Study population

The population in this study consists of adult tobacco users aged ≥18 years who participated in the STEPS 2017 survey in Oman¹⁵. The primary survey was a nationally representative community survey, which was conducted based on the WHO STEPwise approach to surveillance (STEPS). It used a multi-stage cluster sampling procedure and was carried out using face-to-face interviews, with anthropometric measurements taken by qualified staff. The total number of participants was 6743 (response rate was 97.9%), of whom only 512 were tobacco users, accounting for 7.6% of study participants¹⁵.

Ethical approval

This study was based on secondary data from STEPS 2017 survey in Oman. The primary survey was approved by the Central Research and Ethics Committee at the Ministry of Health, Oman. (Approval No. 26/2015)¹⁶. Informed consent was obtained before participating in the study¹⁶. For this study, permission to obtain secondary data was requested and obtained from the Centre of Research and Study, MOH, Oman, on 27 January 2024.

Study design

This study was an observational, analytical, cross-sectional study that presented both descriptive and analytical data based on secondary data from the 2017 STEPS survey in Oman.

Data collection and study instrument

The parent study utilized face-to-face interviews to collect the data, while anthropometric measurements were obtained by trained staff¹⁷. For the purpose of this study, only 31 variables were included.

The independent variable

This study included two independent variables: whether participants had been asked about their smoking status and whether they had been advised to quit smoking by a healthcare provider. To assess if participants received advice to quit, they were asked: ‘During any visit to a doctor or other health worker in the past 12 months, were you advised to quit smoking tobacco?’. Responses were grouped as either ‘yes’ or ‘no’. Similarly, for the question ‘During any visit to a doctor or other health worker in the past 12 months, were you asked about your smoking status?’, the answers were divided into ‘yes’ and ‘no’. Participants who reported not visiting any healthcare provider in the past 12 months were excluded from the analysis for both questions.

The dependent variable

The dependent variable of interest in this study was the quit attempt by tobacco users in the last 12 months in response to the question: ‘During the past 12 months, have you tried to stop smoking?’. Responses were categorized into binary variables of ‘yes’ and ‘no’.

Sociodemographic and health-related variables

Sociodemographic data (including age, sex, nationality, education level, employment status, marital status, and estimated monthly income) and health-related data (including diabetes mellitus, asthma, high blood pressure or high cholesterol, and body mass index) were examined for their association with quit attempts. Additionally, external environmental factors including seeing warning labels on cigarette packages, seeing health promotion in a newspaper or magazine, watching health promotion on television, hearing health promotion on radio, watching TV shows or films containing cigarette scenes, seeing advertisements in cigarette stores, and supporting a rise in tobacco taxes, were examined for their association with quit attempts.

Statistical analysis

For descriptive analysis, the categorical variables were presented as frequencies and percentages. Bivariate analyses were performed to examine the associations between sociodemographic variables, health-related variables, wider environmental variables, and quit attempts. Variables with p<0.05 in the bivariate analysis were retained and included in the multivariable analysis. A multivariable binary logistic regression analysis was performed to analyze the association between receiving quit advice from healthcare workers and quit attempts. Adjustments were made for sociodemographic, health-related, and environmental variables. Results were presented as adjusted odds ratios (AORs) and 95% confidence intervals (CIs). The statistical package SPSS version 24 was used to perform the analysis. Two-tailed tests were used, and p<0.05 was considered statistically significant.

Sociodemographic disparities and quit attempts

The current study showed that quit attempts were significantly and independently high among older age groups, employed individuals, those with higher levels of education, and those with a monthly income of ≥500 OMR, both in bivariate and multivariate analyses, and this was consistent with existing literature^17-20. In contrast to the existing literature¹⁹, unemployed tobacco users were more likely to attempt quitting than employed tobacco users. The current study showed that the older age group was more likely to attempt quitting. While some studies showed comparable findings⁷, others demonstrated no significant association^21,22. The current study showed that female tobacco users were more likely to attempt to quit compared to male tobacco users; however, this was not statistically significant. The study did not assess the effect of area of residence due to the absence of this variable in the parent survey. However, studies have found a significant association between residential area and quit attempts¹⁸.

Several reasons could explain the sociodemographic disparity in attempts to quit. First, access to cessation services and perceptions of their effectiveness may influence intention and subsequently attempts to quit¹⁷. Second, a person’s intrinsic motivation to quit is a powerful predictor of an attempt to quit, as is the rule of family or peer pressure⁸. Third, differences in quit attempt rates across studies may be attributed to variations in study design, country-specific characteristics, national tobacco control policies, and the timing of data collection¹⁷. Understanding these factors can help identify where disparities exist and how they can be effectively addressed.

Quit advice provided by healthcare providers and quit attempts

When adjusting for sociodemographic, health-related, and external factors, receiving advice by healthcare workers to quit tobacco products was associated with a 3.13 times increase chance to attempt quitting (AOR=3.13; 95% CI: 1.46–6.71, p=0.003), and this is consistent with existing literature^22–25. However, the STEPS 2017 survey did not specifically explore the duration of the quit advice or the professional background of the provider, both of which could influence its effectiveness. Approximately 40% of tobacco users make a quit attempt in response to advice from a general practitioner, though such interventions are often limited by time constraints²⁶. The impact of healthcare providers in providing quit advice is not limited to physicians; professionals from various disciplines can also play an effective role, provided they receive appropriate training²⁶.

Behavioral interventions, such as brief advice, individual and group support, telephone counseling, self-help material, and text messages, have varying effectiveness in helping people quit tobacco. Group therapy and individual support are better than self-help and less intensive interventions, with the chance of quitting increasing by 50% to 130%²⁷. However, there is insufficient evidence to determine whether group therapy is more effective or cost-effective than intensive individual counseling¹⁷. On the other hand, individual-based support can increase the chance of quitting by 40% to 80% compared to minimal support²⁸. Telephone counseling increases the chance of quitting smoking, regardless of whether the patient is motivated to quit and/or receiving other tobacco cessation treatment. However, proactive telephone counseling is considered superior to reactive telephone counseling in terms of boosting the quit rate²⁹. Additionally, smokers who received 3–5 calls were more likely to quit than those who received only one call²⁹. Minimal evidence showed that motivational interviewing may or may not help people to quit compared with no intervention or compared with other type of behavioral intervention³⁰. Automated text messagebased tobacco cessation interventions result in greater quit rates than minimal support³¹.

Several challenges can interfere with providing advice to quit tobacco products by healthcare providers. The primary constraint is the limited time and lack of personalized support necessary to effectively deliver evidence-based tobacco cessation advice³². Furthermore, healthcare providers frequently possess insufficient knowledge about the harms of tobacco products and lack adequate training to provide effective tobacco cessation services. Tobacco use status is not routinely recorded during each clinical encounters. Tobacco cessation advice is often limited to doctors and nurses within primary healthcare settings³³, with no clear plan to extend it to other disciplines from secondary or tertiary healthcare. Addressing these gaps could significantly enhance healthcare providers’ capacity to deliver effective cessation interventions at all levels of healthcare.

Health-related factors and quit attempts

The current study found no significant association between having a long-standing medical illness and attempting to quit. The low prevalence of tobacco use in this study group may explain the absence of association between medical background and attempts to quit. However, existing literature has shown that poor health is one of the motivators for tobacco users to quit³⁴. A study in Poland identified general health concerns (57%), personal health issues (32%), and social reasons (32%) as key motivators to quit³⁴.

The current study did not show significant association between exposure to secondhand smoke (at home, in the workplace, or while visiting a healthcare facility) and quit attempts, which was inconsistent to the existing literature²⁶. The current study found no significant association between age of initiation and attempts to quit. Other studies showed that older age at initiation was associated with increased intention to quit²¹.

External factors and attempt to quit

The current study explored external factors that may influence quit attempts. Nearly half (44.0%) of those who saw warning labels on cigarette packages attempted to quit, however, this was not statistically significant (p=0.115). Existing literature found that those who saw a health warning on plain packaging were more likely to attempt to quit²⁵. Furthermore, a study in Australian adults found that plain packaging with larger graphic health warnings increased quitting intention and quit attempts among adult cigarette smokers³⁵. The current study found no significant association between quit attempts and health warning in plain packaging, possibly due to the absence of plain packaging policy on all manufactured tobacco products at the time the primary survey was conducted.

On the other hand, noticing a tobacco-related health warning on TV was associated with quit attempt; with 46.8% who saw this health promotion attempted to quit, p=0.046. No significant associations were observed with warnings seen in newspapers or magazines or heard on the radio.

Implications

Article 14 of the WHO Framework Convention on Tobacco Control (FCTC) recommends that any tobacco cessation program include at least three types of cessation supports: tobacco cessation medication, cessation counseling in a primary care setting, and toll-free Quitline¹³. These should be part of comprehensive, multisectoral tobacco control initiative to ensure effectiveness. Creating an enabling environment that empowers healthcare providers to deliver quit advice at every clinical encounter, by addressing barriers at the national, healthcare system, and individual levels, is essential. Several recommendations can be made from this study.

First, integrate cessation services at all levels of the healthcare system. The electronic record system already has a specialized tobacco cessation module; however, national coordination is required to ensure effective implementation at all healthcare levels. This will guarantee that all tobacco users receive a comprehensive, evidence-based treatment plan to support them throughout their quit journey.

Second, while ongoing tobacco cessation training is being provided at the primary care level to build the capacity of healthcare providers in various healthcare sectors, it is only limited to doctors and nurses. There is no clear plan to expand the service to other sectors. Thus, establishing national training coordination is crucial to broaden training efforts and equip frontline healthcare workers across various disciplines to deliver tobacco cessation support as part of their routine responsibilities.

Third, implement brief advice at every clinical encounter. A well-defined referral pathway should be established for individuals who express a willingness to quit tobacco products¹. Introducing a Quitline service would significantly aid quit attempts.

Fourth, the availability of tobacco medication is a major deterrent to enabling tobacco users to quit, and even when it is available, the 100% taxes on nicotine replacement therapy, make the attempt even more difficult. Thus, it is crucial to make these medications available in the first instance and affordable to those who wish to quit.

Fifth, tobacco cessation program should be supported by population-based interventions, such as multi-sectoral tobacco control policies, as part of FCTC’s demand reduction measures to reduce tobacco uptake while increasing quit attempts and rates. Among these measures are: 1) monitoring tobacco use and prevention policies; 2) protecting people from exposure to secondhand smoke; 3) offering help to quit tobacco use; 4) warning about the dangers of tobacco use; 5) enforcing bans on tobacco advertising, promotion, and sponsorship; and 6) raising taxes on tobacco products. While Oman has made progress, by introducing 100% retail taxation on cigarette products and plain packaging—more can be done, such as ‘complete’ banning of indoor smoking areas¹². Implementing a comprehensive cessation policy can reduce smoking prevalence at 5 years by 3.5–9% and nearly avert 9000 deaths at 40 years. However, having a comprehensive tobacco control policy combined, can reduce smoking prevalence by 38% and 48% at 5 and 40 years and avert 65000 deaths at 40 years¹².

Lastly, implementing a nationwide tobacco control surveillance and monitoring system that routinely tracks tobacco use and assesses the effectiveness of policies is essential for identifying and addressing gaps in tobacco control efforts.

Strengths and limitations

This is the first study to examine the association between receiving advice by a healthcare provider and quit attempts in a nationally representative sample in Oman. The overall response rate for the 2017 STEPS survey was significantly high (97.9%), making the data more generalizable to the entire population. Data collection was done by professional personnel; therefore, the risks of misinterpretation or missing data were minimized to some extent. Finally, the study adjusted for a number of sociodemographic, health-related, and external variables.

Nonetheless, there are some limitations to this study. The major limitation is the cross-sectional design, which precludes the inference of a causal relationship between advice from a healthcare provider and a quit attempt. Furthermore, this study was susceptible to recall bias, response bias, and social desirability bias. The study did not examine the geographical distribution of tobacco users, previous quit attempts, withdrawal symptoms, or quit rates, as these data were not available in the primary survey. The current study did not stratify participants by sex to identify variations in the association between advice to quit and quit attempts, as the prevalence of smoking among women was extremely low.