Public Health Measures vs Tobacco in Gothenburg, Sweden

Background:

According to a World Health Organization (WHO, 2019), “every year, more than 8 million people die from tobacco use, and more than 1.2 million people die from secondhand tobacco smoke-related diseases, including heart disease, cancer, and other diseases.” (WHO). Furthermore, smoking costs the global economy more than $1 trillion a year. when reflecting on the extent of tobacco use and diverse products and harms including but not limited to (smoking-related illness, lost productivity, passive smoking issues, agricultural, environmental). The extent and consequences of tobacco use (combustion, smokeless) are far-reaching. Inevitably imposing a heavy economic toll on households and governments from the loss of human capital and productivity.

With such an extent in damages, one reflects upon all the efforts towards the anti-tobacco initiatives available in the world today. In 2005, a significant effort against tobacco products harm entered into force with the Framework Convention for Tobacco Control (FCTC). In 2008, in order to expand the fight against the tobacco epidemic, WHO introduced MPOWER, a package of six measures that correspond to one or more of the FCTC provisions (Hoffman et al: 2015). These policies are, (1) Monitoring tobacco use and prevention policies (FCTC article 20); (2) protecting people from tobacco smoke (FCTC article 8), assisting to quit tobacco use (FCTC article14); (4) awareness on the dangers of tobacco (FCTC article 11-12); (5) enforcing bans on tobacco advertising and sponsorship (FCTC article 13); (6) raise taxes on tobacco (FCTC article 6), capitalizing on Harm reduction, and limiting availability through taxation. (MPOWER, 2008), Nonetheless, there are about 1 billion daily smokers around the world still. I intend to put this framework under scrutiny, with a focus on the smoking cessation intervention (WHO, encouraging stopping smoking,2001), and find the reasons behind the resilience to remedy this epidemic. Also it is important to point out the growing use of nicotine products that are not combustible and how is this going to develop a nicotine dependent population.

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II. Aim:

If successful, the research should yield the following:

1. advocate for more assistance and helping methods for nicotine users, and find better ways to remedy this issue.
2. influence people and healthcare professional to evolve their practice in regard to this subject.
3. persuade decision makers to focus more on the point of service intervention and increase their level of awareness and anticipation around the hazards of a nicotine dependent population.
4. improve point of service intervention.

III. Research question:

What is hindering the realization of a comprehensive smoke cessation intervention at the point of service and what are the individual factors affecting the quitting of nicotine products?

IV. Methods:

In my study design I chose the inductive approach to produce the theory along the study process.

Phenomenology approach for a qualitative type of study is used to study certain phenomenon.

Using the grounded theory utilizing the ability to obtain in depth knowledge about the subject besides the systematic data collection and analysis allowing a sufficient read through the research question. However, this method has some issues as time, personal interests resulting in posible bias and also encountered obstacles while performing the interviews.

Participants selection:

The best way to my knowledge is to capture the perception of both informants and experts in this subject. This study will include nicotine users of all socioeconomic status (SES). Also, the languages used will be English and Arabic, due to that the sample is heterogeneous. Additionally, to build rapport I will be keen to familiarize myself with the participants, and be polit, respectful, humble, appreciative, interested and engaged.

1. Respondent interview

The interview will take place at hospitals, mainly treating illness related to smoking this might include the emergency department, primary healthcare, cancer centers. Also, considerations will be at mind to where the participants think they are more comfortable to have the interview.

2. Informant/expert interview

This will include healthcare professionals engaged in examining, treating or referring patients. The same etiquette will be extended. Their main contribution will be in finding out if they ask about nicotine use or only smoking during patient history taking, and the steps taken to help these patients quit in regard to advice, counseling, and management. Finally their perspective about a nicotine dependent population.

How to find the participants:

1. A list of hospitals and primary healthcare units as well as cancer and cardiology centers well be developed. A scheduled visit will be done after approval of the study and acquiring appropriate documentations, as well as coordinating with these establishments representatives to help introduce me to the environment.
2. “Snow-Ball methods”, after reaching out to these leaders in the first step, they might refer to others who might like to participate in this study.
3. Number of participants: This cannot be accurately predefined as it depends on the participants’ cooperation and the quality of the information, therefore concept of saturation will be applied. The study will run until the needed information are received.

V. Data Collection:

Semi-structured individual Interview:

Mainly face to face in-depth interview using semi-structured interview guides

which will take 45-60 minute for each interview. The study chose an in-depth interview process to obtain an understanding of what’s hindering the smoke cessation programs within healthcare, as they are the point of service generating valid medical dialogues with the target population of this study. Also, because the topic itself is very resistant to change with unique individual experience , as well as a fairly high level of relapse with multi factorial causes that might be related to private events, all of which lead me to assume that having a focus group interview would risk the credibility of one’s answers due to the peer pressure or discomfort in sharing private or emotional information with others.

• I will be conducting the study in English and/or Arabic as I speak these languages, therefore there’s no need for a translator for it might affect the study.
• The study will be recorded with permission from the participants, and notes will be taken during the interview.
• After the interview is done, I will thank them for their time and that unfortunately I won’t be able to provide the participants with any type of gift because I am a student.
• Semi-Structured interviews will be more beneficial to probe and divulge information that might be brought up during the interview and could be forfeited if committed strictly to a structured questionnaire interview.

VI. Interview guide questions:

• What are the barriers/challenges they encounter?
• What are the most effective methods to remedy the issue of nicotine dependency?
• how can the point of service intervention become more effective?
• What are the reasons around starting the use of nicotine products?
• What are the reasons around relapse after quitting?

VII. Data analysis:

1. First phase is the data collection(inductive phase); all the interviews will be recorded(audio/video)if the participant consent to that, all data will be organized and recorded according to theme with a time/date stamp then backed up on a cloud storage dedicated for this research, I will also learn how to organize a field note.
2. “Transcription analysis”: then handling the data by transforming the full records into written texts “transcription”. To avoid any bias that might be resulting from the lack of experience or subjective interpretation, I will then ask another expert researcher for example my supervisor(s) and if they refer me to a sociologist, or a specialist in a field related to my study that they recommend, to read the transcription and help deduct the most important notes.
3. “Content analysis” will be performed based on these notes. Categorization (formation of themes and subthemes) of the information will be done depending on the type of the information and its description, “coding” as explained in the participant’s selection part above. And then looking into the data if there’s any intersectionality, links in between these categories.
4. during data interpretation if I suspect any confusion in the interpretation, these will be discussed with my supervisor(s) to reach a consensus.
5. Last, latent level of analysis (deductive phase), at this phase interpreted data will be analyzed in relation to the (WHO encouraging stopping smoking, 2001) recommendations which consist of (Address the topic of smoking - Assess smoking status - Advise the patient to quit smoking and determine willingness - Assist, if the patient indicates s/he is ready to attempt quitting or has already taken action to quit - Arrange follow-up – prevent relapse). Afterward this information will be presented to the expert researcher i.e. research supervisor for further validation of the analysis, to be put into the final paper of the study result.
6. finally after the interpretation phase, these interpretations will be sent back through email or other methods of communications with the participants, including a time frame of 15 -20 days for them to review it and share any concerns.
7. in regard to time frame, this will have to depend on the situation and number of participants.

VIII. Ethical issues:

Before starting the research, approval will be obtained from both Central Ethical Review

Board at University of Gothenburg, and the administration concerned in the hospitals in the study.

Informed consent will be obtained and provided to all the volunteering participants. The informed consent will be clear, brief, and accounts to the privacy and confidentiality required. Furthermore the informed consent will have to cover these elements (title of the study, researcher information and contact information as well as academic affiliation, the purpose of the research, study procedures , risks and benefits, confidentiality, compensation, contact information, voluntary participation, recording of data, sharing of results, length of time, their right to stop whenever they need to , the right to ask me to clarify if they find something in the consent that they don’t understand). Participants are anonyms so there won’t be any identification at the individual level, however it will be made clear in the consent that coding will be made for the categorization according to the criteria described in the participant’s selection part (heterogeneity) above. Additionally, their comments will be given a code to provide anonymity.

Ethical considerations:

number of participants willing to volunteer, participants’ approval on recording the interview, access to the intended interview places or the interviewee’s acceptance to do the interview in the suggested locations, all matters mentioned here will be asked and agreed upon on the consent before conducting the interview.

IX. Quality and trustworthiness of the study: according to Lincoln and Guba, and Malterud.

• Clarity: the clarity of the paper will allow for peer review, which will help the credibility and validity of the paper.
• Credibility: the truthfulness in the findings. This can be achieved through techniques such as (triangulation, prolonged engagement, peer debriefing, negative case analysis, referential adequacy, member-checking)
• Validity:

1. internal validity: how good is the causality
2. external validity: how good are the generalizations and can we generalize from a smaller sample to a larger sample.

• Reflexivity: identifying and declaring any bias and preconceptions and engaging in active listing during the interview and avoiding “the knower’s mirror”.
• Relevance: it is very important to identify the value and relevance of this issue in the scientific field.
• Transferability: which is closely related to external validity and implies the application beyond the study setting.

References

1. Georgia State University, “Regulators should not consider 'lost pleasure' of quitting smoking, 2001”. Retrieved from https://www.sciencedaily.com/releases/2017/11/171128160437.htm
2. Malterud, Qualitative research: standards, challenges, and guidelines
3. WHO, “WHO Report on the Global Tobacco Epidemic, 2019 Country Profile Sweden.” World Health Organisation: 2019, www.who.int/tobacco/surveillance/policy/country_profile/swe.pdf. Retrieved October 16, 2019.
4. WHO, “WHO Enocouraging People To Stop Smoking, 2001”. Retrieved from https://www.who.int/mental_health/evidence/stop_smoking_whomsdmdp01_4.pdf