A mixed method study design was carried out to assess smokers self-efficacy, as well as their perception on factors affecting their confidence and smoking cessation in Suva, Fiji between 1^st May to 31^st July 2020. Three randomly selected healthcare centers, among seven available healthcare centers in Suva, were chosen based on geographical distribution to conduct this study including: Nuffield, Samabula, and Valelevu health centers.

We included current smokers who were over 18 years and were attended one of the three selected healthcare centers during the study period. Those who had mental instability to answer questions or were not willing to participate in the study were excluded.

For the quantitative study, the sample size was calculated based on the sample population proportion formula for one month that applied a 50% prevalence of self-efficacy, 95% confidence interval (95% CI), and 5% margin error. It was estimated that about 150 smokers per month attended the selected healthcare centers, therefore, 450 smokers were considered as study sample. By adding a 10% non-respondent rate, in total 495 smokers were selected as a sample. For the qualitative study, those who participated in the quantitative study were chosen purposively and in-depth interview was continued to reach data saturation at 35 smokers attendance.

For quantitative study, a self-administered questionnaire was used to collect data. The questionnaire was developed based on the literature review and other questionnaires that have been used in previous similar studies. The questionnaire had four sections including background information (5 questions), smoking cessation (4 questions), self-efficacy to quit smoking (9 questions), and stage of change (5 questions) 26. A shortened form of the Smoking Abstinence Self-efficacy Questionnaire (SASEQ) 27 was used to measure self-efficacy with 5 Likert scale answers ranging from not at all , not very , moderately, very and extremely . They were scored from 1 to 5 and the total score of <27 was considered as low level , 27-36 as medium level and ≥37 as high level of self-efficacy.

To do face validity, the questionnaire was tested in a pilot study before being used in the main study. Ten smokers who met the study criteria were asked to read the questionnaire and provide their feedback. The content of the questionnaire was tested by three experts in the field of smoking and their comments were used to modify the questionnaire. After the changes were made, the final questionnaire was translated to Fijian and Indian languages by bilingual translators. Reliability of the questionnaire was measured through test-retest reliability and the questionnaire was given to 30 participants in two stages with a final Cronbach alpha of 0.85.

For the qualitative study, a semi-structured questionnaire was used that had two sections to collect participants demographic information, as well as 7 open-ended questions to understand participants perception on smoking and factors affecting their self-efficacy and smoking cessation.

One week before starting this study, the information related to this study was provided to all potential participants in three healthcare centers.Those who were interested in participating in this study were given an information sheet and a written consent form in three languages (Fijian, English and Fiji Hindi) to read and sign before collecting the data. They were asked to fill out the questionnaire in their preferred language (Fijian, English and Fiji Hindi) while they were waiting in the main waiting hall. For those who were not able to complete the questionnaire at the same time, a prepaid envelope was provided and they were asked to complete the questionnaire within one week and return to the researcher. Assistance was provided to those who were not able to read or fill the questionnaire by a bilingual research assistance. For the qualitative study, the same procedure was done, and in-depth interviews were conducted by a trained research assistant in a private room after scheduling a meeting with the participants in one of the selected healthcare centers. The interview was recorded by a digital recorder and each interview took about 30-40 minutes. The recorded interview and transcribed scripts were accessible to the principle investigator which are kept in a computer with password protection. They will be discarded after three years.

Descriptive analysis was done after cleaning the data using Statistical Package for the Social Sciences (SPSS) version 24. The results were presented in the form of frequency, percentage, mean and Standard Deviation (SD). For the qualitative study, thematic analysis was used manually to find the common themes. To do that, transcription was done by two independent researchers and codes were identified after reading and re-reading transcriptions. Similar codes that had the same meaning were combined to make sub-themes and finally similar sub-themes were combined to identify common themes.

Ethical approval was obtained from the College Health Research Ethics Committee (CHREC) and Fiji National Health Research and Ethics Review Committee (FNHRERC) with ID#2019.24.C.D. In addition, the permissions were collected from the doctor in charge of each of the three selected healthcare centers.

Overall, 464 smokers participated in this study with the respondent rate of 93.7%.

Table 1 illustrates general characteristics of participants. The mean age of participants was 32.7 (SD=12.1) with the majority (46.8%) in the age group of 20-29. More than two thirds of them (74.1%) were male. Majority of participants (72.6%) were I-taukei with secondary and tertiary education (43.5% and 48.5%, respectively) and annual income of $8,000-15,000 FJD (26.5%).

When they were asked, “Have you tried to quit or reduce the number of cigarettes,” 86.2% of participants answered yes. As Figure 1 shows, majority of participants mentioned that they tried to quit smoking by own (86.6%) while only 8.9% mentioned they were advised by other health care professionals to quit smoking. Six-point five percent of them quit smoking by attending stop smoking group/class.

Table 2 shows other characteristics of smoking cessation among participants. More than two thirds of participants (72.8%) quit smoking because they wanted to promote their health, followed by healthcare workers advice (50.9%), saving money (28.9%) and their appearance (24.1%). Only 12.5% of them quit smoking due to their relative’s advice. The results also showed that, the main barrier to quit smoking was smoking friends/colleagues (39.9%), followed by physiological craving (31.5%) and withdrawal symptoms (30.2%), while 15.1% of them stopped smoking due to gaining weight. One third of participants (34.7%) believe their spouse can help them to quit smoking, followed by friends (28.8%) and healthcare workers (25.1%), while 11.6% mentioned their colleagues can help them better to quit smoking.

Table 3 demonstrates the stage of smoking according to Stage of Change Model (SCM). The results show that majority of participants (87.1%) were thinking of quitting smoking. It also illustrates that 27.6% of participants were at the stage of “Pre-contemplation” (they had no intention to quit smoking in the next 6 months). More than one third (37.7%) of them were at the stage of “Contemplation” (seriously consider quitting smoking in the next 6 months), while 16.6% of participants were at the stage of “Preparation” (decided to quit smoking in the next 30 days) and 4.95% of them were at the stage of ‘Action” (no smoking in the last 6 months). A small number of participants (2.4%) were at the stage of “Maintenance” (no smoking for more than 6 months).

The mean of self-efficacy score was 27.7 (SD=8.5). Majority of participants (43.1%) had low self-efficacy to quit smoking (<27), 41.2% of them had medium level of self-efficacy to quit smoking (27-36) and 15.7% had high level of self-efficacy to quit smoking (36-45).

Overall, 35 smokers participated in in-depth interviews. General characteristics of participants are presented in Table 4. The results reveal that majority of participants (48.6%) were in the age group of 18-24. They were mostly male (57.1%), I-taukei (77.1%) and Fijian of Indian Descent (20.9%), single (54.3%), with tertiary education (68.6%) and were unemployed (62.9%).

The content analysis revealed the findings of two themes, one is the determinants of self-efficacy and second is factors affecting smoking cessation, as presented below.

Smoking is no doubt a major public health problem as it is the leading cause of preventable death 2. Henceforth, critical information is needed to successfully address smoking prevalence and improve smoking cessation programmes. Of vital information that needs to be explored is the factors affecting self-efficacy and quitting for current smokers. This section discusses these factors, considering the findings from this study and from other studies as well.

The results of our findings suggested that most smokers in this study would want to try to quit smoking by their own, and family members and health professionals, especially doctors, can play a vital role in encouraging them to do so. These findings are consistent with findings from other studies stating that smokers will successfully quit smoking if they are motivated enough, especially during teachable moments ^{during and post illness} and financial hardship moments 182829. Unfortunately, findings from the quantitative study found that majority of the study participants mentioned that they were not advised by their doctor to quit smoking when they visited the healthcare facilities. This is consistent with the findings from other studies and it could be reasoned to the, stress of diagnosis, time constraints, inadequate resources and lack of connection between smoking, cancer and health, beliefs among health professionals that someone else should deliver intensive behavioural support 303132. However, most participants in this study said they received more advice from their family members to quit smoking. This could be attributed to the fact that most of the smokers in this study are married and have 5-6 household members, which gives them many chances to receive advice from these family members. It could also be due to the fact that most of these smokers are aged 20-29 years old and their parents would still be alive to be advising them about making wise decisions in life. Studies have shown that having the advice from family members such as parents and spouse, is an effective way to motivate people to contemplate quitting smoking 3334. Further, findings from the qualitative study also reported the same issue with most of the study participants stating that they are not aware of any doctors or counsellors available to provide support to those who are willing to quit. This supports the influence of family support reinforcing behavioral change 35. The qualitative findings also found that the reasons behind smokers trying to quit smoking by their own include other factors such as having a strong interest to promote their own health and are experiencing financial constraints. Nevertheless, the lack of commitment from health professionals to advise current smokers to quit smoking could be a critical reason to the low self-efficacy of quitting smoking among current smokers as studies have suggested that smokers who intend to quit smoking need support over the course of smoking cessation 3236. Financial constraints could be one of the more important triggers that motivate study participants to quit smoking since we have noted from our quantitative findings that majority of them had a household income of $8,000 - $15,000 FJD per year, live in urban areas, are married and most had 5 to 6 household members. This finding supports the results of other studies stating that socioeconomic status is significantly associated with the ability to quit smoking 3738. In this study most of the study participants are seriously intending to quit smoking, and the fact that more than two thirds of the study participants were thinking of quitting smoking would confirm this. It is inconsistent with the findings from other studies that showed smokers have low levels of intention to quit, primarily because smoking is deeply integrated into their social norms 3940.

The findings of this study also revealed that majority of the smokers who quit the last time reasoned their cessation failed mostly by strong influence from smoking friends and psychological cravings. This is a crucial finding as it indicates that smokers have a low self-efficacy to quit smoking and the self-efficacy results confirmed this, noting that majority of the smokers had a low self-efficacy to quit smoking. These findings are consistent with findings from other studies, noting that smoking family members and friends are the main barriers to quit smoking, while addiction to smoking or nicotine dependence makes it an important part of life which is hard to get rid of 41424344. The findings from the qualitative study reaffirm this revelation as most study participants also highlighted that smoking friends is the main barrier to successfully quit smoking while, and as well as, the lack of will power to refuse a cigarette when it is offered by smoking friends. This is similar to the findings from other studies 4546.

In terms of stages of change model, this study found that less than half of the study participants were at the stage of pre contemplation and contemplation while very few of them were at the stage of preparation, action and maintenance 47. The lack of intention and planning to quit smoking could be attributed to the strong influences of friends smoking, psychological cravings for smoking among current smokers, loss of a way to handle stress and perception that smoking helps establish friendship with other smokers, as was found in both the quantitative and qualitative part of the study 4348. Other studies have also found that smokers do not intend to quit smoking mainly because of addiction or high nicotine dependence, and lack of information and perceived availability of support to quitting 4950. Our qualitative finding also noted that most participants lack the will power to say no when a cigarette is being offered by a smoking friend. It is understandable that very few of the study participants are at the stage of preparation, action and maintenance of quitting smoking because this study only recruited current smokers, and also less than half of the study participants are in the contemplation stage of quitting.