Woman focused smoking cessation programming: a qualitative study

All female clients had sought treatment in an outpatient smoking cessation clinic in Toronto, Ontario that provides individualized treatment to both women and men. A variety of services are provided by an inter-professional team, including: support groups, educational workshops, brief individual counselling, pharmacotherapy (nicotine replacement therapy [NRT], bupropion, and varenicline), and self-help materials. Clients seeking treatment in this clinic on average tend to be more heavily nicotine dependent, older, less educated, have a lower income, and report a greater number of previous unsuccessful quit attempts than the general population of smokers in Ontario [21]. Close to half of those who seek treatment in the clinic are women.

A total of 204 female clients aged 18 years or older who had received services in the clinic between June 2012 and June 2013 were eligible for the study. In an attempt to have a full age range represented in the sample, the list of potential participants was sorted into several age groups (18–29; 30–39; 40–49 50–59; 60–60; ≥70) and telephone calls were made to females randomly selected within each group to invite participation. Telephone calls were made by a research assistant who had not had any previous contact with clients. Of the 160 women we attempted to contact, 99 could not be reached and 21 declined to participate. The 40 females who initially agreed to participate completed a short questionnaire over the telephone to confirm eligibility and to obtain a brief smoking history. Of these, 23 female clients ultimately attended and participated in one of the four focus groups (FG1 to FG4). Female clients were recruited until no new themes were evident during discussion, as occurred during the fourth focus group, and saturation was thus considered to have been achieved. The number of participants in each focus group ranged from 3 to 8. At the time of recruitment, 13 (56.5 %) reported they were still smoking and 10 (43.5 %) had quit. In addition, 14 (60.8 %) were current clients and 9 (39.1 %) were former clients. see Table 1 for additional demographic characteristics. Participants received a $25 CAD honorarium for participation and were reimbursed for the value of public transit travel expenses ($6 CAD). Due to the fact that the project was conducted for the purpose of quality improvement of clinical services, it was exempted from requiring ethics approval from the local institutional research board at the Centre for Addiction and Mental Health. All participants provided written consent before the start of the focus group; the consent form included a description of the study aims, methods, anticipated benefits and potential risks, confidentiality, and the right to refuse consent or withdraw from the study at any time without any negative consequences. In order to protect confidentiality, all identifying information was removed from the collected materials and names were not used when reporting findings. Participants were also encouraged to keep the meeting confidential.

We selected focus group methodology because it permitted a more exploratory examination of our research question than was possible with survey data, while also providing the flexibility to examine topics that arose in greater depth. For this reason, our questions were often more broad (see Additional file 1) so as to encourage the participants themselves versus the researchers to determine what topics were discussed. Focus groups also allowed us to determine what ideas or suggestions raised were supported by the larger group and thus were greater priorities for future implementation. The focus groups took place between July and August 2013. Both focus group moderators were female non-clinical staff that did not work in the clinic; each had previous experience conducting focus groups (NM: 10 years; JP: 1.5 years). The purpose of the focus groups was described to participants as seeking feedback from female clients to help improve services at the smoking cessation clinic. Participants were asked about past quit attempts, challenges they had faced when trying to quit smoking, their thoughts and experiences regarding the services at the clinic, and suggestions for what can be changed in order to improve services. Most questions were designed to elicit personal experiences and opinions from the female clients without being explicitly gender-specific in their phrasing. Focus groups were audio-recorded using a digital recorder (but not transcribed) and a research student took notes electronically during the discussion.

Focus group data was examined using thematic analysis within a phenomenological theoretical framework in order to investigate the lived experience of female clients who sought treatment for smoking cessation at the clinic [22, 23]. Both audio-recordings and notes were used for the analysis. The audio-recordings were used to both confirm and elaborate upon the content of the notes and also provided information regarding non-verbal communication (i.e., emphasis, tone, pauses, etc.) and the notes helped to fill in any gaps where recordings were inaudible. A single coder (JP) analyzed the recordings and notes to identify themes using an inductive process as follows: review of the raw data (recordings and notes); generating codes; identification of recurring themes; arrangement of the initial codes according to theme; and interpretation of each theme. Participant quotations were selected to illustrate each theme and are included throughout the text. Quotations were selected during review of the audio-recordings after themes were identified and were transcribed verbatim. A second analyst (SV) not blind to the original coding followed the same process to identify themes that emerged in the raw data. Any discrepancies were discussed until consensus was achieved. Both coders were not clinicians and had no contact with the participants aside from the conduct of the focus groups.

Participants strongly favoured an adaptive, client-centred approach which allowed treatment to be tailored to meet their specific needs. Their ability to choose from a variety of services (including psychosocial and pharmacotherapy) was viewed as necessary to meet the diverse needs of female clients and important for success.

I like it more tailored to me because we started going one route but we found that, the doctor and I, that it wasn’t working… If I had just been given a prescription and told to go home, see you in 3 months…it wouldn’t have worked. FG4

Though each client had their own preferences, all treatment options were considered helpful by the group as a whole. Participants also reported the benefits of receiving self-help materials and tools which they could use on their own time, such as a diary to chart their tobacco use.

I think it’s a pretty synergistic package. So, the one on one with an MD, the groups, and the education workshops and modules. I think they all work together and I wouldn’t value one of them over another. FG3

An important benefit of treatment at this clinic for many of the participants was the ability to receive free NRT. While it was cited as helpful in removing cost as a barrier to using NRT, the fact that there was a maximum of 6 months (within a 12-month period) provided was cited as stressful for some. Participants stated that some clients did not feel ready to taper off NRT at the end of their 6 months, and some may delay a quit attempt due to concern that they would not make good use of their limited supply if not successful. While the participants recognized the importance of the weaning process and “not becoming dependent on something else” (FG1), it was suggested that exceptions to the 6-month limit should be made on a case-by-case basis for some who need extended assistance.

I’m afraid of running out of my patches because I can’t afford to do it and I’m afraid of wasting when I’m not ready. FG1

Support from staff and fellow clients was cited as particularly helpful to the quitting process. Clients felt the clinic was a non-judgmental environment where they felt understood, in contrast to attitudes some participants had encountered outside the clinic from both loved ones and health care professionals alike. Participants expressed that in the clinic they never felt like they had failed if they were not able to stick to their quit plan, but instead practitioners and other clients continued to offer a very supportive, encouraging environment that helped motivate them to persist with their quit attempt.

I really feel like for the first time these people [in the clinic] understand, they’re not judging you, and that’s so important because so often you are [judged] – “Why are you smoking? Just stop” – and that was a big help. FG1

Support groups were described as an important component of treatment for many clients. Words such as “big motivator”, “fantastic” and “my lifeline” were used to describe these groups. Reasons for finding these groups helpful included: feeling accountable to others, strengthening motivation, reinforcing what had been learned, learning strategies that helped others successfully quit, and allowing those who quit to share their experience and be a role model for others.

For somebody coming in, they might look at me being [quit for] 5 months, oh, maybe feel a little intimidated … but I would like to say to them, hang in there, because I was once like you. I got my inspiration from the lady next to me who had quit for 5 months at that time, so I wanted to be where she was, so that gave me the hope to go further. FG3

While most viewed having individuals at different stages of the quit process together in the same group as beneficial, there was also some interest in groups being divided according to quit status (e.g., ex-smokers only). Not having pre-determined topics in the general support group (versus topic-specific groups) was felt to allow for the discussion to be flexible and responsive to the clients’ needs.

While the clinic was considered a supportive environment, some clients wanted more frequent support, such as through follow-up telephone calls or having the ability to call to talk to a clinician from the program when needed. In addition to receiving support, a few clients were interested in volunteering to offer support to others, such as through a buddy program.

For some women the hours of operation and location of the clinic were cited as barriers to accessing services. Though many were able to visit the clinic during the day, many found daytime hours inconvenient because of the need to take time off work. Adding evening and weekend hours was recommended to make services more accessible. It was also suggested that start times for weekday evening group sessions take into account time needed to commute from work and eat dinner rather than start at 5 pm.

I can’t get to the support groups ‘cause they don’t work with my schedule for work and I feel… like… [attending groups] would help. FG1

Clients living far from the clinic’s downtown location indicated that the availability of services closer to home would make it easier to attend appointments.

I think I didn’t come [to group] because it’s too far, the drive … Even when we leave here, all I’m thinking about is rush hour. I’m going to be stuck in rush hour… I’m far more inclined to go if it’s around the corner. FG3

An additional suggestion made by some clients to improve accessibility of the clinic for women was to offer childcare services.

For women especially… [it would be helpful] if it would be more accessible after hours and daycare would be HIGHLY appreciated. FG1

Clear communication was mentioned as being very important. Participants did not always know about or fully understand all of the services being offered, and believed that communication about services should be clear, readily available, and regularly updated.

At the outset there should be a little outline. Here is the program… FG3

The front desk is the first point of contact… if they could keep hard copy calendars, so when somebody comes in… to see any of the staff, that there is a calendar for the up and coming months and what’s running… the other thing is maybe an option, I have email, I would like to have a calendar sent to me, so that I could you know kinda wiggle my schedule and maybe fit more in. FG2

Some participants who were no longer in treatment said they would have benefitted from being contacted by the clinic when they either cancelled or failed to show for an appointment. A follow-up call might have been enough to encourage them to continue with treatment in the clinic.

Female clients suggested that it would be beneficial if some educational sessions covered women-specific topics, such as smoking cessation during menopause or during pregnancy. Opinions were mixed on whether a female-only group would be beneficial. Many did not think it made a difference if the groups had men or not, however, some thought it would be beneficial and felt more comfortable in a female-only support group.

I would like to see, not gender-specific programs or anything like that, but, maybe some workshops specifically for women who have stopped smoking or are still smoking… maybe have some information available on things that impact women… specifically women’s health… FG2

If I’m talking about my period starting that morning and I’m cranky and I’m in pain, the guy next to me, he’s just not going to get it, he can try, he just won’t understand… sometimes it can be more comfortable… FG4