Results

China's regional contests included a total of 13 848 participants, which was 1.0% of eligible smokers, while the national contest in Finland recruited 6038 participants, being 0.7% of the targeted population.

BACKGROUND VARIABLES

The findings presented in table 1 suggest that respondents to the follow up surveys represent the total samples originally drawn within each country. Concerning the differences between the two countries and two sexes, the Chinese participants were more often men, older, and lighter smokers with fewer previous quit attempts. Marital status differed greatly as well. More than 90% of the Chinese participants were married or cohabiting, compared with 55–70% of the Finnish participants. On average, the Finnish participants had completed more years of education.

PROCESS VARIABLES

The distribution of six process variables are presented in table2. About 75% of participants in both countries intended to quit smoking permanently with the contest. A higher proportion of Chinese participants reported use of nicotine replacement in comparison to their Finnish counterparts, who used other aids more often. Some 80% of the respondents from China reported that they had received family support, compared to 50% in Finland. Support from friends/co-workers, health personnel or other sources was also more frequent among the Chinese quitters.

Most of the Chinese participants indicated that they had learned of the contest through radio, television, newspapers, magazines, family members, friends/co-workers or health personnel, whereas only half of their Finnish counterparts said so. Social smoking was the most important reason for relapse among the Chinese participants, while a stressful situation was the reason cited most often by the relapsed Finnish participants. In China, further reasons to relapse were withdrawal symptoms and stressful situations. Withdrawal symptoms, smoking in environment, and alcohol related problems were further common reasons cited in Finland. When asked whether the contest participation had helped them to quit, a higher proportion of participants in China than in Finland agreed.

ABSTINENCE RATES

In the short run—that is, one month follow up—the Finnish participants managed better than their Chinese counterparts (table 3). In China, women were more successful than men, and in Finland the abstinence rates were roughly the same between the sexes. In the long run—that is, one year follow up—the Chinese participants faired better. Chinese women reached higher rates of abstinence than Chinese men, whereas Finnish men had better results than Finnish women.

DETERMINANTS FOR SUCCESSFUL QUITTING

Table 4 shows the ORs separately for men and women in China and Finland. The 95% CIs show that, in terms of the background variables, older participants tended to be more successful, but significantly only in Finland. Lighter smokers managed better, except among Finnish men. Cohabitation tended to be a successful determinant for cessation among men, but significant among Finnish men only. Lower education was negatively associated with maintained cessation among Chinese women only.

Concerning the process variables, the number of previous cessation attempts was not a significant determinant, although those with more previous attempts tended to be less successful. Family support was positively related to abstinence among Finnish women only. Support from health professionals had a negative result among Chinese men, whereas support from friends or co-workers helped them significantly. Finnish women succeeded better if they received support from health professionals. The role of special measures, such as nicotine replacement therapy, was not a significant determinant, although a positive trend was suggested by the ORs.

Discussion

In general, sizeable differences existed in the background and process variables as well as in the factors contributing to successful cessation maintenance in the two countries. In the short run, the Finnish participants were more successful in cessation. In the long run, however, the Chinese participants succeeded better.

VALIDITY OF RESULTS

Concerning the background variables of the subjects, we did not detect any non-respondent bias in this study. Presumably, however, unsuccessful quitters may be less likely to respond to surveys focused on quitting. To control this bias, the success rates were also calculated as a proportion of the whole sample—the so-called conservative estimate. This particularly makes sense for Finland, where the response rate was quite low. We may assume that the actual success rates are between the conservative estimates and those based on the respondents only.

We did not use any biochemical measures to validate self reported smoking status. The Chinese used telephone and face-to-face interviews conducted by health personnel as data collection methods. To control possible bias from reactive effects, the interviewers provided instructions to motivate the interviewees to report truthfully. In Finland the data were collected by using an anonymous mailed questionnaire, which is likely less biased than data obtained with interview methods.

Although the continuous abstinence rates were low in Finland, the point abstinence rates were surprisingly high. In May 1997 the Smoke-free Finland programme launched a national Quit and Win contest again, which may contribute to the relatively high self reported point abstinence rates at the time point of the follow up.

In China, all participants received a free pack of nicotine gum, which may have caused high reporting on the use of nicotine replacement therapy. However, the pharmacological contents of these products may be different in Finland and China. Thus, the validity of the nicotine replacement's effectiveness was difficult to control in this study.

EFFECTIVENESS

The contest motivated 15 000 registrations in the three target cities of China and 6000 in Finland. The high one month quitting rates (China 50.1%, Finland 65.9%) and one year point rates (China 55.5%, Finland 37.7%) may be an indication of the incentive effectiveness throughout the campaign. For China the campaign may have also built awareness of smoking cessation, and it may help to develop the country's future anti-smoking strategies. In addition to the measurable effects, this kind of community based campaign may have had positive effects on the cessation intentions of those who did not register in this contest.16

The background variables of the participants were different. Compared to Finland, the Chinese campaign attracted older participants, lighter smokers, and persons with fewer previous cessation attempts. On average, the Finnish participants had more years of education and a lower percentage of them were married. Among Chinese men, the proportion of contest participants aged 40–49 years was 35% whereas only 22% of daily smokers in the population was in this age group. In the age group 30–39 years, the corresponding rates were inverted: 26.8% and 32.7%.14 It seems that recruitment was more successful among the age group 40–49 years. This may indicate a need for future interventions in China to target younger age groups.

There were differences in implementation of the campaign in China and Finland. The Chinese campaign had a strong support from the governmental institutions and public health services whereas the Finnish one was mainly working through the coalition of the organisations joined in the “Smoke-free Finland” project, and through direct mailing to households. In addition to the international super prize of US$5000, both campaigns attracted registrants by national or regional super prizes. The Chinese contest in Beijing had a main prize of about US$600 in cash, whereas the Finnish national prize was a 10 day trip for one to the Atlanta Olympic Games where a young Finnish swimmer—a role model for many youngsters—was one of the winning candidates.16 These differences used for mobilisation may have contributed to the differences of the target groups actually reached.

Although the Finnish participants were more successful in one month abstinence (65.9%) than their Chinese counterparts (50.1%), the one year abstinence rate for China (41.7%) was higher than for Finland (18.2%). This result may be partly explained by the fact that China had a higher prevalence of less addictive quitters, as shown in table1. In Finland many of such “easy quitters” had already stopped as a result of previous anti-smoking campaigns. Thus, the Finnish participants included a higher proportion of smokers who may have more difficulties in cessation.17 The high cessation rates of Chinese women may be attributed to social influence and a higher proportion of lighter smokers. Finnish women handled short term cessation quite well, but relapsed more often than men in the long run, which echoes the results of earlier studies as well.1

Although we did not complete a formal cost effectiveness analysis, one could speculate by comparing the cost/participant and cost/successful cessation estimates in two countries. The costs of the Chinese campaigns were altogether $39 690, whereas in Finland the national campaign costs were $110 000. As China had 13 848 participants the cost per participant would be about $3, whereas in Finland with 6038 participants the corresponding rate would be $18. Still greater differences in cost effectiveness could be seen when comparing the cost per successful cessation estimates. When using the most conservative estimates of permanent cessation—38% in China and 12% in Finland—the Chinese campaign reached one target with $8 only, whereas in Finland the cost of the target was $150. This comparison shows a great difference in the cost effectiveness of the two campaigns. However, such a comparison may be too simple, and unfair, because the purchasing power of the US dollar in China and Finland is not comparable.

DETERMINANTS FOR SUCCESSFUL QUITTING

Older age groups of Finnish men were more successful than younger groups, which was a determinant for successful quitting in some previous studies.8 10 12 However, older Chinese women tended to be less successful than younger women. Three reasons might contribute to this result: (1) Chinese society accepts smoking among older women but not among younger women; (2) there was a high proportion of older female participants in the sample; and (3) older participants smoked more.14

In contrast to previous Quit and Win campaign reports,1 9 18 this study found that a lesser amount of previous smoking was related to maintenance of quitting. This result, which is more logical than the ones of previous Quit and Win results, was true for all other groups, except the Finnish men. Like previous Quit and Win results, married or cohabiting male quitters in Finland were more successful. A similar result was not found among Finnish women or among the Chinese participants, although a Chinese survey indicated that those who live alone have a low cessation rate.14 Education was a significant determinant for Chinese women only. Less educated Chinese women were less successful with cessation, which is supported by a previous Chinese study.14

There seems to be a big difference between the characteristics in the two countries, and perhaps also between the cultural norms relevant to smoking. In China adult male smoking is considered normal and socially accepted, but undesirable among females, especially young women. The average age of smoking onset among women is five years later than for men, and most female smokers are lighter smokers.14 China has only recently started to pass legislation to control smoking in some cities. In Finland, where smoking prevalence is quite similar among males and females, anti-smoking legislation and related health promotion methods have been in use since the 1970s.19

Previous studies in Finland,1 the UK,8 and Sweden12 found that those who had made two or fewer previous attempts at quitting were more successful compared to those who had made three or more attempts. This difference was not found significant in this study, although the trend was the same in most cases. The reason why the number of cessation attempts was not a determinant may be, for the Chinese population, due to the fact that the Chinese smoking culture does not yet recognise quitting, since only about 10% of the participants had more than three attempts.

Family support was found to be an important factor related to success only among Finnish women. On the other hand, more than 80% of the Chinese participants reported that they received family support, a result which did permit much variation in this possible determinant. For the quitters who received health professional support, again we have a different picture, Chinese men being less successful and Finnish women more successful. A previous Quit and Win study in Finland10 showed that a combined support received from both health professionals and lay persons was a significant determinant. If the Chinese men did not succeed with help of health professionals, they did so with support of their friends and co-workers. This may be explained by Chinese culture, which in relation to the Finnish one may be considered to be more collective.

CONCLUSIONS

The Quit and Win campaign is a mass smoking cessation method that can be successfully implemented in different countries with variances in smoking habits and rates. However, China and Finland, which are at different stages in anti-smoking policy development, need different practical implementation strategies in future Quit and Win campaigns. China may learn from the Finnish experience of how to attract young smokers to participate, whereas Finland could test the Chinese experience of how to support the maintenance of cessation.