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INT J TUBERC LUNG DIS 16(7):980985

2012 The Unionhttp://dx.doi.org/10.5588/ijtld.11.0748

E-published ahead of print 9 April 2012

Timing and risk factors associated with relapse amongsmokers attempting to quit in Malaysia

S. M. Yasin,*F. M. Moy,M. Retneswari,M. Isahak,D. Koh

*Faculty of Medicine, Population Health and Preventive Medicine, MARA University of Technology, Sungai Buloh,Selangor, Centre for Occupational and Environmental Health, and Julius Centre University of Malaya, Department ofSocial and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Saw Swee HockSchool of Public Health, National University of Singapore, Singapore City, Republic of Singapore; PAPRSB Institute ofHealth Sciences, Universiti Brunei Darussalam, Brunei

Correspondence to: Siti Munira Yasin, Population Health and Preventive Medicine Unit, Faculty of Medicine, MARA Uni-versity of Technology, UiTM Sungai Buloh Campus, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia. Tel: (+60)192 515 325. Fax: (+60) 3 6126 5224. e-mail: sitimu.yasin@gmail.com; smunira@salam.uitm.edu.my

Article submitted 11 November 2011. Final version accepted 5 January 2012.

B AC KGR O UND: Many smokers attempt to quit smok-

ing, but very few succeed.

O B JE C T I VE :To identify the timing and risk factors in-

volved in smoking relapse.ME T HO DS : We conducted a prospective cohort study

among staff in two public universities in Malaysia. Be-

havioural therapy with free nicotine replacement therapy

was given as treatment. Participants were followed up

for 6 months. Relapse was defined as returning to smok-

ing after having quit for at least 24 h.

RESULTS: Of 185 smokers who volunteered to partici-

pate, 120 achieved at least 24-h abstinence, and 80% of

these relapsed within 2 months. Compared to partici-

pants who attended a single smoking cessation session,

participants who attended three sessions had a lower

likelihood of relapse within 6 months of quitting. In

contrast, smokers with a much longer exposure to ciga-rette smoking in the workplace (>3 h per week) had a

greater chance of relapse compared to those with no

exposure.

C O NC L US I O NS :Frequent attendance at clinic sessions

and less exposure to other people smoking in the work-

place can potentially reduce the likelihood of relapse

among smokers who have recently quit.

KE Y WO R DS : smoking relapse; environment; worksite;smoking cessation; Malaysian

RELAPSE is the most challenging problem encoun-tered by clinicians and researchers concerning addic-tion.1Studies in the United States have reported thatthe rate of relapse within 1 year after an attempt toquit smoking ranged from 70% to 90%.2,3Smokerswhocontinuously failed to maintain an abstinence of2 weeks after a designated quit date,4and the ma-jority of those who experienced an early initial lapse,eventually progressed to full relapse.5

Although there are no previous data on relapse inMalaysia, the rate of relapse identied in Westernstudies may explain the reason for the high percent-age of Malaysian males (49%) who were currentsmokers in 2006,6despite various efforts by the Ma-laysian government to establish smoking cessationservices, provide free pharmacological treatment andconduct health promotion activities.

Survival curves from smoking cessation trials haveshown that the majority of relapse cases occur duringthe rst 510 days after an attempt. Thus, the initial510 days act as a window period prior to the achieve-ment of long-term abstinence. After this critical period,relapse curves of both control and treatment groups

in intervention studies become parallel.7,8 However,the evidence is contradictory: a study of elderly smok-ers by Cui et al. in the United States claimed that thegrace period was the rst 30 days of cessation,9whilea recent review paper reported that the maximumnumber of relapses occurs within 70 days, and reachesnearly zero incidence after 100 days.10

The process of relapse is determined by multiplefactors11that interact in a non-linear manner, leadingto a relapse event.12,13Yong et al. found that relapseoccurred sooner among younger smokers, those withmany smoking colleagues, smokers with a history ofschizophrenia and those who attended fewer smokingcessation programmes.9Shiffman et al. studied multi-ple psychological and treatment factors that inuencethe progression from lapse to full relapse.7,14,15Thesestudies have contributed new perspectives on risk fac-tors involved in the process of relapse. However, thecomplexity of the relapse process may differ acrosspopulations and subpopulations, and no isolated mea-surement can encompass the entire process.16A betterunderstanding of the factors that inuence the rate ofrelapse and the dynamics of relapse among Asian

S U M M A R Y

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Smoking relapse 981

populations could provide opportunities for futureinterventions and improved cessation services amongthese populations.

This study had the following objectives: 1) to de-scribe the process of relapse within the rst 6 months

of quitting, and 2) to identify factors associated withrelapse. This study provides new insights into relapseamong Asian populations, which is currently unex-plored. This study may also be a useful reference forhealth care providers and programme designers indeveloping strategies to prevent relapse following at-tempts to quit smoking.

METHODS

Recruitment and participation

In a prospective cohort study, data were collected be-

tween November 2009 and August 2010 at Univer-sity A and between March 2010 and November 2010at University B. We established smoking cessationprogrammes at each university. Student centres and astudent college were used as temporary outreachsites. All employees working at the two sites were tar-geted for the study with full approval from the uni-versity ethics committee and university boards. In-formed consent was obtained from all participants.

At University A, there were over 6000 workingstaff, while University B had a staff population ofslightly over 15 000. Both universities encouragesmoke-free environments, although enforcement was

inadequate. For example, University A had set a max-imum of RM200.00 (US$65) penalty to smokerssmoking on campus, but smokers were not ned whenthey were identied. University B on the other hand,had some anti-smoking activities and penalties inplace, but they were not properly implemented. Par-ticipants were recruited through e-mails sent to allstaff and letters to the heads of departments at bothuniversities. Further invitations were issued throughthe university staff portal, posters and via the mainuniversity websites to enhance participation. Inter-ested staff members who had smoked at least ve cig-

arettes daily in the previous year and who agreed tobe followed up, were able to read and write in Ba-hasa Malaysia and had no serious mental or healthcondition, were invited to participate in the study.

The treatment consisted of combined medical andcognitive behavioural therapy. Questionnaires relatedto smoking history, socio-demography, stress andcoping and family support were administered priorto treatment. Medical treatment consisted of free nic-otine replacement therapy (NRT) gum or patches,depending on the patients medical history, degree ofnicotine dependence and preference. Light smokers(2 weeks.

Cognitive behavioural therapy involved threetwice-weekly counselling sessions offered during of-ce hours. The rst session was conducted in groupsand the two subsequent sessions were individual.These sessions covered coping strategies, risks andbenets of quitting, relapse prevention, stress reduc-tion and weight control. Subsequent follow-ups werealso arranged for those requiring additional support.To avoid bias, similar cognitive behavioral therapysessions were conducted and all sessions were led bythe same medical ofcer and an assistant.

We collected baseline information during the rst

clinic session at the start of treatment. Abstinence wasdetermined during interview follow-up sessions andwas conrmed by carbon monoxide (CO) < 8 ppm17using the Mini Smokerlyzer (Bedfont Scientic Ltd,Rochester, UK). Relapse was determined during2-weekly follow-up appointments for the initial2 months, and patients were contacted after 6 months.Data on lapses were assessed with a quit-smoking di-ary during each follow-up visit.

Data collection

Socio-demographic and smoking history

Socio-demographic and smoking history included agegroup, age at smoking initiation, educational achieve-ment, work category, number of initial cigarettes perday and previous quit attempts.

Quitting history and relapse

A self-reported quit-smoking diary was supplied foreach smoker to record the number of cigarettes theysmoked per day. The written diary was shown to themedical ofcer during follow-up. Quitters were thosewho achieved a minimum of 24 h abstinence dur-ing the observation period, as dened by studies onsmoking relapse.13,18After achieving 24 consecutive

hours of abstinence, any subsequent smoking episode(even a puff) was considered a lapse. The date of aninitial lapse episode was counted as the date of re-lapse. CO assessments were conducted during follow-up and after 6 months to ensure the validity of the re-ported abstinence. The exact date of smoking relapsewas determined from the quit-smoking diary.

Environmental inuences

The questionnaire was adapted from a path analysisstudy of 481 respondents followed by telephone sur-vey for a total of 3 years in a cohort of US adults. 19The questionnaire consisted of three questions meantto examine the inuence of the worksite environment,the home environment and peer smoking on smokingcessation. This is based on the hours of exposure to

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982 The International Journal of Tuberculosis and Lung Disease

other people smoking within the past 7 days both athome and at work, and the number of colleaguessmoking at work. The effect of these inuences onsmoking relapse was examined. The questionnairewas translated into the Malay language using forward

and back translation. Reliability analysis revealedCronbachs alphas between 0.80 and 0.83 and corre-lations between 0.5 and 0.8.

Statistical analysis

Data management and statistical analysis were per-formed using a database created with SPSS 15.0 forWindows (Statistical Package for the Social SciencesInc, Chicago, IL, USA). A descriptive analysis wasperformed. Categorical variables were analysed usingthe 2tests, and quantitative variables were analysedby independent t-tests. The main analysis of interest

for predictors of relapse was survival analysis. TheKaplan-Meier technique was employed to plot thesurvival graph of the timing of relapse. We investi-gated potential risk factors for relapse during the rst6 months of cessation using the Cox proportional

Table 1 Socio-demographic and smoking characteristics

Total(N=185)

n(%)

Demographic characteristics Age group, years

183031404150>50

Education status Primary school Secondary school Diploma and above

Occupational status Support group Professionals

Marital status Single Married Divorced

77 (42) 43 (23) 43 (23) 22 (12)

5 (2)107 (58) 73 (40)

175 (93) 13 (7)

68 (37)113 (61) 4 (2)

Smoking history

Number of cigarettes/day 0.05, Table 1).

Lapse episodes and relapse curve

Only 120 participants were included in the relapseanalysis, as the others did not achieve 24 h quit sta-tus, including 15 smokers who were not contactableor failed to record their initial lapse episode. Aftersuccessfully achieving 24 h of abstinence, the partici-pants average time to an initial lapse was 9.43 days(Figure). The graph can be divided into three phases:

the rst phase is the rst 14 days after the quit date,during which the survival rate quickly decreased from100% to 40%. The second phase was from day 15 today 60, the period during which the survival rategradually fell to approximately 25%. The third phaseextended from 60 days to the end of the 6-month pe-riod (180th day), during which the curve became

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Smoking relapse 983

much atter. The survival rate at the end of 6 monthswas 20%. Overall, we may conclude that the vastmajority of relapses (up to 80%) occurred during theinitial 2 months after the quit date. The highest num-ber of relapses was seen in the rst 2 weeks (60%);

20% of participants never relapsed (Figure).

Risk factors of relapse at 6 months

Ten variables were included in the analysis of poten-tial risk factors for relapse at 6 months (Table 2). Weidentied two factors associated with smoking re-lapse at 6 months: 1) smokers attending all threesmoking cessation sessions had a lower risk of relapsecompared to those attending a single session, and

2) smokers who had much longer exposure to ciga-rette smoking at the workplace (between 38 h and9 h) had more than twice the likelihood of relapsecompared with those with no workplace exposure.

DISCUSSION

The smoking relapse process is dynamic,20 and nosingle model can explain all occurrences within therelapse period.5 Our results indicate that the mostimportant time for preventing smoking relapse isduring the rst 2 weeks of follow-up and extends to2 months post-cessation. Based on the survival curveshown, we suggest that at least three clinic follow-up

Table 2 Risk of smoking relapse at 6 months

Totaln(%)

Relapsed(event) cases

n(%)Hazard ratio(95%CI)*

Socio-demographic characteristics Occupational status Support group Professionals

Marital status Single Married Divorced

111 (92.5) 9 (7.5)

43 (35.8) 75 (62.5) 2 (1.7)

87 (91.6) 7 (7.3)

38 (39.6)57 (59.4) 1 (1.0)

Reference1.27 (0.523.10)

Reference0.72 (0.411.26)0.30 (0.042.43)

Smoking history Number of cigarettes/day

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984 The International Journal of Tuberculosis and Lung Disease

sessions are needed for optimal cessation success. Therst follow-up should be within a few days of thequit date, the second between week 1 and week 2 andthe nal between week 2 and week 3. Moreover, wesuggest that health and non-health professionals, in-

cluding doctors, nurses, psychologists, counsellorsand support groups, involved in the area of smokingcessation, should follow up with recently quit smok-ers up to 2 months post-cessation, which may pro-vide external support to enhance their motivation tosustain quitting effectively.

This study contributes to the limited knowledgeabout factors involved in smoking relapse. Our rstnding showed that smokers who attended multipleclinic sessions had a lower risk of relapse within6 months. The association between relapse and clinicattendance has been examined in very few studies.

One such study, in the United States, reported similarresults.9However, we can also relate greater numberof clinic sessions to a higher success rate in maintain-ing smoking abstinence,11which reduced the numberof relapses.

We also found that the hours of exposure to work-site smoking hastened the occurrence of relapse. Ourdata on the inuence of environmental exposure onrelapse were consistent with other studies in thisarea.21,22Although these studies found positive asso-ciations between environment and relapse, they didnot examine the inuence of relapse on the durationof exposure. We hypothesised that extended exposure

to the smell, sight and accessories of cigarettes mayincrease the urge to smoke and act as an externalstimulus to initiate smoking after a short period of ab-stinence. Although we did not study the relationshipbetween smoking urges and extended exposure to thesmell, smoking accessories and sight of cigarettes,other studies have proven that these exposures may berelated to an increase in temptation23and craving.24

Although our study proposes that clinic-basedsmoking cessation programmes are a good method ofincreasing cessation rates and preventing smoking re-lapse, this may not be a viable option worldwide.

This is especially true for low- and middle-incomecountries, where funding is often a major concern.Countries benet from a more comprehensive to-bacco control approach to cover a greater populationmass; this entails complete bans on cigarette advertis-ing, increases in taxation and establishing quitlineservices.25 In addition, clean indoor air restrictionsare moderately feasible in developing countries, asthis would increase the number of smokers attempt-ing to quit and the number of successful quitters, andprevent subsequent relapse, as this study suggests.

A number of limitations in this study should be ac-knowledged for future improvements. First, the studysample included a relatively homogeneous group ofsmokers of primarily Malay ethnicity. The secondlimitation of this study was the inability to generalise

the ndings to clinic- and hospital-based settings.These sites have a variety of smokers, some of whomare referred by specialist clinics and others who areself-referrals. Furthermore, this study may not cap-ture smokers who have achieved abstinence without

help or medication, and have then relapsed. Addi-tional obstacles and challenges detected during ourface-to-face counselling were lack of awareness ofemployers in allowing smokers to attend the clinicsessions, poor perception and knowledge about quit-ting and relapse among smokers, the addictive natureof tobacco and the indirect inuence of smoking col-leagues. These factors should be considered by healthand non-health providers when attempting to imple-ment such programmes. Nonetheless, some of theseconstraints may not be clear and warrant further re-search (e.g., cost, acceptability, feasibility).

Our study also has some strengths. First, as a pio-neering investigation of the risk factors for smokingrelapse in clinic and worksite settings in Malaysiaand the Asian region, it provides new insights intothe problem of smoking cessation and may promotefurther research in this area. Second, this was a pro-spective study, which is more reliable than involvingformer smokers retrospective recall,26,27which is sub-ject to bias.28

We conclude that frequent attendance at clinic ses-sions may potentially reduce the incidence of relapseamong former smokers who attempt to quit with as-sistance. Health care providers, programme imple-

menters and personnel involved in smoking cessationare advised to design appropriate programmes by em-phasising the importance of additional follow-up dur-ing the rst 2 weeks post-cessation, as the likelihoodof relapse is very high. To prevent further relapse, wesuggest that employers enforce strict smoke-free work-site initiatives and provide a supportive environmentfor quitting smoking. Lastly, the idea of smoking ces-sation among Asian populations is still in its infancy,and urgent efforts to promote smoke-free lifestylesand smoke-free environments are required.

Acknowledgements

The authors thank the participating study sites in the StudentCentre, University of Malaya and Perindu College, Mara Univer-sity Technology for providing an appropriate place for the coun-selling sessions. They also thank R M Zaki and clinic assistantN Hadzah for their help in data collection. Funding for thisstudy was provided by the University of Malaya Research Grant(PS161/2009B, RG051/09HTM). This funding body had no rolein the study design, data collection, data analysis or interpreta-tion, writing of the manuscript or the decision to submit the paperfor publication.

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C ADR E : Un grand nombre de fumeurs tentent darrter

de fumer, mais bien peu y arrivent.

O B JE C T I VE : Identifier le moment de la rechute du ta-

bagisme et les facteurs de risque qui y sont associs.

M T HO DE S : Nous avons men une tude prospective

de cohorte parmi le personnel de deux universits pu-

bliques de Malaisie. On a utilis comme traitement lap-

proche comportementale et un traitement de remplace-

ment nicotinique gratuit. Les participants ont t suivis

pendant 6 mois. On a dfini la rechute comme un retour

la fume aprs un arrt dau moins 24 h.

RSU LTATS : Sur 185 fumeurs qui ont particip volon-

tairement, 120 ont obtenu une abstinence dau moins

24 h, parmi lesquels 80% ont rechut ensuite dans les

2 mois. Par comparaison avec les participants qui avaient

assist une seule session darrt tabagique, les partici-

pants ayant assist trois sessions encouraient un risque

de rechute plus faible au cours des 6 mois aprs larrt.

A loppos, on a not un risque de rechute plus lev

chez les fumeurs ayant t exposs plus longtemps la

fume de cigarette sur les lieux de travail (plus de 3 h

par semaine) par comparaison avec ceux qui navaient

pas t exposs.

C O NC L US I O NS : La participation frquente des ses-

sions cliniques et une moindre exposition la fume des

autres sur les lieux de travail sont susceptibles de rduire

les risques de rechute chez les fumeurs qui ont rcem-

ment abandonn leur tabagisme.

MAR C O DE R E F E R E NC I A : Muchos fumadores intentan

abandonar el tabaquismo, pero muy pocos lo consiguen.

O B JE T I VO :Investigar los aspectos temporales y los fac-

tores de riesgo que influyen en las recadas.

MTODOS: Se llev a cabo un estudio de cohortes pro-

spectivo, en el cual participaron miembros del personal

de dos universidades pblicas en Malasia. Se suministr

como tratamiento una terapia conductual con sustitu-

cin libre de nicotina y se practic un seguimiento de

6 meses a los participantes. La recada se defini como

el regreso al tabaquismo despus de haberlo abando-

nado como mnimo por 24 h.RESULTADOS:De 185 fumadores voluntarios para par-

ticipar en el estudio, 120 logr al menos 24 h de absti-

nencia y un 80% present una recada en los 2 meses si-

guientes. En comparacin con los que asistieron a una

sola sesin sobre el abandono del tabaquismo, los parti-

cipantes que acudieron a tres sesiones tuvieron una pro-

babilidad menor de recada en los primeros 6 meses del

abandono. De inters, los fumadores con una exposi-

cin mucho ms prolongada al tabaquismo en el lugar

del trabajo (ms de 3 horas por semana) exhibieron un

mayor riesgo de recada que los participantes sin esta

exposicin.

C O NC L US I N:Una asistencia asidua a las sesiones clni-

cas y una menor exposicin a otras personas que fumanpuede disminuir la probabilidad de recada en los fuma-

dores que han abandonado recientemente el tabaquismo.

R S U M

R E S U M E N