Improving Smoking Cessation Engagement of Disadvantaged Population

This qualitative study aims to assess the capability of healthcare managers and staff for implementation of smoking cessation program for the disadvantaged population. It will explore perceptions and experiences of healthcare service managers and staff, as well as identify barriers and facilitators for the implementation of smoking cessation program.

Title: Improving smoking cessation engagement of disadvantaged population through
healthcare managers and staff: A qualitative study.
Abstract:
Background:
Reaching disadvantaged people for the implementation of smoking cessation is an important
issue. Healthcare managers and staff can be vital components for the delivery of smoking
cessation programme for the disadvantaged people. However, actual potential of healthcare
managers and staff has not fully exploited. This qualitative study will be carried out to assess
the capability of healthcare managers and staff for implementation of smoking cessation
programme. Moreover, this study will also be helpful in identifying barriers and motivators
for smoking cessation programme.
Aims : 1) to explore perceptions of healthcare service managers and staff for implementation
of smoking cessation, 2) to understand experience of healthcare service managers and staff on
effective implementation of smoking cessation programme and 3) barriers and facilitators
experienced by healthcare service managers and staff for the implementation of smoking
cessation programme.
Methods: In this study, qualitative descriptive study design will be implemented. In this
study, semi-structured interviews and focus group will be carried out. In this study, 35
participants will be recruited. Among these, 5 participants will be managers of healthcare
services and 30 will staff members.
Conclusion : This study will be helpful as the evidence based study for implementation of
smoking cessation programme.
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Table of contents:
1. Introduction and rationale 3
2. Literature review 3
3. Research question, hypotheses and aims 10
3.1 Research question 10
3.2 Aims 10
4. Methods 10
4.1 Methodology 10
4.2 Research design 11
4.3 Participants and sampling strategy 11
4.4 Measures/materials/apparatus 12
4.5 Tool development 13
4.6 Analysis 13
4.7 Procedure 13
4.8 Ethical consideration 14
5. Discussion 14
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1. Introduction and rationale:
Smoking cessation rates are lower among low socioeconomic status people in comparison to
the people in the higher socioeconomic status people. Health behaviour is mainly responsible
for the augmented prevalence of smoking and reduced rate of smoking cessation in
disadvantaged people. Mortality rate is 50 – 60 % more in low socioeconomic class as
compared to high socioeconomic class due to smoking.
In the recent past, it is evident that smoking cessation increased in developed countries like
UK; however, rate of cessation is lower among low socioeconomic status people. Lower rate
of smoking cessation among low socioeconomic class is mainly due to higher uptake and
lower stopping of smoking (Flemming et al., 2016). In UK, decline in the smoking
prevalence is mainly due to the reduced uptake and not due to improved quitting. In people
with low socioeconomic status, smoking quitting is further low. It is necessary to improve the
importance of quitting smoking among people with low socioeconomic status. Disadvantaged
people need to make aware of the current policies, programmes and interventions for quitting
smoking (Wilson et al., 2017). Hence, it is necessary to improve social influence among
disadvantaged people for quitting smoking.
2. Literature review:
Bryant et al. (2011) conducted qualitative study to establish the support of community
welfare organisations for delivering smoking cessation support to disadvantaged groups. This
qualitative study aimed to discover the perception of community welfare organisation
managers, staff and clients about the positive attitude to provide and receive smoking
cessation support, organisational barriers to support and different ways of support suitable for
smoking cessation. Discussion topic for clients were current smoking behaviour, previous
quit efforts, inspiration to quit and; attitude and choices for various cessation strategies.
Discussion topic for managers and staff include policies to quit smoking, methods of smoking
cessation and preferences for implementation of cessation strategies. Thematic analysis was
implemented for the analysis of the collected data.
Managers and staff attitudes towards smoking: Managers and staff members of mentioned
about their support for the smoking cessation in clients. Managers and staff members stated
that they understood the importance of smoking cessation in clients and it can affect well-
being of the client. Managers and staff members were willing to provide support to the staff
members by providing advice and support for quitting smoking.
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Current provision for smoking cessation: Most of the services did not support clients for
quitting smoking. It is mainly due to certain barriers. Barriers for the smoking cessation were
similar across all the services. These barriers include lack of priority for smoking cessation
and lack of training and time for providing services for quitting smoking. Staff and managers
reported that education and training about health and financial aspects of the smoking are
helpful in addressing this issue.
Manager and staff acceptability of providing quit support: Managers and staff members
mentioned that community service organisation is the suitable setting for providing smoking
cessation service to the clients. Moreover, it was also evident that external specialised
services would be helpful in improving smoking cessation services.
Client acceptability of receiving cessation support from the CSO: Clients demonstrated
positive inclination towards the smoking cessation by expecting support from the staff of
community service organisation.
Types of cessation support considered appropriate to offer clients in the CSO setting: Clients
also reported that they received support from the staff related to accommodation, life skill
training and counselling. However, in this study demographic data of the participants was not
mentioned. Hence, it would be difficult to assess whether collected data was from the
disadvantaged population or mixed population. In this study, different constraints like time
constraint, deficiency of resources and deficiency of client motivation were mentioned.
However, strategies to fulfil these constraints were not mentioned. Reporting of these
strategies would have been helpful in planning more effective future studies.
Leppanen et al., (2019) conducted a qualitative study for tobacco cessation based on the
supposed barriers and facilitators among the service providers. In this study, exploratory
qualitative study design was implemented based on the semi-structured interviews.
Participants of this study were primary health care (PHC) providers with knowledge and
practical training in the tobacco cessation programme (TCP). Data collection and analysis
was based on the Consolidated Framework for Implementation Research (CFIR). These
domains include intervention characteristics, outer setting, inner setting, characteristics of
individuals involved and process of implementation. Data from the participants were
collected through semi-structured interviews. Questions in the interviews were guided by
Interview Guide Tool.
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Most of the participants reported that their patients responded positively for TCP through
either complete quitting or drastically reducing the tobacco use. Participants reported that
counselling proved effective as compared to the pamphlets or oral advice for the
implementation of the TCP. Few of the participants reported that TCP alone is not adequate
for tobacco cessation; however, information campaign is necessary for tobacco cessation.
Authors reported that motivational interviewing as a part of counselling proved beneficial in
the effective implementation of the TCP. Moreover, authors reported that advertisement in
the waiting room and provision of guidelines for use of TCP proved facilitators for TCP. TCP
can be implemented effectively; if the patients have long-term viewpoint, positive inclination
towards TCP, self-efficacy and social support. However, strategies to improve self-efficacy
were not reported. Moreover, specific social support needs to be mentioned. Social support
can be extended through diverse sources; hence, specific social support needs to be
implemented for effective implementation of TCP. Participants reported that TCP should be
patient centred approach which should be implemented for the specific target population.
Moreover, participants accepted that volunteer involvement of participants is necessary for
the successful implementation of TCP. Participants reported that TCP was implemented with
positive approach; however, access of TCP by the socioeconomically disadvantaged group is
limited due to current approaches for the implementation of TCP. Organisational support, the
availability of abundant resources and positive attitude of the service providers are necessary
aspects for successful implementation of TCP among socioeconomically disadvantaged
people.
Research gap observed in this paper were implementation of information campaign for
tobacco cessation. It is not clear whether counselling need to be provided individually or in a
group.
Bonevski et al., (2011) conducted a qualitative focus groups and in-depth interviews study to
explore financial aspects responsible for the smoking cessation among clients and their carers
of disadvantaged welfare agency. In this study different strategies for quitting smoking were
assessed. These strategies included individual quit smoking counselling, non-financial
incentives to quit smoking, suggestion of alternative therapy like acupuncture, suggestion of
alternative therapy like hypnosis, provision of Government sponsored financial incentives
and offering of free or subsidised NRT.
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Financial aspects in smoking cessation: It has been demonstrated that there is a strong
correlation between the insufficient financial resources and the consideration of money spent
on the smoking. It has been considered as the prominent stimulus for quitting smoking. This
can be considered as the important aspect in the socio-economically disadvantaged people
because these people are usually deficient with adequate financial resources. Nicotine
replacement therapy (NRT) is one of the prominent strategies for quitting smoking. However,
socio-economically disadvantaged people can not avail NRT. Hence, it is the significant
barrier for smoking cessation in disadvantaged group. It is necessary to develop cost-effective
NRT for the disadvantaged people. Smokers reported that cost of smoking and NRT is almost
similar; hence, they wish to continue with the smoking instead of NRT. However, few of the
participants reported that they are willing to take NRT; if it is provided with subsidised rates.
Provision of financial incentives to the smokers proved be the prominent theme for the
smoking cessation. Financial incentive proved to be most effective factor for quitting
smoking because financial incentives were provided after the confirmation of smoking
quitting. Financial incentives were provided after the gap of quitting smoking and
confirmation was made through testing saliva and breath. Staff and managers of the
disadvantaged welfare organisation reported similar perception as that of clients. Staff and
managers reported that smoke quitting aids are equally costlier as that of smoking cost.
Hence, these proved to be significant barriers for quitting smoking. However, staff and
managers had opinion that though quit aids are expensive these can be less harmful and less
painful as compared to the smoking. In terms of financial rewards; staff members and
managers gave mixed responses. Few of the staff members agreed upon financial rewards;
however, remaining staff members looked for the non-financial rewards for quitting smoking.
Since, discrepancy observed among clients and staff members for financial incentives;
consensus, need to be made among them for effective implementation of quitting smoking
programme. It is necessary to understand the forces behind the financial incentives for
quitting smoking which would be helpful in resolving discrepancy among staff members and
clients. Effective implementation of smoking cessation programme not only depends on
acceptability of clients but also depends on the service providers. Authors reported that
unbiased sampling of the participants is necessary for robust outcome of the study.
Participants should not be recruited based on their interest to quit smoking; however,
participants not interested in quitting smoking should also recruited.
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Brunette et al. (2015) developed and implemented an easy-to-use, web-based and
motivational decision support system which is called as ‘Let’s Talk About Smoking’. This
web-based decision support system was implemented to assess whether this system would be
helpful in improving engagement of disadvantaged people in smoking cessation as primary
treatment in the primary care clinic. Web based decision support system was designed based
on the evidence based smoking cessation treatment. In this study, outcomes of the 38
participants were reported. Smoking cessation characteristics of the participants were
assessed at the baseline and after 2-months exposure of the participants to the web-based
decision support system.
Participants knowledge about quit smoking: All the participants recruited in this study were
well versed the with knowledge about the ill effects of smoking. They mentioned that
smoking produces lung disease, heart disease, cancer and wrinkles. This is very important
information collected in relation to smoking because awareness of smoking illness among the
smokers can be helpful in possibility quicker adaptation of smoking cessation treatment.
However, most of the participants were lacking knowledge about the smoking cessation
medication.
Satisfaction of the participants with the service: Participants expressed satisfaction with the
decision-support system. Satisfaction of the participants in the intervention is important
aspect in the provision of intervention because it would be helpful in improving adherence of
participants in intervention. Participants mentioned that provided information was good or
excellent. 100 percent participants agreed to recommend web-based decision support to their
friends. Approximately 35 % participants reported that they used smoking cessation treatment
after completion of intervention.
Motivation for quitting smoking: Web based motivational decision support system helped in
motivating the participants to use different smoking cessation treatment like NRT,
counselling and evidence-based cessation treatment. It indicates that this decision support
system would be helpful in multidimensional use of smoking cessation treatment. Rate of use
of smoking cessation treatment were higher in nonpregnant smokers as compared to the
pregnant smokers. Certain characteristics like age, gender, Fagerstrom Nicotine Dependence
Score, number of cigarettes smoked per day, level of reading comprehension, amount of
mental health distress (CSI Score) and level of social support (MSPSS score) did not
predicted use of smoking cessation treatment. However, efforts were not made to identify
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reasons behind this unpredictability. Future studies need to be planned to establish correlation
between these characteristics and smoking cessation treatment. Few of the participants
continued smoking after exposure to web based decision support system; however, in these
participants number of cigarettes significantly reduced. Similar findings were observed in
previous studies conducted with kiosk computer website decision-support system.
Technology in providing smoking cessation service : It indicates web-based systems are
useful in increasing involvement in smoking cessation treatment. It has been established that
websites are the potential and cost-effective strategy for improving engagement of
disadvantaged people in smoking cessation. However, small sample size was enrolled in this
study; hence, it would be difficult generalize these findings. Henceforth, similar studies need
to be conducted in the larger clinical trials with enrolment of heterogenous population.
Roddy et al., (2006) conducted qualitative study in 39 smokers to identify barriers and
motivators to gain access to smoking cessation services. In this study, different barriers were
identified to access smoking cessation intervention. These barriers include fear of being
judged, failure fear, inadequate information of available smoking cessation services and
perception of costlier intervention like Nicotine Replacement Therapy and negative publicity
of bupropion. Participants put forwarded their motivators to access smoking cessation
services. These motivators include favouritism for personalised intervention, combination of
cost effective, available and effective pharmacological therapies with the counselling, flexible
schedules for the intervention services and availability of subsidised complementary services.
Fear of being judged: Most of the participants feared that getting access to smoking cessation
would expose their smoking addiction. Hence, they would be judged as bad.
Fear of failure: Participants expressed that they are not willing to adhere to smoking cessation
because of fear of failure. Participants were stressed and they were with mental obsession of
smoking. Moreover, their willpower was not strong. All these characteristics made them
perceive that they might experience failure in smoking cessation interventions.
Inadequate information of available smoking cessation services: Participants expressed that
they are not aware of the smoking cessation services. It might be due to unavailability of
attractive smoking cessation services. It was evaluated using the visual prompts like pictures,
flip chart and leaflets. These participants were more aware of smoking in comparison to the
smoking cessation services.
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Perception of costlier intervention like Nicotine Replacement Therapy: Participants had
perception that NRT is costlier and it would put financial burden on them.
Negative publicity of bupropion: Participants had perception that bupropion which proved
useful in quitting smoking is associated with adverse effects.
Personalised intervention: Participants stated that personalised approach of smoking cessation
gives them more access to smoking cessation. Moreover, participants became more
responsive due to personalised intervention.
Combination therapy: Combination therapy comprising of counselling and cost-effective
therapy made more deprived participants to access to smoking cessation therapy.
Flexible schedules: Flexible timings of the smoking cessation intervention helped participants
to attend the smoking cessation services on the regular basis.
Henderson et al., (2011) conducted a qualitative study to evaluate the factors responsible for
the smoking cessation among the deprived community people. Focus group research
methodology was implemented and thematic analysis was used. Following were the
motivating factors identified for smoking cessation in deprived communities: counsellors,
flexibility in accessing smoking cessation, attitude, behaviour and knowledge of counsellors,
person centred smoking cessation support and supplementary support between two smoking
cessation session, health reasons, support from family, relative and friends and location for
providing smoking cessation session. There were different themes identified in this study.
These themes include characteristics of smoking cessation service, reasons for giving up
smoking and the importance of support from family, relatives and friends for smoking
cessation.
Characteristics of smoking cessation service: In this study, characteristics which could be
most useful for smoking cessation were identified. These characteristics include
approachability to counsellor, attitude, behaviour and knowledge of counsellor, convenience
of appointment to the counsellor and person-centred smoking cessation support and
supplementary support between two smoking cessation session. Availability of local smoking
cessation services proved to be most useful for the participants and participants mentioned
that General Practitioners referred them to these local services. Most of the participants
reported that they accessed these services due to its local location. On the contrary, few of the
participants mentioned that they were not accessing services because they didn’t like its
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location. Moreover, participants mentioned that publicity of service location through
advertising would be helpful in improving their accessibility for the smoking cessation
services. Participants expressed that characteristics of the counsellors like humbleness, un-
biased approach and down-to-earth nature helped them to adhere to the smoking cessation.
Participants were satisfied with the counsellors because they were knowledgeable and they
were well aware of the smoking cessation process. Un-biased approach of counsellors in
integration with knowledge about smoking cessation proved to be more effective in smoking
cessation. Participants mentioned that flexibility in physically preference services and
additional support the phone helped to improve their adherence to smoking cessation
services. Participants preferred one-to-one support rather than group support.
Reasons for giving up smoking: Prominent reason like health issues is one of the most
important factors for accessing smoking cessation in the participants because participants
were concerned about the ill health effects of smoking. Participants were aware of the ill-
effects like breathing problem and heart diseases due to smoking. Few of the participants
reported that they were availing smoking cessation services for the family members. Few of
the participants gave preference to the family values over financial reasons for accessing
smoking cessation services; though, these participants were financially disadvantaged.
Importance of support from family and friends: Participants reported that support from the
family members in addition to the counsellors helped them to access to smoking cessation
services. Moreover, it was evident that quitting smoking for the participants was difficult for
the participants without support form the family members.
3. Research question, hypotheses and aims:
3.1 Research question:
What actions need to be taken to improve engagement of disadvantaged population of
Birmingham, United Kingdom in smoking cessation
3.2 Aims:
Aim of this study is 1) to explore perceptions of healthcare service managers and staff for
implementation of smoking cessation, 2) to understand experience of healthcare service
managers and staff on effective implementation of smoking cessation programme and 3)
barriers and facilitators experienced by healthcare service managers and staff for the
implementation of smoking cessation programme.
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4. Methods:
4.1 Methodology:
In this study, qualitative study will be implemented. Qualitative research is suitable for this
study because qualitative research is useful for exploratory research. Qualitative research is
useful in understanding perceptions, opinions and motivations (Andrew, 2016). In the current
study also, perceptions, opinions and motivations of the healthcare professionals about the
smoking cessation will be explored. Quantitative research methodology can also be used by
generating quantitative data. Since, this is an exploratory study; generation of qualitative is
necessary. Hence, qualitative study will be used instead of quantitative study in this smoking
cessation research in disadvantaged people (Andrew, 2016).
4.2 Research design:
In the current qualitative research, descriptive design will be implemented. Main purpose of
the descriptive research to describe, explain and validate the outcome (Wolgemuth, 2016). In
the current study, perceptions, knowledge and experience of the healthcare professionals
related to the smoking cessation among the disadvantaged people will be described,
explained and validated. Descriptive qualitative research design will be carried out through
interviews and focus group. Semi-structured interviews will be conducted to gather the data.
Semi-structured interviews are most appropriate methods for this research because these
types of interviews provide flexibility to the participants while providing information.
Interview questions in this study will be prepared through the literature and through
involvement of experts in the field. Moreover, questions will also be designed based on the
previous studies conducted in the hospital and in accordance with the requirements of the
current study. In semi-structured interviews, interviewer will get opportunity ask follow-up
questions to get more insight in the subject (Wolgemuth, 2016).
4.3 Participants and sampling strategy:
Purposive maximum sampling approach will be implemented for the recruitment of the
participants. This approach is appropriate for this study because wide range of healthcare
professionals and staff can be recruited. Purposive sampling method is judgemental and
selective method and it is a non-probability method because recruitment of participant is
based on the judgement of researcher. Moreover, this sampling method is appropriate for this
research because participants will be recruited based on the specific characteristics of the
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participants (Punch, 2013). Specific characteristics of these participants will be healthcare
professionals with knowledge and experience in smoking cessation.
Following will be the inclusion criteria for the participants: 1) healthcare service managers
and staff with minimum bachelor educational qualification, 2) healthcare service managers
and staff with minimum one-year experience in smoking cessation programme, 3) healthcare
service managers and staff with knowledge of different therapies for smoking cessation (Haas
et al., 2015; Fu et al., 2016).
In this study, 35 participants will be recruited. Among these, 5 participants will be managers
of healthcare services and 30 will staff members. Top-to-down approach will be implemented
for the recruitment of the participants. Senior managers will be informed about the study
design and these senior managers will inform and motivate other staff members for the
participation in the study. All the participants will be provided with the consent and written
brochure will be provided to all the participants with information comprising of details of the
study (Fu et al., 2014).
4.4 Measures/materials/apparatus:
For this study main themes will be perception, opinion and experience about smoking
cessation, service policies about smoking cessation, facilitators and barriers for smoking
cessation. These themes will be based on five themes.
These five themes include:
1) Knowledge of healthcare service managers and staff about the smoking cessation:
Questions in these themes will be appropriate for the disadvantaged population. Participants
responses for questions in this theme be will collected on five-point Likert scale (1 - Strongly
disagree, 2 – Disagree, 3 - Neither agree nor disagree, 4 - Agree and 5 -Strongly agree).
Likert scale is widely used psychometric scale which is useful in the research study with
interview based questions. Likert scale is useful tool for assessing the agreement or
disagreement of participants related to specific question which is useful understanding
opinion or feeling of specific subject (Forman et al., 2017; Peletidi, Nabhani-Gebara, and
Kayyali, 2016).
2) Role of healthcare service manager and staff in smoking cessation: Questions in this
section will also be evaluated based on 5-point Likert scale. Questions in this theme will be
dependent on the roles and responsibilities of managers and staff members for the
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implementation of smoking cessation in the disadvantaged population. Questions in this
theme will also address issues related to care delivery and psychological support with
reference to the outlined plans (Forman et al., 2017; Szatkowski and Aveyard, 2016).
3) Education and training: In this theme, questions related to education and training of
participants about smoking cessation will be addressed. Questions in this section will be
useful in understanding type of education and training related to smoking cessation received
by the managers and staff members. Questions in this section will also be helpful in
understanding whether managers and staff members received appropriate training and
education (Forman et al., 2017; Peletidi, Nabhani-Gebara, and Kayyali, 2016).
4) Prior involvement in the smoking cessation programme: Questions in this theme will also
be helpful in the gathering the information related to prior experience of participants in
smoking cessation programme (Forman et al., 2017; Szatkowski and Aveyard, 2016).
5) In this section, demographic data of the participants will be collected.
4.5 Tool development:
Several steps will be followed for the development of tool to determine the different themes
of interview questions. These steps include application of theoretical basis for developing
themes, designing individual themes, conducting item analysis to eliminate irrelevant items,
assessing the reliability of tool through internal consistency, stability and equivalence and
determining the construct validity of the tool (Berg and Lune, 2013; Collins and Stockton,
2018). Specific questions will be constructed according to the specificity of the scale.
4.6 Analysis:
During analysis, audiotaped data will be transcribed verbatim and transcripts will be
analysed. Data will be coded during analysis which would be helpful in eliminating bias.
Coding will be performed by the researcher who is not part of the study. Data will be
analysed through thematic analysis. Thematic analysis will be most appropriate method for
this qualitative research because it is dependent on the theoretical assumptions and research
questions. In the current study, interview questions will be designed on the literature based on
theoretical assumptions. Thematic analysis will be performed in different steps like becoming
familiar to the data through transcription, generating the initial codes through coding the
collected data, searching for themes which answers the research question, reviewing the
themes to refine overlapped themes, defining and naming the themes to analyse the data with
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each theme and producing the report (Chapman, Hadfield and Chapman, 2015; Vaismoradi,
Turunen, and Bondas, 2013).
4.7 Procedure:
Focus group: Focus group will be conducted with the participants who have contact with
clients at least weekly once. All the eligible staff members for focus group will be invited for
focus group. Invitation for focus group will be sent to all the eligible participants through the
managers. Focus group will be conducted in a private room by the two researchers. In focus
group, participants will discuss about the issues and requirements for implementation of
smoking cessation. Focus group is a discussion among small and diverse people. These
people carry out open discussion about specific issues which would be helpful in determining
perceptions and opinions of the larger group. It is a type of qualitative interview process
during which researcher take notes or records about the perceptions and opinions of each
member of focus group (Rezk-Hanna et al., 2018). In this smoking cessation study, focus
group will be more appropriate because sharing of ideas, perceptions and opinions of
different people will occur.
Interviews: Interviews will be carried out for the managers. Semi-structured interviews will
be carried for the managers. Interviews will be carried out by the single experienced
interviewer. Researcher who is not known to the participants will be recruited for conducting
interviews. It will be helpful in eliminating problem of biasness. Known interviewer might be
biased towards participants because most of the data in this study will be subjective data
(Biener and Hargraves, 2015). Interviews will be carried out approximately for 45 to 60
minutes and entire interview process will be audio recorded for the future use. All the
participants will be informed about the audio recording.
4.8 Ethical consideration:
Ethical consideration in qualitative research is important aspect to maintain integrity,
reliability and validity of the research. Study protocol will be approved by the institutional
research ethical committee. Ethical approval will be helpful in ensuring all ethical practices
are being utilised. Study will be conducted according to the codes and policies of the
Institutional Review Board (IRB). Participants will be given an opportunity for voluntary
participation and informed consent will be taken from the participants. Ethical standards will
also be maintained through confidentiality and anonymity of the participants.
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5. Discussion:
Themes which will be addressed in this study will be based on the existing literature.
Application of evidence-based themes for conducting studies would helpful in obtaining
more robust and valid outcome. Moreover, it would also be helpful in designing widely
acceptable protocol.
Limitation of the study include recruitment of the participants from organisation in one
region. Recruitment of participants from the organisations of different regions and
participants with diverse characteristics would be in helpful wider applicability and
generalizability of the outcome of this study. In this study, all the themes will be studied on
the same platform. Distinction of different themes like pro-smoking and anti-smoking would
have been useful in obtaining more specific insight of the different themes used for the
smoking cessation. In this study, interviewer would be non-disadvantaged. Non-
disadvantaged interviewer would be helpful in reducing biasness during data collection.
However, it could negatively impact data collection process due to educational, social and
cultural differences. In this study, interviewer or researcher will not directly communicate
with clients; however, mangers and staff members would communicate with the clients. This
could be considered as strength of this study because clients might not be comfortable or
unwilling to express their personal views on sensitive issue like smoking. Best practice
guidelines will be implemented in this study to improve the trustworthiness of this study. In
this study, interviewers will be involved in the designing smoking cessation plan; it would
lead to social desirability bias in the study. Methodological strength of this study would be
application of comprehensive and validated tool for the data collection. The many constructs
in the data collection tool would be helpful in collecting comprehensive data. Application of
validated tool would be helpful in improved transferability of the data. Major limitation of
this tool would be non-consideration of interactions among different constructs. Tool
development for the collection and analysis of the data would be dependent on the available
literature and prior experience in the similar setting. It would be difficult to construct similar
tool based on the literature because themes in the tool need to be relevant to specific
population in the study. Most of the which would be gathered through the tool which would
be subjective data. Demographic data mostly affect the subjective data. Hence, demographic
information of the participants should be considered while considering toll for the data
collection. Experienced researcher in the relevant filed should be involved in establishing the
themes and validating the research tool. It would be helpful in minimising the constraints of
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applicability of the research tool. Hence, data collected from the research tool can be
generalised to other population. In conclusion, this study would be helpful in improving
strategies which need to be implemented for the smoking cessation intervention. Health
inequality as a result of smoking would be minimised by providing specific intervention to
the disadvantaged people. This study would be helpful as the evidence-based study for
implementation of smoking cessation programme.
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