Factors affecting smoking initiation and cessation among adult smokers in Fiji: A qualitative study

INTRODUCTION Smoking as a public health challenge is globally considered the main risk factor of many non-communicable diseases (NCDs). Knowing factors contributing to smoking commencement and cessation is the necessary step to develop prevention strategies to combat this issue. To date, no study has been conducted in Fiji, therefore this study aimed to explore the reasons adult smokers initiate smoking and cessation in Fiji. METHODS A qualitative study was conducted among 35 current smokers who were interviewed between 1 May and 31 July 2020 in Suva, Fiji. Three health centers were chosen randomly to collect data and purposive sampling was applied to reach study participants. A semi-structured, open-ended questionnaire was used to guide the interviews. The content of in-depth interviews was transcribed and data were analyzed using content and thematic analysis. RESULTS The results of this study showed that most of the participants were male (57%), I-taukei (77%), single (54%), had attained tertiary education level (69%), were of Christian religion (77%), and unemployed (63%). Two main themes were identified including: ‘factors affecting smoking initiation’ and ‘factors affecting smoking cessation’. ‘Peer pressure’, ‘smoking myth’, ‘smoking as a fun’, ‘unpleasant event in life’ and ‘smoking establishes friendships’ were factors affecting initiation of smoking; while ‘knowledge on smoking harms’, ‘financial constraints’, ‘desire to improve health’, ‘constant request from family members’, ‘desire to save time’, ‘religious factors’ and ‘cultural factors’, were factors affecting smoking cessation among smokers. CONCLUSIONS This study highlights the main factors affecting smoking among adult smokers in Fiji. Considering these factors in future health planning will help policy makers and decision makers to develop tailored interventions to combat this health issue.


INTRODUCTION
of smoking was higher among younger adults aged 25-34 years. It was also more prevalent in the iTaukei Fijian community, as 23% of iTaukei women were smokers compared to 2.1% in Indo-Fijian women 6 .
Henceforth, improving smoking cessation programs is important and understanding the perspectives of smokers on factors affecting initiation and smoking cessation is also important as it can help form the planning of smoking cessation programs to meet the needs of smokers when they intend to quit 7 . Some of the common perspectives that are often associated with a smoker initiating smoking include: smoking as a coping mechanism for social problems they face; being curious of what it is like to smoke; and smoking being a social norm and widely practiced 7,8 . Further, having a strong influence from smoking friends; thinking that smoking makes the mind more relaxed; smoking makes the person appear as more grown up and independent from parents; and smoking helps people to forget their problems [9][10][11] . On the other hand, some of the perceptions that are commonly known in the literature about factors that encourage smoking cessation include: bans on indoor smoking; restricting advertising and selling of tobacco; support of family and friends; and spiritual support [12][13][14] . To date, there has not been a study conducted in Fiji on factors contributing to smoking initiation and cessation, therefore this study aimed to explore the reasons for adults becoming smokers and the factors affecting smoking initiation and cessation in Suva, Fiji.

Study design and setting
This study applied a qualitative design to explore factors affecting smoking amongst current adult smokers who attended three public health centers in Suva, Fiji, between 1 May and 31 July 2020. Nuffield, Samabula, and Valelevu were chosen randomly among seven health centers. In this study, public clinics were chosen as smokers were accessible for a long time and facilities to conduct interview were also available.

Population and sample
All smokers attending the three selected health centers were considered as the study population. Patients or family members accompanying the patient who were smokers during the study period or had smoked at least 10 cigarettes per day and had high nicotine addiction, measured by the Fagerström test, both males and females, and self-identified as Fijian, were included in the study. Those who were nonsmokers were excluded and smokers who had mental instability or were not willing to participate in the study, were excluded. A purposive sampling was used to choose participants and data saturation was reached after interviewing 35 participants.

Data collection tools
A semi-structured, open-ended questionnaire was used to guide the interviews. The questionnaire was developed based on the literature and research questions. The questionnaire had two sections including demographic questions and 7 open-ended questions to understand the factors affecting smoking initiation and cessation.

Study procedures
All potential participants were informed about the aim and procedure of the study one week before starting the interviews through flyers and announcements provided by the health centers. Those who met the study criteria were asked to read an information sheet and sign a consent form. A trained research assistant conducted all the interviews after scheduling face-toface interviews that were feasible for both interviewer and interviewee, in a privacy room in each heath center. Each interview took 30-40 minutes and was recorded.

Data management and analysis
All interviews were transcribed by the research assistant and triangulation was checked by the other researchers. Thematic analysis was used to analyze the data. To do that, each transcript was read and re-read, by the research assistant and the main researcher, to find the sentences which were most frequently repeated in each interview. Using a codebook, codes were identified and similar codes were merged to determine subthemes; similar subthemes were combined to identify common themes 15 . If the identified codes were not similar there was a discussion between two coders to resolve the difference.

Study rigor
In a qualitative study, it is important to ensure rigorousness and trustworthiness. In this study, trustworthiness was based on four criteria: credibility, dependability, confirmability and transferability 16,17 . For the credibility, all participants were informed about the aim and study procedure before involving them in the study, both verbally and using an information sheet. All participants were asked to sign a consent form. Interviews were conducted at a time and place that were suitable for both interviewer and interviewees. Essential information was provided to the research assistant in terms of conducting the interview and data collection. The interview tool was pilot tested before implementing it in the interview. All the interviews were recorded by a digital recorder and transcription performed on the same day of the interview. For dependability, transcriptions were read and re-read to correct all potential errors. Two independent coders read all the transcripts and identified codes separately and discussed the differences. For the confirmability, all the researchers discussed the identified codes, themes and subthemes, and confirmed them. Transferability was done using purposive sampling and by continuing interviews until data saturation was reached.
Permission to conduct interviews was obtained from the medical officers in charge of the selected health centers. All participants were informed about the aim and objectives of the study, the potential benefits, or harms and their right to participate in the study using an information sheet. Those who met the study criteria were asked to sign the consent form. Information sheet and consent form were provided in Fijian, Fiji Hindi and in English, to give freedom to participants to choose the version they were comfortable with. They were informed that participating in the study is completely voluntary and they could stop participation at any stage. Participants were kept anonymous and all information was confidential. After completing interviews, for the participants who had smokingrelated health issues, advice was provided and they were asked to visit a doctor. Table 1 gives information on the sociodemographic characteristics of the 35 study participants. Most participants were aged 18-24 years (49%), male (57%), iTaukei (77%), single (54%), had attained tertiary education level (69%), of Christian religion (77%), and were unemployed (63%).

RESULTS
Two themes were identified after analyzing the data. They include 'factors affecting smoking initiation' and 'factors affecting smoking cessation'. Each theme includes different subthemes that are presented in Table 2. To protect participants' confidentiality, participants are presented as P1, P2, etc.

Subtheme 4: Unpleasant event in life
The majority of the participants stated that the reason for their smoking was they had a tragic experience at some point in their life and that smoking is an activity that helps them cope with the tragic moment: 'Started when I lost a family member, very close '

… I think the main reason behind it was because of my peers and I think that if I don't smoke, I'm not part of that circle of friends. So this was back in school and when we did it, it was done without people knowing and when I said people these include my teachers, my mentors in school and of course my parents back at home.' (P34; 24 years, Male)
A participant even mentioned that he regarded the person who shares a cigarette with him to be his true friend: 'You know for me friendship is something that I cherish and so when someone smokes with me ... oh … He or she will be my really good friends.' (P34; 24 years, Male) Some participants mentioned that they usually share a cigarette with others during smoking and they call these practices as 'peace-pipe': 'Aahh … I just stop smoking for 3 months and start again because of peer pressure, mainly when I drink grog with my friends. Aahh and they ask me to join in peace-pipe.' (P10; 28 years, Female) Another participant stated: 'umm … because when I drink grog that is why I wanted to start again. Also, roaming around with my friends while they are smoking, I can smell it and so I wanted to start again.' (P20; 25 years, Female)

Theme 2: Factors affecting smoking cessation
This theme has seven subthemes including: 'knowledge on smoking harms', 'financial constraints', 'desire to improve health', 'constant request from family members', 'desire to save time', 'religious factors' and 'cultural factors'. They also believed that quitting smoking will help them to gain weight and improve their physical appearance: 'Yes! I think it will help us to gain some weight as I will eat well, and our physical appearance will improve too.' (P18; 18 years, Male)

Subtheme 4: Constant request from family members
Most of the participants had also mentioned that they believed that the constant request from parents and other family members can help motivate them to quit smoking.
'... but I am trying my best because … I have been inspired by the people like my mum … my grandma who has never smoked completely… so I told them how do they do it … they leave it slowly … they cannot just leave it all of the sudden … I will just leave it all of a sudden …' (P7; 25 years, Male) Subtheme 5: Desire to save time Some participants mentioned that quitting smoking helps them to minimize time wasted on unnecessary activities such as smoking: '… and yes, because I can focus more on my schoolwork because usually when we go out smoking, we spend one, two hours, not just smoking but chit chat stuff. So yes it saves time.' (P25; 20 years, Female)

Subtheme 6: Religious factors
Most of the participants mentioned that religion is a facilitating factor that helps smokers to pursue smoking cessation: '… ahhhhh maybe just go to church and umm because ahhh going to church is that relationship with God is ummm clean so yes I think going to church would help me a lot (help quit smoking).' (P5; 21 years, Male) They believe this can happen, especially during the observance of some special religious occasions: 'Yes, I adhere to it since its being implemented by the church, if not, something bad might happened to me. The church has really helped me a lot, not only during the taboo, but also by sharing the scriptures in the bible, really help me that time to quit smoking.' (P17; 32 years, Male)

Subtheme 7: Cultural factors
Some of the participants mentioned that smoking cessation was considered as a group agreement for a period of time, so that it is a kind of respect to law or unwritten rule:

DISCUSSION
Smoking is a major issue globally, considered the main reason behind the prevalence of premature deaths. Countries worldwide are working hard to get evidence to help with evidence-based interventions to successfully combat it. The evidence from this qualitative study gives a picture of the factors affecting smoking initiation and smoking cessation among adult smokers in Suva, Fiji. The findings are similar to studies in other parts of world.
The findings support the claims of other studies that some of the factors affecting smoking initiation include peer pressure, misperception that smoking relieves stress (smoking myth) and that smoking is perceived as fun and is a pleasurable activity [18][19][20] . It is also worthwhile to note from this study that some respondents genuinely believe from their experience that smoking relieves stress and tension. Furthermore, our findings show that some people begin smoking as a way of coping with their loss or sadness, a way of establishing friendships with others and that smoking goes well with drinking kava and alcohol. This is similar to the findings from studies in other countries, which noted that smoking is associated with alcohol and drug consumption [21][22][23][24][25][26] . These findings could also be the main reason why Tomlinson 27,28 , mentioned that smoking is deeply integrated into the lifestyle of the vast majority of the Fijian people who like to socialize, when kava consumption is often widely practiced. This is vital information that could help inform health providers on the best approach and mechanisms of proactively addressing the prevalence of smoking in Fiji.
In terms of smoking cessation, this study also found some factors that affect smoking cessation including: requests from family members and friends and support to quit smoking 29 ; health issues 30 ; religious factors 31 ; financial constraints 32 ; health and fitness; and increased social awareness 33,34 . Nevertheless, it is noted that role of culture, such as the observance of a taboo during cultural events and occasions such as funerals, is a unique factor that helps facilitate the process of smoking cessation among smokers. Religious factors, such as the observance of the Lent season among Christians and EID among Muslims, have also been found in this study as an important reason for smokers to quit smoking. On the other hand, similar to other studies, it is noted that some of the barriers to smoking cessation found in this study include: strong influence from smoking friends and families 35 ; nicotine addiction [36][37][38] ; accessibility of cigarettes 39 ; misunderstanding that quitting smoking can damage health; lack of support from social networks such as family and friends 39,40 ; misperception and/or misunderstanding that accepting cigarettes from a friend is a token of friendship 41,42 ; and the lack of willpower to refuse a cigarette when being offered by a smoking friend 39 .
The findings of this study provide valuable guidelines to public health professionals. They should adopt their training based on individual characteristics of smokers by considering the differences in socioeconomic status as well as cultural background. For Fiji, as people have different ethnicities, culture, and languages, it is important to apply community based smoking cessation programs based on the real needs of smokers 43 . Schools should be actively involved in anti-smoking campaigns, to prevent smoking at an early age. Developing antismoking policies and taxation should be considered as a priority at the governmental level.

Limitations
Although, this is the first qualitative study about smoking in Fiji, this study was conducted only among adult smokers. Conducting a study among all age groups may give more valuable information regarding the factors affecting smoking in Fiji among different age groups. Conducting interviews among healthcare workers could also provide valuable information about other challenges related to smoking among adults.

CONCLUSIONS
The results of this study highlight some important factors that affect initiation of smoking and smoking cessation among adult smokers in Fiji. These factors are categorized as individual, social, cultural and financial determinants that form a framework to combat smoking. They should be considered within the context of a culturally diverse society in Fiji. Policy makers and decision makers should consider social norms, along with cultural and religious factors in future smoking cessation programs. The factors identified in this study can be used in developing tailored interventions that affect smoking cessation. Using different health promotion theories and models such as the Behavioral Intention Model (BIM) or Health Belief Model (HBM), can increase the effectiveness of smoking cessation programs at the individual level.