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Year : 2021  |  Volume : 18  |  Issue : 4  |  Page : 327-332

The experience of a Middle Eastern smoking cessation program: A focus group study of providers’ perspective

1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Beirut, Lebanon
2 Department of Family Medicine, American University of Beirut Medical Center, Beirut, Lebanon
3 Hariri School of Nursing, American University of Beirut Medical Center, Beirut, Lebanon
4 Division of Urology, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon

Date of Submission27-Jun-2021
Date of Acceptance28-Jul-2021
Date of Web Publication18-Dec-2021

Correspondence Address:
Nadim Kanj
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, American University of Beirut Medical Center, Riad El Solh 1107 2020, Beirut.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/MJBL.MJBL_44_21

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Introduction: Almost one-third of the Lebanese population are active smokers, with limited knowledge about their attitudes toward existing smoking cessation interventions. This study aims at exploring the facilitators and barriers facing a smoking cessation program (SCP) in a Lebanese tertiary referral center from the providers’ perspective. Materials and Methods: This is a qualitative study comprising a focus group discussion (FGD) among five practitioners from the SCP. The data collected were then transcribed and summarized by coding, simplifying, and transforming the raw data into major themes and subthemes as per the Miles and Huberman method of organization. Results: Facilitators and barriers fell under three subthemes: (1) participant factors, (2) provider factors, and (3) system factors. Facilitators included motivation and concerns about health among patients, in addition to increased behavioral support from providers. Meanwhile, barriers were much predominant and included stress factors and nicotine addiction among patients, time constraints among providers, lack of an effective referral system, inaccessibility, and unavailability of pharmacotherapy as well as a pro-smoking environment with weakly enforced tobacco legislation. Conclusion: Our findings implicate the need for multilevel strategies to help improve smoking cessation interventions. Addressing identified barriers is of paramount importance to help develop effective, accessible, and culturally specific tobacco treatment.

Keywords: Cessation program, qualitative, smoking, tobacco, underdeveloped countries

How to cite this article:
Koubaissi SA, Jawhar S, Romani M, Honein G, Degheili JA, Kanj N. The experience of a Middle Eastern smoking cessation program: A focus group study of providers’ perspective. Med J Babylon 2021;18:327-32

How to cite this URL:
Koubaissi SA, Jawhar S, Romani M, Honein G, Degheili JA, Kanj N. The experience of a Middle Eastern smoking cessation program: A focus group study of providers’ perspective. Med J Babylon [serial online] 2021 [cited 2022 Jan 24];18:327-32. Available from: https://www.medjbabylon.org/text.asp?2021/18/4/327/332748

  Introduction Top

Tobacco use has been responsible for avoidable early death and disability all over the world due to the adverse health effects that it causes, including malignancy, as well as cardiovascular and respiratory diseases.[1] The smoking prevalence in low- and middle-income countries is estimated to reach more than 40%, and it exceeds 30% in Lebanon, ranking first for tobacco consumption compared with other countries of the Eastern Mediterranean Region (EMR).[2]

Most smokers are familiar with the health consequences of tobacco consumption and many desire to quit, but quitting without assistance has been shown to be difficult due to nicotine’s addictive nature.[3] However, tobacco cessation interventions, including pharmacotherapies such as nicotine replacement therapy (NRT), Bupropion and Varenicline, and behavioral support (as simple as brief advice from health-care practitioners), have been proven to increase the odds of smoking cessation.[4] In developed countries, tobacco cessation programs have been proven to be cost-effective in promoting abstinence among smokers, leading to fewer tobacco-related diseases and lower mortality.[5] Meanwhile, there exists a challenge to implement efficient tobacco control policies and treatment programs in the EMR countries, where the availability and affordability of cessation services and pharmacotherapy were revealed to be lacking or insufficient.[6] The perceived costs of providing a sustained tobacco dependence treatment support and the lack of clear evidence about its cost-effectiveness remains the main challenge toward implementing smoking cessation interventions in this region.[7]

Most of the smoking cessation evidence in the literature is established from quantitative and intervention-focused studies, with limited findings coming from qualitative research. Qualitative approaches afford an in-depth way to explain unanticipated findings or clarify relationships found in quantitative research. By focusing our study on the views of the providers, we aimed at identifying the factors perceived by tobacco treatment providers to influence quitting attempts and outcomes among smokers seeking cessation support to optimize the delivery of comprehensive smoking cessation treatments.

  Materials and Methods Top

Overview of smoking cessation program

This study involves an outpatient smoking cessation program (SCP) at the American University of Beirut Medical Center (AUBMC) in Beirut, Lebanon. The program is staffed with two smoking cessation physicians, three specialized nurses, and one administrator. At the first visit, participants are introduced to the program and undergo a full assessment during which medical history, physical assessment, pulmonary function test, and carbon monoxide level are assessed. Nurses also complete a behavioral assessment form that records patients’ tobacco use, smoking habits, and nicotine dependence. This is followed by a visit to the physician to receive the appropriate treatment plan based on international practice guidelines (NCSCT—National Centre for Smoking Cessation and Training).[8] The plan includes choosing a quit date with the help of the physician, consenting on smoking cessation pharmacotherapy (NRT, non-nicotine medications, or combination therapy) along with behavioral support, and setting a follow-up plan that lasts for one year. The follow-up sessions are either done in-person or through the telephone and take place every week for two months. In parallel with the weekly visits, two follow-up visits with the physician are arranged (at one month and two months post-quit date). After two months from quitting, the patients are contacted once per month for one year to ensure compliance and maintenance of abstinence.

Design and participants

The participants were recruited health-care staff from the SCP who were invited by e-mail to participate in the study along with a written consent form. E-mails were retrieved from the institution’s available mailing list. Five out of six providers (including two tobacco-treatment physicians, two specialized nurses, and one administrator) agreed to participate in the FGD. Those who agreed to participate provided written informed consent before the FGD. Ethical approval to conduct this study was acquired from the Institutional Review Board at the AUBMC.


The FGD was 1-h long and took place in the participant’s workplace. The focus group was conducted by a researcher, GH (Ph.D.), with varied research experience, including extensive experience in facilitating focus group interviewing and qualitative methods. The researcher used a semi-structured interview with a prepared set of questions covering topics related to smoking cessation services and interventions as well as enablers and barriers related to success or failure of cessation among smokers [Table 1]. The discussion was audio-recorded and transcribed by one interviewer and reviewed by another to eliminate errors.
Table 1: Focus group questions

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Two of the research team members reviewed the transcription on multiple occasions while performing a content analysis on the data.[9] Initial coding was performed with a generation of multiple category codes with specific but different ideas. A second focused coding stage was then completed by eliminating or merging the initial coding categories into wider themes, connecting multiple similar codes, and unifying recurrent ones. One major theme was finally concluded, and it was divided into three subthemes, followed by exemplary quotes for further clarification [Table 2]. This ongoing process of data reduction was consistent with the Miles and Huberman method of organization.[10]
Table 2: Themes, subthemes, and specific exemplary quotes from the focus group discussion

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A central theme that emerged from the FGD was facilitators and barriers contributing to successful smoking abstinence among smokers who had enrolled in the program, which split into three subthemes: participant, provider, and system level. Additional exemplary quotes for each subtheme are shown in [Table 2].

Participant level

The program’s providers believed that motivation was a significant enabler for successful smoking cessation and that “coming to the program depends on how much they are excited or serious about quitting” (M.2). Also, the main intrinsic factor that encouraged young smokers to think about stopping smoking was the prospect of living a healthy lifestyle, especially “educated parents who know the harmful effects of smoking on their kids, so they do it to prevent diseases and protect their children” (T.2). Interestingly, providers found that smokers with worse health status have better chances to succeed in quitting. Another major factor facilitating smoking cessation was the presence of social support, “encouraging people around them” (R.2) and the fear of tarnishing their social image: “One of the university professors mentioned that he is a role model for his students, not only in his profession but also in other aspects of life” (M.2).

When discussing barriers to cessation, providers believed that those less likely to comply with the program tended to be younger, less committed, and had a high baseline level of anxiety or depression “because they see smoking as a stress reliever” (M.3). This same group of providers, when asked to quit smoking, would do so as they were being pressured by their parents or relatives; “and coming only for their [parents], they don’t quit, and they relapse easily” (M.2). They also stated that patients reported concerns of peer rejection, losing the pleasure of smoking, “having to pass through the withdrawal symptoms” (R.3), and changing their lifestyle habits. Another issue was the time constraint as a result of traffic and travel distance operated as logistic barriers, contributing to poor compliance.

Provider level

Providers’ perceived facilitators were reduced physician fees “we only charge the patients for the first visit and the remaining ones are free of charge” (M.2), nurses’ behavioral support with their continuous personal efforts to be “available all the time if they need any help, even outside working hours” (R.2), technology use, and implementation of awareness campaigns.

The main barriers were physicians’ time constraints since “usually a smoker patient needs a minimum of 30 minutes to assess, counsel, educate whereas a regular clinic appointment is only 20 minutes, so I feel pressured by the time when I merge smoking cessation appointments with regular appointments” (M.3). The nurses reported a similar challenge since they believe that a patient’s visit must be long enough to provide adequate “psychological support that takes sometimes more than half an hour before talking about smoking cessation itself” (T.3). Finally, although nurses’ international training was very helpful for delivering behavioral support, they thought it was “different than the culture [they] are dealing with” (T.3) and that “more practice and experience is needed” (T.4).

System level

Unlike today’s implemented efforts to make the campus smoking-free, no well-organized directives were set at the launch of the program to fight for smoking cessation or tobacco control.

Practitioners believed that the referral of hospitalized smokers to smoking cessation services is still “[…] lacking even from oncologists or cardiologists who are probably counseling their patients, but they don’t refer them” (M.3). Similarly, from the nursing staff who are not sufficiently trained on delivering smoking cessation interventions: “they ask the patients if they smoke or not and this is it” (M.3), without implementing the five As (Ask, Advise, Assess, Assist, and Arrange). Besides, the availability and cost of smoking cessation medications were a barrier for all enrolled participants. Since the hospital’s pharmacy did not have any available stocks for outpatients, “we used to check the availability of the medications for our participants in pharmacies near the hospital on monthly basis” (M.3).

Moreover, funds to provide a Quit line to the program are insufficient, and “it would help more if the insurance companies cover the smoking cessation services or encourage smokers to participate” (R.3). The government also plays a crucial role in reducing smoking. However, Lebanon’s tobacco control legislation and preventive measures are weakly enforced despite the presence of laws for banning smoking in public places. Finally, policies related to cost and accessibility of tobacco products are absent and despite our efforts “to convince participants that [smoking cessation services] cost the same as the cigarettes, we find that the locally produced cigarette pack costs only 1000 Lebanese pounds!”(N.3).

  Discussion Top

Findings from this article described the factors influencing smoking cessation outcomes among smokers who had enrolled in a tobacco-treatment program from the providers’ perspective. Using a focus group discussion, the program’s providers determined considerable facilitators and barriers that affected the smokers’ attempt to quit, which were represented as three subthemes (participant-, provider-, and system-related). Most of the barriers that were mentioned by the providers fell under the system level, which can be explained by the dominant pro-smoking environment in Lebanon and negligible efforts toward tobacco control policies and legislation.

The main subthemes of our findings are supported by evidence from other studies. Considering the facilitators and barriers at the participant’s level, providers believed that health concerns, having negative health consequences,[11],[12],[13],[14] and the presence of social support,[15],[16],[17],[18],[19] positively influence cessation attempts and outcomes among smokers. Motivation to quit was also considered an enabler; however, numerous studies have assessed the association between motivation and smoking cessation but revealed conflicting results. Some studies revealed motivation to predict quit attempt alone, whereas other studies found it to be predictive of successful cessation maintenance.[19],[20],[21],[22],[23],[24] This may be explained by the changeable nature of motivation over time along with a difference in the sample of smokers and the tools used to measure motivation to quit and its variability across studies. Meanwhile, young smokers and smokers who had high levels of anxiety and depression were predicted by providers to have less successful cessation attempts, as shown in earlier studies where smoking cessation success was reported to be lower in smokers with depressive and anxiety symptoms.[25]

When it comes to the factors affecting care delivery and directly linked to the providers themselves, it was found that the demanding treatment of addiction and the long time it needed was the main barrier. Another barrier was the incompletely adapted international behavioral therapy training they received, and the one required for the Lebanese culture. Both of these factors go in alignment with previously reported studies,[26] including those conducted in medically underserved communities,[27] such as the case in Lebanon.

Finally, during the FGD, providers viewed the unavailability of pharmacotherapy and the cost of cessation services as significant barriers to successful quitting, attributing these obstacles to the absence of the governmental role in implementing tobacco control policies. This is clearly explained by the lack of access and financial coverage of cessation treatments in the EMR region, which urgently demands implementing national plans to better adopt tobacco control policies.[28],[29] By providing greater access to cessation services along with subsidized or financially covered treatments through governmental bodies or insurance companies, we expect better encouragement toward treatment use and increase quit attempts among smokers, leading to decreased smoking rates in our community.[30],[31],[32] Not to mention also the importance of establishing office- and hospital-based cessation and interventional programs, aiming to address provider- and system-level barriers, along with targeting deficiencies in our healthcare system, that are averting tobacco control. Implementing system-wide smoking status documentation of patients and referral programs, as well as providing counseling training opportunities for clinicians should be a priority in promoting physician involvement in cessation efforts and enhancing smokers’ engagement in tobacco treatment programs.[30],[31],[32]

  Conclusion Top

Our study identified participant-, provider-, and system-related facilitators and barriers influencing quit attempts and outcomes among smokers seeking assisted cessation. These findings implicate the need for contextualized multilevel strategies to improve and develop effective, accessible, and cultural-specific smoking cessation services. A better understanding of these factors from the perspective of providers, who deliver direct care to smokers, can help explain gaps and offer insight on successful practice change related to cessation interventions. Health practitioners and public health researchers can use such knowledge to better support policies, clinical practice, and care delivery of tobacco treatment to this unique population.

Ethical consideration

Ethical approval was acquired from the Institutional Review Board at the American University of Beirut. Before enrollment in the study, written informed consent was obtained from the SCP providers.

Authors’ contributions

MR and NK were responsible for the conceptualization and management of the project. SK and JAD were responsible for the article preparation, FDG transcription, coding and quoting, and interpretation of findings. SJ and JAD were responsible for the article preparation and interpretation of findings. GH was responsible for the focus group discussion interview and interpretation of findings. All authors have read and approved the article.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Reitsma MB, Fullman N, Ng M, Salama JS, Abajobir A, Abate KH, et al. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: A systematic analysis from the Global Burden of Disease Study 2015. The Lancet 2017;389:1885-906.  Back to cited text no. 1
Piné-Abata H, McNeill A, Murray R, Bitton A, Rigotti N, Raw M. A survey of tobacco dependence treatment services in 121 countries. Addiction 2013;108:1476-84.  Back to cited text no. 2
World Health Organization. WHO Report on the Global Tobacco Epidemic, 2011: Warning about the Dangers of Tobacco: Executive Summary. Geneva: World Health Organization; 2011.  Back to cited text no. 3
Tobacco Use and Dependence Guideline Panel. Treating tobacco use and dependence: 2008 update. Rockville, MD: US Department of Health and Human Services; 2008. Available from: https://www.ncbi.nlm.nih.gov/books/NBK63952/. [Last accessed on 03 Mar 2021].  Back to cited text no. 4
Lightwood JM, Glantz SA. Short-term economic and health benefits of smoking cessation: Myocardial infarction and stroke. Circulation 1997;96:1089-96.  Back to cited text no. 5
World Health Organization⊠. WHO global report on mortality attributable to tobacco. Geneva: World Health Organization; 2012. Available from: https://apps.who.int/iris/handle/10665/44815. [Last accessed on 20 Apr 2021].  Back to cited text no. 6
Lee JE, Park EC, Chun SY, Park HK, Kim TH. Socio-demographic and clinical factors contributing to smoking cessation among men: A four-year follow up study of the Korean Health Panel Survey. BMC Public Health 2016;16:908.  Back to cited text no. 7
NCSCT Briefings. The National Centre for Smoking Cessation and Training (NCSCT). Available from: hhttps://www.ncsct.co.uk/pub_briefings.php. [Last accessed on 03 Apr 2021].  Back to cited text no. 8
Nyumba T, Wilson K, Derrick CJ, Mukherjee N. The use of focus group discussion methodology: Insights from two decades of application in conservation. Methods Ecol Evol 2018;9:20-32.  Back to cited text no. 9
Engle M. Qualitative Data Analysis: An expanded Sourcebook (2nd ed.): Matthew B. Miles and A. Michael Huberman. Thousand Oaks, CA: Sage publications, 1994, 336 pp. Am J Eval1999;20:159-60.  Back to cited text no. 10
Joshi V, Suchin V, Lim J. Smoking cessation: Barriers, motivators and the role of physicians—A survey of physicians and patients. Proc Singapore Healthc 2010;19:145-53.  Back to cited text no. 11
Gallus S, Muttarak R, Franchi M, Pacifici R, Colombo P, Boffetta P, et al. Why do smokers quit? Eur J Cancer Prev 2013;22: 96-101.  Back to cited text no. 12
Buczkowski K, Marcinowicz L, Czachowski S, Piszczek E. Motivations toward smoking cessation, reasons for relapse, and modes of quitting: Results from a qualitative study among former and current smokers. Patient Prefer Adherence 2014;8:1353-63.  Back to cited text no. 13
Kluge A. A qualitative inquiry into smoking cessation: Lessons learned from smokers. Atlanta, GA: Emory University; 2009. Available from: https://etd.library.emory.edu/concern/etds/0g354f89r?locale=en. [Last accessed on 11 Apr 2021].  Back to cited text no. 14
Mermelstein R, Cohen S, Lichtenstein E, Baer JS, Kamarck T. Social support and smoking cessation and maintenance. J Consult Clin Psychol 1986;54:447-53.  Back to cited text no. 15
Hanson BS, Isacsson SO, Janzon L, Lindell SE. Social support and quitting smoking for good. Is there an association? Results from the population study, “Men born in 1914,” Malmö, Sweden. Addict Behav 1990;15:221-33.  Back to cited text no. 16
Chandola T, Head J, Bartley M. Socio-demographic predictors of quitting smoking: How important are household factors? Addiction 2004;99:770-7.  Back to cited text no. 17
Creswell KG, Cheng Y, Levine MD. A test of the stress-buffering model of social support in smoking cessation: Is the relationship between social support and time to relapse mediated by reduced withdrawal symptoms? Nicotine Tob Res 2015;17:566-71.  Back to cited text no. 18
Van den Brand FA, Dohmen LME, Van Schayck OCP, Nagelhout GE. “Secretly, it’s a competition”: A qualitative study investigating what helped employees quit smoking during a workplace smoking cessation group training programme with incentives. BMJ Open 2018;8:e023917.  Back to cited text no. 19
Borland R, Yong HH, Balmford J, Cooper J, Cummings KM, O’Connor RJ, et al. Motivational factors predict quit attempts but not maintenance of smoking cessation: findings from the international tobacco control four country project. Nicotine Tob Res 2010;12(Suppl):S4-11.  Back to cited text no. 20
Zhou X, Nonnemaker J, Sherrill B, Gilsenan AW, Coste F, West R. Attempts to quit smoking and relapse: Factors associated with success or failure from the ATTEMPT cohort study. Addict Behav 2009;34:365-73.  Back to cited text no. 21
Cox LS, Wick JA, Nazir N, Cupertino AP, Mussulman LM, Ahluwalia JS, et al. Predictors of early versus late smoking abstinence within a 24-month disease management program. Nicotine Tob Res 2011;13:215-20.  Back to cited text no. 22
Bauld L, Ferguson J, McEwen A, Hiscock R. Evaluation of a drop-in rolling-group model of support to stop smoking. Addiction 2012;107:1687-95.  Back to cited text no. 23
Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: One-year outcomes. Addiction 2005;100(Suppl 2):59-69.  Back to cited text no. 24
Fond G, Guillaume S, Artero S, Bernard P, Ninot G, Courtet P, et al. Self-reported major depressive symptoms at baseline impact abstinence prognosis in smoking cessation program. A one-year prospective study. J Affect Disord 2013;149:418-21.  Back to cited text no. 25
Rezk-Hanna M, Sarna L, Petersen AB, Wells M, Nohavova I, Bialous S. Attitudes, barriers and facilitators to smoking cessation among central and eastern European nurses: A focus group study. Eur J Oncol Nurs 2018;35:39-46.  Back to cited text no. 26
Blumenthal DS. Barriers to the provision of smoking cessation services reported by clinicians in underserved communities. J Am Board Fam Med 2007;20:272-9.  Back to cited text no. 27
Heydari G, Talischi F, Mojgani N, Masjedi MR, Algouhmani H, Lando HA, et al. Status and costs of smoking cessation in countries of the Eastern Mediterranean region. East Mediterr Health J 2012;18:1102-6.  Back to cited text no. 28
AlMulla A, Hassan-Yassoub N, Fu D, El-Awa F, Alebshehy R, Ismail M, et al. Smoking cessation services in the Eastern Mediterranean region: Highlights and findings from the WHO Report on the Global Tobacco Epidemic 2019. East Mediterr Health J 2020;26:110-5.  Back to cited text no. 29
Fiore MC, McCarthy DE, Jackson TC, Zehner ME, Jorenby DE, Mielke M, et al. Integrating smoking cessation treatment into primary care: An effectiveness study. Prev Med 2004;38: 412-20.  Back to cited text no. 30
Maziak W, Eissenberg T, Klesges RC, Keil U, Ward KD. Adapting smoking cessation interventions for developing countries: A model for the Middle East. Int J Tuberc Lung Dis 2004;8:403-13.  Back to cited text no. 31
World Health Organization. Regional Office for the Eastern Mediterranean. Integration of tobacco cessation efforts into primary health care in the Eastern Mediterranean Region; 2012. Available form: https://apps.who.int/iris/handle/10665/116812. [Last accessed on 05 May 2021].  Back to cited text no. 32


  [Table 1], [Table 2]


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