of the SEQ-12 on both subscales indicate greater self-efficacy to refrain from smoking. The SEQ-12 measures confidence in ability to refrain from smoking when facing internal stimuli (e.g. feeling nervous) and external stimuli (e.g. being with smokers). The psychometric properties of this scale have been empirically examined with the Cronbach's alpha coefficients of 0.95 and 0.94 for internal stimuli and external stimuli, respectively, indicating excellent internal consistency . The intraclass correlation coefficients were 0.95 and 0.93 for internal stimuli and external stimuli, respectively, demonstrating excellent test-retest reliability .
The primary outcome measure at the six-month follow-up was the self-reported 7-day point prevalence of abstinence. Secondary outcomes included: (1) self-reported reduction of ≥ 50 % in cigarette consumption, and (2) self-efficacy against smoking at 6 months. Other outcomes were also assessed, examining factors that predicted successful quitting or a reduction in cigarette consumption after six months.
This study was approved by Institutional Review Board of the University of Hong Kong and Hospital Authority Hong Kong West Cluster (reference UW 06–323 T/1348). Female smokers were recruited through WATT members’ referrals. Those eligible were invited to participate in the study after they were told its purpose. They were given the option of participating or refusing and were told that their participation was voluntary without prejudice. To introduce greater flexibility as subjects received the tailor-made intervention, they were able to select either a face-to-face or a telephone intervention at baseline and one month. Written consent was obtained from those subjects electing face-to-face counseling at baseline and verbal consent from those receiving telephone counseling at baseline. In the case of those under 18, written informed consent was obtained from their parents or guardians. After consent was obtained, the subjects’ smoking status and quitting history were assessed by the nurse counselors. In addition, this information was collected at one-week and one-, three- and six-month follow-ups. Continuous assessment allowed the counselors to monitor participants’ quitting processes and provide further reinforcement of behavioral changes.
Data analysis was performed using the Statistical Package for Social Science software, version 20.0 for Windows. Descriptive statistics were used to calculate the frequency and percentage (categorical data) or the mean and standard deviations (continuous data) of different demographic and social-economic characteristics. Chi-square test was used to detect any difference in self-reported 7-day point prevalence quit rate at 6-month follow up between those who received face-to-face counseling and those who received telephone counseling. According to our previous experiences in conducting smoking cessation interventions, most participants who were lost to follow-up or refused to further participate were people who had relapse or resumed smoking. Therefore, intention-to-treat analysis was used, with participants who lost to follow-up treated as smokers with no reduction in cigarette consumption compared with baseline. Paired t-test and chi-square test were used to compare data between baseline and 6-month follow-up for those who continued smoking. Bi-variate analysis was used to examine associations between variables at baseline and self-report tobacco abstinence in the past 7 days at 6-month follow up. Logistic regression analyses were conducted to identify predictors of successful quitting and reduction in cigarette consumption by at least 50 % at 6-month follow-up, with female smokers who continued to smoke as the reference group. The technique of backward elimination was used to minimize suppressor effect, which ensured that a variable could only make statistically significant contribution when other variables were controlled or held constant.