Knowledge, attitude, and beliefs toward group behavior therapy programs among male adults attending smoking cessation clinics, cross-sectional analysis

Smoking is one of the leading public health concerns [1]. Globally, almost 23% of adults smoke tobacco products; this includes more than 1 billion males and 250 million females [2]. In Saudi Arabia, a recent study that assessed the prevalence of smoking among adults showed that the prevalence of cigarette smoking was around 21.4% in 2018 [3]. It has been shown that smoking is considered a significant risk factor for developing several chronic diseases such as pulmonary disease, heart disease, and lung cancer [4]. The World Health Organization recognized tobacco as the second leading risk factor for death worldwide [5]. Therefore, implementing smoking cessation strategies would assist in reducing the burden of these diseases.

Many approaches have been utilized for smoking cessation. The biopsychosocial approach has been proven to increase the rate of smoking cessation. This approach includes pharmacological and non-pharmacological interventions. Pharmacological treatment includes nicotine replacement therapy (NRT), Bupropion, and Varenicline (Champix/Chantix). The non-pharmacological interventions include considering the positive and negative environmental factors that might play a role in the effectiveness of treatment [6]. Several studies have shown the significant impact of combining pharmacological approaches with supportive intervention in successful smoking cessation [7]. One of these studies showed an increase in chance from 70 to 100% to quit smoking [8].

Additionally, smoking has a behavioral component related to physical addiction to nicotine. Behavioral intervention improved long-term smoking cessation. There are a variety of behavioral therapy interventions, including individual behavioral counseling, brief advice/interventions, telephone counseling, open-group forms of behavioral therapy, and closed-group forms of behavioral therapy. However, open-group forms of behavioral therapy are better and more cost-effective compared to the other types [9‐11].

Previous studies showed that group therapy assists individuals in learning many behavioral techniques for smoking cessation and providing each other with mutual support [12‐14]. A recent Cochrane review that assessed the group behavior therapy programmes for smoking cessation concluded that group therapy is considered superior than self-help and other less intensive intervention in smoking cessation. However, the review demonstrated lack of evidence for assessing the effectiveness for group therapy compared to intensive individual counselling [12]. Another review that assessed the usefulness and advantages of group behavior therapy among smokers, conclude that group intervention should be incorporated the management plan for smoking cessation wherever possible, because it is generally more efficient that individual intervention [13].

A study from Canada in 2002 aimed to assess the efficacy of other partner support groups in smoking cessation; they found that people who received partner group support had a higher cessation rate [15]. Another randomized clinical trial conducted in China studied the effectiveness of group intervention in smoking cessation among smokers and found that group intervention was highly effective compared to the control group [16]. In addition, behavioral counseling was found to be highly effective therapy [12].

As part of Saudi Vision 2030, the government of Saudi Arabia is determined to enhance the quality of preventive and therapeutic healthcare services. The recent prevalence of tobacco uses and its consequences are among the major public health concerns in Saudi Arabia. Tobacco control is urgently needed in the country due to increasing in the number of smokers and its related deaths. It has been estimated that around 70,000 Saudis die from smoking-related diseases every year [17].

The Ministry of health in Saudi Arabia has established the Tobacco Control Program in 2002. This program offers several services related to all aspects of smoking awareness, its harms and methods to combat it. Additionally, it provides a series of smoking cessation clinics located in many cities around the country [18]. These clinics equipped with trained personnel, to offer free consultation as well as provision of free pharmacological treatment. Group behavior therapy is not provided as a modality of tobacco cessation assistance although it has been shown to be effective in previous studies. Understanding the knowledge, attitude and beliefs of people attending the smoking cessation clinics toward group behavior therapy would guide the decision maker to integrate this method in the smoking cessation services.

Since the application of group behavior therapy programs in Saudi Arabia is lacking, the aim of the current study was to understand the knowledge, attitude, and beliefs toward group behavior therapy programs and its associated factors.

The findings confirm a deficit in knowledge about group behavior therapy. This might be due to the unavailability of this therapy approach in Saudi Arabia and the social barrier of smoking stigma in our community. Regarding the factors associated with knowledge deficit, it is clear that the level of education was associated with their knowledge. In addition, previous attempts to quit smoking and the number of cigarettes used per day, influenced the participants’ attitude and beliefs toward group behavioral therapy. Otherwise, there was no significant association between sociodemographic factors and smoking behavior with attitudes and beliefs toward group behavioral therapy.

However, a study found that smoking cessation success differed from country to country due to socioeconomic, personal, and political reasons. In addition, they found that age and income both have an association with success in smoking cessation. According to their study, as income increases the most positive effect on participants to quit smoking and success in cessation. In addition, as age increases, success in cessation increases, especially in the lower-education group [22].

It has been found that most of the respondents were young males; 79% of them had had attempted to quit smoking multiple times. In line with a previous study conducted in Makkah, 70.2% had tried at least once to quit smoking [23]. Another study that studied public knowledge and attitudes regarding smoking and smoking cessation treatments in New Zealand showed that 86% of the participants tried to quit smoking at least once [20]. Consequently, 78.3% of those who previously attempted to quit smoking started from one attempt to six attempts [18]. From these results, it is clear that the failure in smoking cessation programs could be a result of dependence on the pharmacological approach without any supportive intervention.

The current study revealed that the number of cigarettes used per day significantly influenced participants’ attitude and beliefs toward group behavioral therapy. Results showed that smokers consumed 10–20 cigarettes per day. The last survey conducted by the Saudi Health Interview Survey in 2020 showed the daily use of cigarettes with an average of 15 cigarettes per day [19]. This indicates a decrease in tobacco consumption compared to previous years and reflects the efforts of smoking cessation clinics. It is necessary to highlight the conclusion of prior research that smokers who consumed more than 20 cigarettes per day dropped out more frequently in the initial group meetings (p = 0.031) [24]. From this standpoint, the consumption of cigarettes might be a vital factor that can determine relapses during therapy.

Smoking habits tend to be acquired at an early age and are significantly associated with a high prevalence of smoking [3]. Similarly, as shown in our results, the average onset of smoking is between 11 and 20 years. In the current study, it has been found that the mean age of smokers was 35. Additionally, if we assume the onset of smoking 20 years ago, the smoking age would be almost 15 years, while the Saudi Health survey showed that the prevalence of smoking at the age of 15 years was 29 and 60.9% and that it started before 18 years [19, 25]. Therefore, this emphasizes the implantation of awareness programs at a young age, as suggested in a previous study in Saudi Arabia, that the preventive programs should started in primary schools before the age of 13 [26]. This suggestion is consistent with what has been found in a previous study that concludes the significance of prevention programs to reinforce non-smoking perceptions and behaviors after using a random clinical trial to assess the effects on smoking initiation and changes in beliefs [27]. It is critical to note that another study that showed that adult smokers older than 35 years were more likely to adhere to treatment (p = 0.017) than younger smokers [24]. This implies that most of the smokers who seek help are adults.

Smokers who want to quit had less knowledge than what we assumed about group behavior therapy programs. The reason behind this can be related to the lack of application of group behavior therapy programs since the programs are mainly dependent on the pharmacological approach with limited psychosocial interventions. Nevertheless, results showed that the participants’ level of education was significantly associated with their knowledge of this therapy approach. Although some participants were well educated, it did not affect their behavior. This finding was similar to that of a previous study [28].

In contrast, a study in Turkey found an association between level of education and success in smoking cessation. As the level of education had a greater positive effect on participants to quit smoking and progress in cessation. In addition, the higher the education level and age, the greater the success in cessation [22]. Hence, we suggest targeting the educated population while initiating these programs to obtain the ultimate results.

It is worth discussing these impressive results that previous attempts to quit smoking significantly influence the attitude and beliefs toward group behavioral therapy, which indicates that smokers encounter a serious problem with relapses. Additionally, the factors associated with success or failure to attempt smoking cessation showed that motivation is an essential factor in quitting smoking and maintaining cessation in the future [29, 30]. By reviewing the literature, many studies concur with the combination of pharmacological approaches with supportive intervention [7]. One study found an increase in chance from 70 to 100% to quit smoking [8]. In another review, a meta-analysis of 40 trials showed a significant benefit of the combination of pharmacological and behavioral therapy [31]. In addition, a study conducted on female prisoners showed that the combination of behavior therapy and pharmacological therapy was efficient compared to control groups [32].

Other studies have shown that smokers failed due to social reasons or friends’ influence (44%) [33]. This factor leads us to a critical question associated with the failure of quitting smoking. Does the smoker need to establish group behavior therapy programs to overcome the social impact?

This study demonstrated a deficit in the knowledge of people attending smoking cessation clinics regarding the group behavior therapy. Moreover, it showed that multiple factors play a role in smokers’ knowledge and attitudes, such as previous attempts to quit smoking, the number of cigarettes used per day, and the level of education. Although, The Ministry of Health in Saudi Arabia provided smoking cessation clinics in several regions around the country, these clinics mainly provide a pharmacological treatment. Group behavior therapy is not routinely provided as a modality of tobacco cessation assistance in these clinics. Despite the effectiveness of this method in smoking cessation, increase population awareness about the role of group behavior therapy in smoking cessation is required before this method is implemented in the routine practice.