Investigating the socio-demographic characteristics and smoking cessation incidence among smokers accessing smoking cessation services in primary care settings of Qatar, a Historical Cohort Study

Background Tobacco dependence is a chronic disease that often requires repeated interventions and multiple attempts to quit. Cigarette smoking is the leading preventable cause of mortality. Globally, an estimated 1.3 billion people smoke. In Qatar, Smoking cessation services (SCSs) are provided free of charge to citizens and at a minimal cost to non-citizens. This study aimed to measure the effectiveness of the smoking cessation program adopted by the Primary Health Care Corporation (PHCC) of Qatar. This was achieved through calculating the percentage of smoking cessation service users (survival probabilities) who maintained the non-smoking status after selected follow up periods. Moreover, the study highlightedthe possible association of selected explanatory variables with smoking cessation survival probabilities. Methods


INTRODUCTION
Globally, smoking and its associated health implications has been a major public health concern over the decades (1)(2)(3).Accordingly, to the World Health Organization (WHO) there are 1.3 billion tobacco consumers worldwide which causes 8 million deaths annually (4).Evidence suggests that smoking contributes to a myriad of preventable diseases and premature deaths (3).Smoking rates estimated to be as high as 50 percent for men in developing countries and mostly concentrated among those of low socioeconomic status (5,6).
Cigarettes are the most common smoking item consumed in the various geographical settings compared to the other tobacco products (4).
There have been various interventions and preventive strategies that have been implemented in various settings through smoking cessation services (7,8).These interventions mainly constitute therapeutic and behavioral interventions (7,9).The framework convention on tobacco control (FCTC) was launched under the auspices of WHO as an international coordinated response to tackle the tobacco epidemic (10).The various strategies advocated by the initiative included implementing tax measures to restrict tobacco consumption, promoting smoke-free environment at work and public places, restricting and banning all types of marketing of smoking products and strengthening legislative measures to prevent illicit trade of tobacco products (11).Despite these global initiatives, a signi cant portion of the population continue to smoke globally (12).
It is extensively discussed in literature that there are different factors contributing to smoking initiation such as and not limited to attitudes and beliefs, nicotine dependence, availability of avored tobacco products, use of e-cigarettes, previous experience with smoking even few puffs, depression, poor school performance and substance abuse (13)(14)(15)(16)(17)(18).In addition, there are various factors linked with smoking behaviors, accessibility of smoking cessation services and compliance to the various cessation interventions.These mainly include socio-demographic characteristics of smokers, cultural issues, economic status, ethnicity and age (3).
Clinician involvement increases the likelihood of smoking cessation.The goal of smoking cessation establishment is to offer evidence-based services (19).Tobacco dependence interventions, if delivered in a timely and effective manner, signi cantly decrease the risk of smoking-related morbidity and mortality (20,21).The clinician's role is to document smoking status, offer advice to quit, evaluate the patient's interest in quitting.Then, for those interested in quitting, offer tools, techniques, and follow-up.For those not ready to quit, the clinician can use motivational interviewing to move the smoker towards quitting.(22)(23)(24)(25).
Qatar has well-developed and modernized healthcare system with comprehensive primary health care services which provide specialized smoking cessation services.Despite these healthcare resources smoking remains a major public health concern (26).Whereas the overall prevalence of smoking was 16.4% among the studied population in the STEP wise survey, and the percentage of smoking among men was almost 27 folds higher than that among women (31.9% vs. 1.2%) (27).
To reduce inappropriate variation in smoking cessation support practice and to promote e cient use of resources, PHCC developed a smoking cessation guideline aimed to describe appropriate care based on the best available scienti c evidence and broad consensus for smoking cessation practice (28).Since SCSs are already in place within the PHCC, this study may cover the current situation and discover any gaps and de ciencies that may be presented within the services provided.
The main aim of the study is to investigate the demographic pro le, attributes and the incidences of smoking cessation among individuals receiving smoking cessation services in primary care settings of Qatar, as well as assessing the rate of relapse for those who initially quitted smoking after attending the SCCs.The ndings of the study may inform policymakers and public health authorities in Qatar to develop evidence-based tobacco control policies.

Study design:
This is a historical cohort study implemented on a primary care level.

Study population:
Smokers were recruited in the study who were accessing smoking cessation clinics and were registered at primary health care centers in Qatar on June 30 th , 2021.Smokers who did not complete 42 months of follow-up since quitting smoking were excluded from the study.

Sample size calculation:
The non-parametric exponential model for survival analysis used to calculate the required sample size for performing survival analysis on persons who reported quitting smoking during their enrollment period for smoking cessation program (29).The model was fed with the following parameters: Length of accrual period = 42 months T, the length of follow-up period-time from end of accrual to analysis = 6 months α, the signi cance level = (.05)Two-sided test Estimated Survival probability at time t=12 months= 0.5 Upper and lower critical values for the estimated survival probability = 0.05 (95% con dence interval of 1-year survival rate of 0.45 to 0.55) The sample size required for performing the required survival analysis under the above model parameters was 330.Under the assumption of 50% rate for quitting smoking during the smoking cessation program visits we needed to double the required sample size to 660 to end with the required 330 who quitted smoking.In addition, we added another 130 participants to the required sample size to account for an expected 20% non-response rate.The nal sample size became 790.

Data collection:
A simple random sample of 790 participants were extracted from the PHCC electronic registry of all attendees to the SCCs until 31/6/2021 to take part in this study.That was after exclusion of those who did not complete 42 months of follow-up on that date.Of those participants, only 490 have gave their verbal consents to participate in the study.Data were collected by well-trained data collectors through phone interviews with the participants used a structured questionnaire form.Prior to data collection, the questionnaire was piloted amongst 20 selected past users of SCC and their feedbacks were used to make any necessary amendments.
The study tool: The structured questionnaire has developed by the researchers, the content and face validity have established by an extensive literature review, consultation of the community medicine faculty and experts in the eld of smoking cessation (5,.The questionnaire has originally prepared in English and translated into Arabic language with back translation to ensure its validity.The translation done by the lead researcher using several medical dictionaries and then was revalidated again by two Community Medicine Experts after reverse translation.After conducting an extensive literature, the aim and objectives of the study served as a guide for the researcher in developing the content of the questionnaire.
The nal version of the questionnaire covered several areas which were the history of visits to SCCs with their initial outcome, the sociodemographic characteristics of participants, impact of smoking cessation on health status and the socio-economic status of participants, as well as the withdrawal symptoms of smoking cessation.
The component of the study tool which includes multiple choice questions, some of the patients may have more than eligible choices or responses.The interaction between the different choices or responses can in uence the reported percentage of the overall response rates, for example the reasons for visiting SCC.A copy of the questionnaire added as a supplementary le.

Data analysis:
Statistical analysis was done using IBM SPSS Statistics software version 28.Descriptive statistics were done rst.The association between selected explanatory variables (age, gender, nationality, income, marital status, and educational level) and mean survival time for keeping the non-smoker status was tested for statistical signi cance by Kaplan Myer test in bivariate model.
The effectiveness (success) of the smoking cessation program will be assessed at two levels using incidence rates.The short-term success rate is the incidence rate of quitting smoking during the clinic contact time (primary smoking cessation rate/the percentage of participant quitted smoking directly by attending the SCC).Among those who successfully quitted smoking the long-term success will be calculated using the survival rate (being free from smoking habit relapse) after 1, 6, 12, 24, 36 and 42 months of quitting smoking during clinic visit.As shown in Table 2, more than 85% of participants reported that attending the SCCs was due to their self-decision followed by 18% reported family and relatives' pressure as a reason.This shows that making the decision to abstain from smoking is usually based on different motives and reasons, but in the end personal decision is the basis.Note: *The categories for reported reasons are not mutually exclusive.
Table 3 shows that 311 (63.5%) of the study's participants have quitted smoking during their attending of SCCs and receiving the SCSs.This means that the person quit smoking during the period of his/her visit to the SCC to obtain the service, and this period usually ranges from one day to three months.It also showed that the relation between quitting of smoking with the nationality and the educational level of participants was statistically signi cant.Qataris had a signi cantly lower quit rate than the other two nationality groups.A lower educational level was associated with a signi cantly higher quit rate.Following the content of Table 4, Fig. 1 is a line graph (survival curve) showing the cumulative incidence rate of maintaining the non-smoking status after selected follow up periods extended to 42 months for those who initially quitted smoking after attending the SCCs at the primary health care centers in Qatar.This graph showed that the median survival for the non-smoking status was 36 months.
As shown in Table 5, all the tested explanatory variables failed to predict signi cant differences in the risk of smoking relapse for those who initially quitted smoking after getting SCSs.Otherwise, the results showed that the mean survival time (MST) increased visibly with age ≥ 40 years old and showed that there is difference in the mean between Qataris and other Arabs (30.9 vs. 24.4respectively).

DISCUSSION
The SCCs through PHCC in Qatar provide a comprehensive approach combines educational, clinical, and social strategies.
The following paragraphs will discuss the results of this study in four main themes which are: 1-the smoking characteristics of the participants, 2-the reported reasons for attending the SCCs or seeking for SCSs, 3-the relation between smoking cessation initiation and speci c factors related to the participants, and 4-the rate of smoking relapse or the duration of smoking abstinence and its relation with speci c characteristics of the participants.

1-THE SMOKING CHARACTERISTICS OF THE PARTICIPANTS(see table 1)
The sociodemographic characteristics of participants The study recruited mostly males with females constituting only 4.5% of the total sample of smokers.
Evidence suggests that males have a higher tendency of smoking tobacco (31,32,85).Nevertheless, recent published literature suggests a change in smoking habits with higher prevalence among females (33,34). .Literature suggests that there are higher rates of smoking among ethnic minorities and marginalized populations (81, 86).The signi cant percentage of smokers (87%) in this study are non-Qataris and represent the expat population.These ndings substantiate the fact that smoking cessation services needed to be adapted to meet the needs of these communities (87).
In the study, more than half of the smokers included in the study had low-and middle-income status.
These ndings are comparable to studies conducted in US and China which indicate the association of poverty levels with current smokers (5,32).
Evidence suggests that there is a higher risk of smoking addiction among individuals who are single as compared to married and with children (88, 89).Against the evidence, 86.5% of smokers attended the smoking cessation clinics were married as indicated in this study.This nding may be related to the demographic composition of the State of Qatar, where foreigners represent approximately 90% of the country's population, and most of them are married couples who come to work in the country.
Interestingly the ndings of the study report high prevalence of smoking among participants having a substantial educational background.On the contrary, literature suggests that tobacco consumption is more common among populations groups with low literacy levels and comprising of marginalized segments of the society as previously discussed (32,35).
Type of smoking item: Although, globally there is a signi cant number of smokeless tobacco users, cigarette smoking remains the most common route of tobacco consumption as indicated in this study (82, 83).Cigarettes are easily available and can be bought at a cheaper price in Qatar as compared to other tobacco products.That might be the reason that majority of smokers (96.3%) consumed this smoking item.
In the study a few participants (n=22) reported of utilizing electronic cigarettes.This may be associated with lesser availability of these products and strong legislative measures pertaining to sales and advertisement in Qatar.However, in recent times literature documents that there has been an exponential rise in the usage of electronic cigarettes elsewhere (36).E-cigarettes were introduced as a less harmful replacement for tobacco consumption, but evidence suggests that it is associated with detrimental health outcomes with excessive use particularly among younger population (74,75).Uncontrolled advertisement, easy accessibility and misconceptions about its usage has resulted in its high uptake (90).
Moreover, there is a low frequency of other smoking items reported in the study such as pipe smoking, contrary to its widespread prevalence in other regions of the world (77,78).This high percentage of waterpipe using was due to participants perception that tobacco smoking from a waterpipe was less addictive, less harmful, and more social acceptability than cigarette smoking (40).

2-THE REPORTED REASONS FOR ATTENDING THE SCCs OR SEEKING FOR SCSs (see table 2)
The results of the study shows that making the decision to abstain from smoking is usually based on different motives and reasons, but in the end personal decision is the basis.
In the study self-decision represented the rst reason for smoking cessation among 85.7% of the participants.Many other studies from different regions of the globe supported this nding (41,42,79).
Several studies emphasized that social support including family and friends exerts the greatest effect on quit attempts specially when it is continuing and nondirective as indicated by this study (35,37,41).The in uence of society on quitting smoking has different faces and frameworks, as con rmed by many studies from different societies.For example, having a partner who dislike smoking or support quitting had a positive in uence on quit attempts (38, 79), social avoidance by non-smokers acted as motivation for smoking cessation (37) and relatives encouragement or illness acted as speci c reasons for quitting (44).Peer-pressure to quit smoking was prevalent in less than 5% of participants in the study.
Usually, support from colleagues was associated with successful smoking cessation (38).
Health complaint perceived as being related to smoking was positively associated with smoking cessation among 9.2% of the participants in this study.Generally, health harms, health concerns or health problem as well as protecting own health indicated to be important reasons of smoking cessation in several studies (35,37,39).Twenty-two participants in this study reported that doctors' warning was a reason behind seeking smoking cessation services.This nding supported by other studies (37,41,45).
Against the expectations of the researchers in this study, the cost of smoking and using of social media platforms did not represent important reasons behind taking the decision to quit smoking.

3-THE RELATION BETWEEN SMOKING CESSATION INITIATION AND SPECIFIC FACTORS RELATED TO THE PARTICIPANTS (see table 3)
Smoking cessation is usually mediated by the socioeconomic characteristics of people which affect their habits as well as their decisions.( 46) The ndings of the study indicated the effectiveness of the smoking cessation services provided within primary care settings of Qatar as nearly two thirds of participants reported initially quit smoking after receiving the services.
Evidence suggests that sustained, accountable and comprehensive smoking cessation initiatives can effectively manage tobacco consumption within communities and provide the necessary help to smokers to quit the habit (47)(48)(49).
Various studies have demonstrated the association of age of smokers with compliance to smoking cessation services and expected outcomes.Apparently, the ndings suggest the younger the age group the lower the likelihood of smoker to quit smoking, whereas the compliance to cessation services increases with age (50)(51)(52).Interestingly, the average abstinence rates increased when multimodal interventions (pharmacological and non-pharmacological) used (43).Many important age-related differences should be considered when planning and implementing smoking cessation interventions such as the age of starting smoking (53,54).
In this study, smoking cessation was relatively higher among females compared to males.Literature suggests that quitting smoking between males and females is different to a certain degree, and many factors may affect this difference, such as age, the amount of smoking, or many other factors (50,54,71).
This study showed a statistically signi cant relation between the nationality of the participant and smoking cessation.Arabs other than Qataris had 67.4% quitting rate compared to 40% among Qataris.
This may be due to socioeconomic differences between these groups.In a study from New York, Black and Latino respondents perceived less smoker-related stigma than White respondents (61).
Quit smoking is relatively higher among low-income population as showed in this study and others (47).
Studies contradicting the results of this study showed that smokers with higher income or higher social level were more likely to intend to quit smoking and to be abstinent for longer time (55,91).However, other studies have found no income differences in quit attempts (62, 64).
Different studies have indicated the clear impact of marital status on smoking status and the decision to quit smoking (56, 67, 68).This study was associated with relatively higher smoking cessation initiation among married participants.This may be due to many factors, such as thinking about the health of children or interest in preserving the family's economic resources.
Contrast to our ndings, smokers with higher education were more likely to intend to quit, to make a quit attempt, and to be abstinent for different periods (50,63).Respondents in a study showed that higher education level associated to perceiving more smoker-related stigma than respondents with less education (61).However, other studies have found no educational level differences in quit attempts (62, 64).The rst year after smoking cessation constitutes the period of highest risk for relapse as indicated in this study and others (69,70).This risk of relapse decreases with increasing the period of cessation (57,69).
This study showed that females are less likely than males to maintain the status of smoking abstinence as found in other studies (58, 66).This nding is contradictory from one study to another.Whereas a study showed that genders were equally likely to maintain short-term abstinence, but females were more likely to relapse subsequently (58).Another study showed that being male increases the chance of relapsing (72).
Relapse rate is higher among young people compared to older as indicated in this study and others (57,72,73).A study indicated that age was a signi cant predictor of smoking cessation (59).The same study showed that earlier age of starting smoking represented a cause of not quitting compared to people started smoking in older age (59).Age difference was not affecting the relapsing rate in another study (70).
The race or ethnicity represented a speci c factor affecting smoking cessation and smoking relapse (59).This study indicated that relapse rate is higher among other Arabs compared to Qataris with MST of 24.4 months vs. 30.9months.The effect of race, ethnicity as well as geographical origin on smoking relapse was clear in different studies (57,59).
Usually, the nancial strain has a negative impact on smoking cessation interventions.Contrary to expectations, in this study the results indicated that the duration of smoking abstinence going inversely with the level of monthly income.Research has shown that ex-smokers experiencing nancial burden are more likely to relapse or having a shorter smoking abstinence (60, 65).This may be related to the negative impacts of the nancial strains on the mental and the psychological status of people, which in turn may work as a basis for smoking relapsing.
In contrast to this study where was almost similar relapse rate between married people and who never married, relapse rate was higher among never married, widowed, divorced and separated individuals, compared to the married individuals in another study (57).A study indicated that marital status was a signi cant predictor of smoking cessation (59).
The effect of education level on smoking relapse or abstinence duration was relatively limited in the study.On the other hand, another study indicated that education was a signi cant predictor of smoking cessation (59).Longer duration of smoking abstinence associated with low educational level in a study from China (73).Higher education associated with higher smoking relapse in another study (72).

STRENGTHS OF THE STUDY
This study helps to develop a better understanding of smoking cessation presented through the smoking cessation clinics in the primary care settings of Qatar.One of the important advantages of this study was including population from different ethnicities and geographical origins.The researcher had the ability to examine multiple outcomes and covari ates over different time duration.

LIMITATIONS OF THE STUDY
Potential biases in the sample, and reliance on self-report.The self-reported nature of the data introduces the possibility of reporting inaccuracies in the outcomes; for example, errors in recalling quit date.
Although these issues could lead to overestimating the outcomes, there is no reason to believe they would vary by socioeconomic status and the characteristics of the participants, so the relationships between the outcomes and socioeconomic status as well as the characteristics of the participants would not be affected.Depending on self-reported smoking status without biochemical validation, could be a limitation of this study.
The actual sample size in the study was much lower than the calculated one due to the high nonresponse rate, this could have led to non-response bias.
Part of the limitations included in the study is that we haven't discussed the interventions provided to each participant.Another limitation that hasn't been discussed is the frequency of visits to the SCCs.
Usually, the frequency of visits depends on the client compliance and response to the treatment.Finally, not discussing the participants social environment in the study is a limitation.But for the record, during providing the behavioral interventions to the clients, doctors discuss the social life of the clients (family members, if the client smokes at home or not, If the client smokes in front of his/her children, his/her accommodation, etc….) and document their conversations.

CONCLUSION AND RECOMMENDATIONS
The SCSs provided through the PHCC proved to be highly effective in helping smokers to quit smoking on both short and long terms.Establishing laws and regulations that attempt to cut back on selling cigarettes in Qatar and preventing the spread of modern alternatives for cigarettes such as vapes, pipes, and other tobacco products since they aren't widely spread or available in Qatar tobacco markets.It is advised that doctors in other clinics within the PHCC inform their patients to act against their smoking problems by attending the SCCs.
Furthermore, smoking cessation interventions within the PHCC should speci cally focus on Individuals below the age of 30, Arab people including Qatari citizens and individuals which are highly educated and achieve a high income since they are the groups with the least success rate in smoking cessation and the groups which relapsed the fastest after they quit smoking.

Declarations
Ethics approval and consent to participate:

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Figure 1

Table 1
Description of the study sample (N = 490)

Table 2
The relative frequency of reported reasons for attending the SCCs, (N = 490)

Table 3
The primary smoking cessation rate immediately after/during receiving of SCSs (range from 1day to 3 months) by selected predictors, (N = 490) As shown in Table4, only 2.3% of individuals who initially quitted smoking after SCC visits relapsed and resumed smoking as early as one month after completing their clinic visits.This relapse rate increased to 23.3% after 6 months and 38.7% after 12 months.After 24 months or more of quitting, this rate stabilized at around the level of 50%.

Table 5
The mean survival (maintaining the non-smoking status) time in months predicting smoking relapse for those who initially quitted smoking after attending SCCs.
In this study, the relapsing rate to smoking increased dramatically by time until passing 24 months from quitting.After that, the rate became relatively stable around the level of 50%.This nding is supported by other studies from different countries (62, 63).
This study has been performed in accordance with the Declaration of Helsinki and have been approved by the Primary Health Care Corporation's Institutional Review Board (PHCC-IRB) in Qatar.Informed consent form have been obtained from all participants in this study, either directly from the participant or from his/her legal guardian in case of illiterate or below the age of consent (<18 years of age).