Facilitators and Barriers of Treatment-Seeking and Service Improvement Recommendations for Quit Smoking Clinics in a Rural Context: A Qualitative Study

Abstract

The study examines the barriers and facilitators influencing rural smokers in seeking treatment at quit-smoking clinics using Andersen’s Healthcare Utilization Model. It explores predisposing, enabling, and need factors affecting healthcare utilization and provides recommendations for improving quit-smoking clinics services. Qualitative research design was employed. Data were collected through purposive sampling, and in-depth interviews (IDIs) were conducted with eligible informants. Framework analysis was used to analyze data. Fourteen informants (11 referred clients to the quit smoking clinic, 3 voluntary) participated in this study. Framework analysis revealed subthemes related to predisposing factors (social influences, individual perceptions, knowledge of smoking cessation methods) and enabling factors (access to services and medical, distance, employment, waiting times and treatment as well as effectiveness of services). The need factors which have been identified are poor health symptoms due to smoking and greater perceived need for help to quit smoking. Recommendations from informants to enhance smoking cessation clinic services are discussed. The findings of our study emphasize the role of predisposing, enabling, and need factors in shaping treatment-seeking behaviors. Key recommendations include enhancing clinic promotion, improving accessibility, implementing group counseling, strengthening policies on tobacco control, refining treatment approaches, and conducting follow-up studies on former smokers. These insights are valuable for clients, healthcare providers, and policymakers in supporting smoking cessation efforts and advancing public health initiatives.

• Identifies key predisposing, enabling, and need factors influencing rural smokers’ use of quit-smoking clinics.

• Reveals barriers such as distance, limited access, work constraints, and long waiting times.

• Highlights facilitators including social support, perceived health risks, and awareness of cessation methods.

• Recommends improving clinic promotion, accessibility, treatment approaches, and follow-up for sustained cessation.

Introduction

The tobacco epidemic causes over 8 million deaths globally each year, including 1.3 million from second-hand smoke. ¹ In Malaysia, 19% of those aged 15 and above are current smokers, making smoking a major health risk that strains the healthcare system and reduces quality of life.^1,2 This burden was more pronounced in rural areas, which traditionally recorded higher smoking prevalence and lower smoking cessation rates. ³ In Malaysia, based on the National Health and Morbidity Survey (NHMS) 2019, 27.5% of adults aged 15 and above in rural areas were smokers, compared to 22.1% in urban regions. ⁴

Quitting smoking remains the most effective way to improve smokers’ health at any age. ¹ In line with the WHO Framework Convention on Tobacco Control (ratified by Malaysia in 2005), over 200 quit-smoking clinics (QSCs) and 47 government hospitals offer evidence-based pharmacological and behavioral cessation services.^{5 -7} However, uptake remains low—only 3444 smokers sought treatment through government QSCs, ⁸ and about 18 600 successfully quit in 2019, representing just 0.38% of Malaysia’s 4.9 million smokers. ⁹ This low participation poses a major challenge to achieving Malaysia’s goal of reducing smoking prevalence by 30% by 2025 and becoming a smoke-free nation by 2045. ¹⁰

Studies have shown that a number of factors contributed as barriers against seeking or maintaining professional treatment for smoking cessation. A scoping review of 40 studies revealed that changes in life circumstances, life stressors, shifting priorities, busy schedules, and challenges in attending scheduled sessions, along with availability constraints, daily activities, and work commitments, were common barriers to accessing quit smoking services. ¹¹ Another frequently mentioned obstacle was the lack of access to pharmacotherapy. Additionally, difficulties related to transportation and service availability further hindered access. A significant barrier to smoking cessation services was also the lack of readiness to quit, low interest, and limited motivation among smokers. ¹¹ A qualitative study in Malaysia among individuals who defaulted treatment at QSCs revealed that individual (eg, reluctance to quit, low confidence in quitting, and mixed feelings about smoking cessation, workplace factors, social interactions, and health-related burdens) and service factors (eg, the expertise and personal qualities of healthcare professionals, and the effectiveness, safety, and accessibility of pharmacotherapy) were reasons for defaulting. ¹² These challenges may be intensified in the rural population, where permissive smoking norms, low health literacy and difficulty accessing quit smoking services predominate. ³ However, studies focusing on strategies to improve the uptake of professional interventions to quit smoking in the rural population is lacking in this region.

A way to help identify barriers to utilizing smoking interventions and improve their effective delivery is through the application of a theoretical model. The Andersen’s Healthcare Utilization Model proposes that healthcare utilization is influenced by predisposing (eg, demographic and health characteristics of the individual), enabling (eg, access to a health clinic) and need factors (eg, perceiving a need to quit smoking). ¹³ Despite the availability of QSC nationwide, limited research has explored the factors influencing rural smokers’ use of these professional cessation services in Malaysia. Applying a theoretical framework such as Andersen’s model is therefore important to better understand these determinants and to improve the effectiveness and reach of QSC services in rural settings. Thus, this study aims to examine the barriers and facilitators that influence rural smokers in seeking treatment based on the Healthcare Utilization Model, in terms of their predisposing, enabling and need factors. In addition, recommendations for service improvement for QSCs are explored.

Methodology

Study Design and Setting

This study has followed the EQUATOR guideline, specifically the consolidated criteria for reporting qualitative research (COREQ) ¹⁴ checklist (Supplemental File 1). It employs a qualitative research design with a phenomenological approach to explore individual experiences in seeking smoking cessation treatment. In-depth individual interviews (IDI) were utilized as the primary data collection method. The study was conducted between February 2022 to April 2023.

Population and Study Location

The study population consisted of clients who received treatment either through referral or voluntarily in 2020 and 2021 in government-funded QSC facilities. A pool of 115 clients were listed, including 104 referred clients and 11 who sought treatment voluntarily. This study was conducted at Hospital Pekan, a district hospital primarily serving rural populations in Pahang state, Malaysia.

Research Instruments

A semi-structured interview schedule was developed based on the Andersen’s Healthcare Utilization Model to examine the barriers and facilitators influencing smokers in seeking treatment (Supplemental File 2). The schedule was validated by 2 experts in smoking cessation and underwent a preliminary test (pilot study) to ensure the suitability of the questions. Additionally, the pilot study aimed to evaluate the clarity of the interview questions to ensure they effectively addressed the research objectives. The pilot study provided researchers with experience in formulating additional questions during interviews and refining their skills in conducting in-depth, face-to-face interviews.

Sample Size and Sampling Method

To minimize potential researcher bias, QSC clinic staff were responsible for screening and contacting prospective participants via telephone to obtain their consent to participate in the study. A total of 14 individuals were selected through purposive sampling to ensure maximal variation in the participants and alignment with the study objectives. Inclusion criteria of participants included Malaysian citizens aged 18 and above, were current or ex-smokers who had accessed health care services or the QSC in Hospital Pekan, and were able to communicate in Malay, English, or Mandarin. Individuals who refused to participate in the interview or could not be contacted for an interview were excluded from the study. Maximal variation sampling stratified participants into individuals who (1) have never attended the QSC or had a referral to attend the QSC due to being diagnosed with a smoking-related chronic disease, but declined the health care staff’s invitation for an appointment, (2) attended the QSC for 1 to 2 times, and defaulted afterward, (3) are currently attending the QSC but have not quit smoking, and (4) have attended the QSC, successfully quit smoking for the past 6 months and discharged from treatment.

Ethical Considerations

This study received approval from the Medical Research Ethics Committee (MREC) and was registered under the National Medical Research Register (NMRR ID-22-01754-X1N [IIR]). The research adhered to the Declaration of Helsinki and the Malaysian Good Clinical Practice Guidelines to safeguard the rights and privacy of informants.

Data Collection Method

The interviews were conducted by Ching Yee Hong, pursuing a Master’s degree at the time of the study. The interviewer was a practicing health education officer in a rural Quit Smoking Clinic, who was interested in the utilization of QSC in Malaysia. She had 6 years of professional experience in the field and was actively practicing at a rural QSC.

Data were collected through in-depth individual interviews (IDIs) conducted sequentially and face-to-face at Hospital Pekan. Each interview lasted between 30 and 45 min and was digitally recorded with participants’ consent. Interviews were conducted in the participants’ preferred language (Malay, English, or Mandarin) to ensure comfort. Prior to participation, all informants were fully briefed on the study’s purpose and provided written consent.

No prior relationship existed between the interviewer and the participants before data collection, and only the interviewer and participant were present during each session. Field notes were taken concurrently to support and enrich the subsequent data analysis.

Data Analysis

Interview transcripts were transcribed verbatim by Ching Yee Hong after each IDI session. Upon completion of data collection, transcriptions were verified through member checking to ensure data accuracy. ¹⁵ Data were analyzed using framework analysis, with the assistance of NVivo software (Version 12) to systematically manage the data. The researchers identified key themes through the framework analysis process based on the predisposing, enabling, and need factors that influenced smokers’ decisions to seek treatment.

Results

Demographics

Saturation was reached after interviewing the 10th informant. However, to ensure adequate sampling and data collection, an additional 4 informants were interviewed to ensure no new information emerged. Table 1 presents the demographic information, smoking characteristics and treatment status of the informants involved in this study.

Table 1.

Informants’ Demographic Characteristics.

No.	Informant code	Age range (years)	Age started smoking (years)	Duration of smoking (years)	Current smoking status	Treatment status
1	K1-1	55-60	21-25	36	Smoking	Never attended
2	K1-2	25-30	16-20	10	Smoking	Never attended
3	K2-1	30-35	16-20	16	Smoking	Declined after contacted
4	K2-2	40-45	11-15	30	Smoking	Declined after contacted
5	K2-3	35-40	11-15	25	Smoking	Declined after contacted
6	K3-1	30-35	11-15	19	Smoking	Attended
7	K3-2	60-65	16-20	44	Quit	Attended
8	K3-3	40-45	16-20	28	Smoking	Attended
9	K4-1	35-40	31-35	4	Quit	Discharged
10	K4-2	45-50	16-20	31	Quit	Discharged
11	K4-3	50-55	11-15	39	Quit	Discharged
12	K4-4	50-55	21-25	27	Quit	Discharged
13	K4-5	55-60	21-25	34	Quit	Discharged
14	K4-6	65-70	16-20	49	Quit	Discharged

A total of 14 informants participated in the study, comprising 11 referred clients and 3 voluntary clients. All participants completed the interview process, and no withdrawals occurred. The sample included 1 female and 13 males, with ages ranging from 21 to 70 years. More than 50% of the informants were public sector employees, and 50% successfully quit smoking. The majority (86%) had been diagnosed with various chronic illnesses, while 71% had used tobacco products for more than 20 years. Additionally, 65% of the informants had a secondary school education as their highest level of formal education.

Identified Themes

Based on Andersen’s Health Utilization Model, 3 key factors which were predisposing, enabling, and need factors, were examined to identify barriers and facilitators influencing smokers’ engagement with smoking cessation treatment. Accordingly, the data were analyzed in alignment with relevant factors, themes, and subthemes. The study identified 6 main themes and 13 subthemes (Table 2).

Table 2.

Themes and Sub-Themes.

Theme	Sub-theme
Predisposing Factors
1. Social	I. Family Influence II. Peer Influence  III. Exposure to Others’ Experiences
2. Individual	IV. Impact of Smoking Habits on Oneself and Others V. Self-Confidence in Quitting Smoking  VI. Experience of Quitting Attempts VII. Knowledge of Smoking Cessation Methods and QSC Facilities VIII. Perceived Effects of Smoking Cessation
Enabling Factors
1. Changes in Smoking Habits Based on Financial Status
2. Smoking Cessation Clinic Services	I. Access to Services II. Distance to the Clinic  III. Employment  IV. Waiting Time and Treatment Efficiency as a Motivating Factor V. Service Effectiveness  VI. Access to Medication
Need Factors
1. Clients’ Health History
2. Perceived Need for Assistance in Quitting Smoking
Recommendations for Enhancing Smoking Cessation Clinic Services
1. Increased Promotion of the Clinic
2. Separate Facilities for Smokers
3. Group Counseling Sessions
4. Government Policies	I. Banning Cigarettes II. Expanding Non-Smoking Areas
5. Treatment Approaches	I. On-the-Spot Counseling During Inspections and Law Enforcement II. Medication Use
6. Follow-Up Studies on the Effects of Smoking Cessation

Predisposing Factors

Theme 1: Social

The primary theme within the predisposing factors is social influences, which encompass an individual’s status within the community, their ability to manage challenges, and their access to resources. This includes family influence, social support from the community, educational background, employment status, and urban or rural residency.

Subtheme 1: Family Influence

Nine out of 14 participants reported that their family members were a significant motivator for seeking smoking cessation treatment. The following statement illustrates this:

In terms of motivation, my children, my wife, and even my in-laws encouraged me to quit smoking because none of them smoke. . . For my children, I decided to quit as a gift for my second son’s birthday. (K4-1)

Conversely, 3 out of 9 participants mentioned that family members were their biggest barrier to quitting smoking, particularly if other family members were smokers themselves, thus diminishing their motivation. This is reflected in the following statement:

It’s hard to quit when my husband still smokes. For example, if I say I don’t want to smoke, but my husband smokes near me, I can still smell it. Then he tells me that I can’t quit suddenly and that I should continue smoking, so I end up listening to him. (K1-2)

Subtheme 2: Peer Influence

Three out of 14 participants reported that their friends were a significant barrier to seeking smoking cessation treatment. They admitted that being around friends who smoke increased their likelihood of smoking, even if they had the intention to quit. One participant explained:

Ever since I started riding motorcycles again, most of my friends don’t smoke. So, I started feeling embarrassed to smoke in front of them. I think finding the right group of friends is important. Social support matters. (K1-1)

On the other hand, the majority of informants (10 out of 14) stated that their peers played a crucial role in encouraging them to seek smoking cessation treatment. However, some also identified peer influence as a challenge, as illustrated by the following statement:

Friends can be a barrier. If I’m not smoking, they’ll encourage me—‘Come on, let’s have a smoke’—so I end up following along. It really challenges my will to quit. (K4-5)

Subtheme 3: Exposure to Others’ Experiences

Four out of 14 participants mentioned that observing the negative consequences of smoking on people around them motivated them to seek smoking cessation treatment. One participant shared:

When I was in high school, my uncle passed away in his 30s due to throat cancer. He started smoking at a relatively young age. (K4-1)

However, 2 participants reported that witnessing others’ experiences deterred them from attempting to quit, fearing negative health consequences. One participant recounted:

My uncle once quit smoking suddenly after being discharged from the hospital. But then, he had a heart attack soon after quitting. (K3-3)

Theme 2: Individual

Individual factors constitute one of the main themes under predisposing factors, encompassing smokers’ attitudes, values, and knowledge about healthcare services, as well as their perceptions of the necessity and utilization of these services. The following sub-themes have been identified:

Subtheme 1: Impact of Smoking Habits on Oneself and Others

The majority of informants acknowledged their awareness of the negative health consequences of smoking, both for themselves and those around them. These adverse effects served as motivation for them to seek treatment.

It causes illness, and it also wastes money. As for others, I have always known about the effects of smoking; for instance, when we smoke in front of our children, they are also exposed to the same health risks. (K4-5)

However, a minority of informants (3 out of 14 participants) perceived no negative impact of smoking on either themselves or others. One participant stated:

How should I put it? It’s just a habit, so it feels normal. Just like how we eat rice every day, smoking is part of my routine. My health is fine so far (laughs). . . I haven’t noticed any negative effects on myself or others. (K2-3)

Subtheme 2: Self-Confidence in Quitting Smoking

More than half (8 out of 14) expressed a lack of confidence in their ability to successfully quit smoking. One participant noted:

I have had the intention to quit for a long time. I once visited the clinic for another treatment and saw a banner about quitting smoking. I knew such services were available, but I lacked the strength and motivation to go. (K4-2)

Conversely, a smaller group (4 out of 14) expressed confidence in their ability to quit smoking, attributing success primarily to personal effort rather than external support. One participant commented:

The key factor is oneself. The clinic is just a support system, not a solution. Ultimately, it depends 100% on the individual. No matter which clinic or hospital you visit, if you are not willing to change, nothing will help. Even if you go to a smoking cessation clinic, if you don’t want to change, it won’t make a difference. (K2-3)

Subtheme 3: Experience of Quitting Attempts

Half of the informants (7 out of 14) reported prior attempts to quit smoking, but their independent efforts were largely ineffective, leading them to seek treatment at the Smoking Cessation Clinic (QSC). One participant stated:

Hmm. . . I tried twice before, but it didn’t work. This is my third attempt, and now I have come to the clinic. If we are willing to try, who knows? Previously, I tried on my own, but maybe with guidance from QSC, the outcome will be different. (K1-1)

Meanwhile, 3 participants indicated that their attempts to quit smoking had failed because they viewed smoking as a stress-relief mechanism. One participant shared:

Smoking helps relieve stress. Back in college, whenever I felt stressed, smoking helped me relax (laughs). Later on, even now, smoking has also become a social activity. For example, if a friend is smoking and I run out of cigarettes, I ask for one, and that’s how friendships are formed. (K4-5)

Subtheme 4: Knowledge of Smoking Cessation Methods and QSC Facilities

Half of the informants (7 out of 14) had knowledge of smoking cessation methods or were aware of the existence of QSC facilities. One participant noted:

Mass media, television ads, and social media provide information that encourages quitting. I know the methods—stop buying cigarettes, avoid friends who smoke, and look up ways to quit on social media. (K3-2)

However, a smaller group (n = 4) lacked awareness of where, how, and who could help them quit smoking. One participant admitted:

I don’t know where to go, who to ask, or how to start. (K1-2)

Subtheme 5: Perceived Effects of Smoking Cessation

A significant portion of informants (n = 10) who had previously visited a smoking cessation clinic but did not continue treatment expressed concerns about potential negative effects after quitting smoking. These concerns acted as barriers to seeking further treatment at QSC.

Not right now. . . I’ll quit slowly. If I quit suddenly, I might get heart problems. (K3-3)

Enabling Factors

The key enabling factors influencing smoking behavior changes include financial status and the availability of smoking cessation clinic services.

Theme 1: Changes in Smoking Habits Based on Financial Status

The majority of informants (n = 10) stated that cigarette prices and their financial situation did not serve as motivation to seek treatment at QSC.

I don’t feel burdened by cigarette prices because smoking is already a habit (smiles). . . In terms of finances, I always allocate money for cigarettes, so it’s not really a burden. (K2-3)

Conversely, a smaller group (n = 4) felt that the increasing cost of cigarettes was a financial burden, and if prices continued to rise, they might be motivated to seek treatment at QSC. One participant explained:

I feel like I’ve wasted a lot of money on cigarettes. . . It’s becoming a financial burden (compared to previous prices). Prices keep increasing, and if they go up even more, it might push me to quit. (K2-1)

Theme 2: Smoking Cessation Clinic Services

This theme comprises 6 subthemes: access to services, distance to the clinic, employment, waiting time and treatment efficiency as a motivating factor, service effectiveness, and access to medication.

Subtheme 1: Access to Services

The majority of informants (n = 11) reported receiving phone calls from the clinic, which they perceived as a form of support that encouraged them to seek treatment. Additionally, the clinic’s flexible appointment schedules facilitated their attendance. One participant described their experience:

The clinic called me first; I didn’t reach out to them. They called after I was discharged from the hospital, offering help. I thought, ‘They want to help me, so why not?’ So I came to the clinic. (K4-2)

Subtheme 2: Distance to the Clinic

Some informants (n = 7) stated that distance was not a major obstacle to attending treatment sessions. One participant noted:

Transportation is not an issue, and neither is my job. Distance is not a barrier to seeking treatment. (K3-1)

Subtheme 3: Employment

Some informants (n = 7) reported that their employment did not pose a barrier to seeking treatment, as they received support from their employers. The following statement from a participant illustrates this:

Yes, my job is not a barrier for me to come to the clinic. (K1-1)

Subtheme 4: Waiting Time and Treatment Efficiency as a Motivating Factor

Several informants (n = 6) indicated that a short waiting time and a smooth treatment process enhanced their satisfaction with the services received. The following participant statement supports this:

I am satisfied; there are no major issues with the waiting time and treatment. It takes about an hour to complete everything. . . Compared to other clinics, the process here is smooth. (K2-1)

Subtheme 5: Service Effectiveness

Almost all informants (n = 13) expressed that the services provided were highly effective in helping them quit smoking, particularly through counseling sessions and regular health monitoring. The following statement highlights this:

Yes, very much so. It is highly beneficial, particularly in terms of motivation. The most interesting aspect is the treatment approach. . . such as counseling sessions and health screenings. So, we are always aware of how long we have quit smoking, whether our weight has increased, and other aspects. The method is highly effective and has helped me significantly. (K4-1)

Subtheme 6: Access to Medication

This study revealed an interesting finding regarding access to medication. One informant reported discontinuing their treatment due to difficulties in obtaining medication from the pharmacy unit, as medication was only available from Monday to Friday and could only be dispensed by authorized personnel:

I feel medication can be a problem too. . .. The problem arises when it comes to the time to take the meds. I just skipped the meds because I was frustrated with the pharmacy; it was so hard to get the meds. . ..They can’t give you the meds on weekends, they only give it to you on weekdays. It was so troublesome, so aah, no need [to take it anymore]. (K2-3)

Conversely, another informant stated that access to medication facilitated their continuation in the smoking cessation program because of the belief that the medication weas effective.

Need Factors

Two main themes were identified under the need factors: (1) clients’ health history and (2) the need for assistance in quitting smoking.

Theme 1: Clients’ Health History

A majority of informants (n = 10) reported that their health condition was the primary motivation for seeking treatment. Symptoms such as chest pain and fatigue after smoking were the main factors that prompted them to seek medical assistance.

My health condition now is what drives me to seek treatment. After smoking, my chest hurts, and I feel exhausted. I cannot do anything; I have to sit and rest. (K2-1)

Theme 2: the Need for Assistance in Quitting Smoking

A significant number of informants (n = 11) acknowledged their need for professional assistance in quitting smoking, as their previous attempts had been unsuccessful.

The reason I sought treatment is, as I said, I cannot quit on my own. So, I tried to seek help from specialists. . . My own methods did not work (I have tried to quit many times), so I needed to seek professional help. (K4-1)

Recommendations for Enhancing Smoking Cessation Clinic Services

Based on feedback from informants, several recommendations have been proposed to improve the services provided by smoking cessation clinics.

Recommendation 1: Increased Promotion of the Clinic

Informants suggested that promotional efforts for smoking cessation clinics should be intensified, as many individuals remain unaware of their existence.

There needs to be more promotion because some people still do not know about this clinic. . . Many people ask where they can get help to quit smoking. (K4-4)

Recommendation 2: Separate Facilities for Smokers

Some informants recommended the establishment of dedicated facilities for smokers seeking treatment to ensure they are not grouped together with patients receiving treatment for other health conditions.

I suggest that smoking treatment should have a special facility, separate from other patients. Smokers are not necessarily sick, but they are mixed with those who are. There should be a dedicated department for them because they come voluntarily, whereas others are there because they have to seek treatment. (K4-2)

Recommendation 3: Group Counseling Sessions

Informants proposed implementing group counseling sessions to provide smokers with peer support in their efforts to quit smoking.

It would be good to have a session with three or four smokers (group counseling). Sometimes this kind of support group can help. (K4-1)

Recommendation 4: Government Policies

Banning Cigarettes

Several informants suggested that the government should impose a total ban on cigarettes to address the issue of illicit cigarette trade and reduce the overall number of smokers.

There are many challenges, such as smuggled cigarettes. The government should completely ban cigarettes to solve the problem. (K4-1)

Expanding Non-smoking Areas

Informants recommended extending smoke-free zones to minimize exposure to cigarette smoke.

There should be more places where smoking is prohibited. (K2-1)

Recommendation 5: Treatment Approaches

On-the-Spot Counseling During Inspections and Law Enforcement

Informants proposed providing immediate counseling for individuals caught smoking in restricted areas, with the involvement of law enforcement authorities.

I suggest on-the-spot counseling. If someone is caught smoking in public and fined, why not also provide immediate counseling? More sectors should be involved, such as the police or enforcement officers. They have the authority to issue fines, and we can provide counseling. (K4-2)

Medication Use

Some informants recommended incorporating pharmacological interventions, such as Champix, as an effective method to assist smokers in quitting.

Using Champix is one of the key success factors. . . Yes, medication like Champix is very helpful. I took Champix, and within eight days, I was able to quit smoking. (K4-1)

Recommendation 6: Follow-Up Studies on the Effects of Smoking Cessation

Informants suggested conducting follow-up studies on individuals who successfully quit smoking at intervals of 3 months, 6 months, or 1 year.

Yes, there should be follow-ups after successfully quitting smoking—at three months, six months, or a year—to evaluate their health condition. We need to consider various aspects, including age and the effects of quitting. (K2-3)

Discussion

This study aimed to investigate the barriers and facilitators that influenced rural smokers in seeking treatment, and their recommendations for service improvement for QSCs.

Predisposing Factors

Predisposing factors play a crucial role in influencing smokers’ decisions to seek smoking cessation treatment at the QSC at Hospital Pekan, Malaysia. The primary motivational factors identified in this study include family support, experiences of others, awareness of the harmful effects of smoking, past quit attempts, and knowledge of smoking cessation methods. Family support, particularly from spouses, children, and siblings, emerged as a significant motivator for smokers to seek treatment.^16,17 Additionally, the experiences of individuals who successfully quit smoking or suffered health complications due to smoking acted as a catalyst for seeking assistance. ¹⁸

Awareness of the negative health consequences of smoking, both for the individual and their surroundings, also served as a strong motivator to seek treatment. The majority of informants expressed concern over the risks of diseases such as cancer and heart disease, as well as the harmful effects of secondhand smoke on their families, aligning with previous research findings. ¹⁶ Furthermore, past failed attempts to quit smoking independently reinforced the need for professional treatment. ¹⁹ Knowledge of available smoking cessation methods and the presence of QSC facilities were also identified as crucial factors in motivating smokers to seek help. ²⁰

However, several barriers hinder smokers from seeking treatment. Peer influence and exposure to individuals who continue smoking often make quitting challenging.^21,22 Additionally, a lack of self-confidence in quitting smoking emerged as a major obstacle, consistent with previous studies.^16,22 Some informants also expressed concerns about potential health complications after quitting smoking. While other studies suggest that concerns about future health risks encourage smoking cessation, the findings of this study present a different perspective. ²³

Enabling Factors

Enabling factors play a crucial role in facilitating access to healthcare services. The findings of this study indicate that the Smoking Cessation Clinic (QSC) at Hospital Pekan serves as a key enabling factor for informants seeking smoking cessation treatment. One of the primary factors driving access to this treatment is the ease of access to QSC, as most informants found the hospital’s location to be convenient, consistent with the findings of Shaheen et al. ²⁴ Furthermore, geographical distance was not identified as a significant barrier, contrasting with a study by Rosário et al ²⁵ and Mushtaq et al, ¹⁸ which highlighted transportation and travel costs as obstacles to healthcare access.

Additionally, employment factors contributed to informants’ ability to attend QSC, as most reported receiving support from their employers in terms of leave approval. Such social support has been shown to influence employees’ health-seeking behaviors. ²⁶ Furthermore, short waiting times and efficient treatment sessions, along with high-quality service, enhanced informants’ satisfaction, consistent with the findings of Atholere, ²⁷ which emphasized the importance of optimal waiting times in healthcare services. The effectiveness of the treatment provided at QSC was also acknowledged by the majority of informants, indicating that high service quality was a crucial factor in ensuring patient satisfaction and willingness to seek treatment. ²⁴

This study revealed conflicting findings on the role of financial status in encouraging them to seek treatment or quit smoking. For some, financial status did not significantly influence smoking cessation treatment-seeking behavior. On the other hand, a smaller proportion of participants acknowledged that the rising cost of cigarettes was becoming a financial burden and might motivate them to seek treatment, which aligned with another study that found financial stability and rising cigarette prices to be important determinants in smokers’ decisions to quit in Malaysia. ¹⁶ A systematic review on Lower- and Middle-Income Countries, however, found that there was a lack of empirical evidence to show that socioeconomic status affected how prices and taxes were related to tobacco use. ¹⁷ These discrepancies suggest that financial status in itself may be inadequate as a sole determinant of quit decision; our findings suggest that other financial considerations such as financial stability, sensitivity to price changes, and smoker characteristics such as level of smoking dependence may conjointly play a role in influencing a smokers’ treatment-seeking decisions. This highlights financial status as an enabling factor in Andersen’s Healthcare Utilization Model may not be uniformly applicable for all smokers. For example, rural smokers in Malaysia may be differentially affected by other socioeconomic factors such as existing social networks or the cultural normalization of smoking in rural areas.

Need Factors

Need factors refer to individuals’ perceived necessity for treatment, whether based on their health history or the requirement for professional assistance. The findings of this study indicate that the health history of clients was the primary factor driving most informants to seek smoking cessation treatment at QSC Hospital Pekan. Previous health complications heightened their awareness of the need to quit smoking to reduce the risk of disease recurrence. Kosasih et al ²⁸ similarly reported that individuals with a history of chronic illness were more likely to seek healthcare services.

Moreover, the need for professional assistance was identified as an essential factor in smoking cessation efforts. Most informants believed that professional counseling at QSC increased their chances of successfully quitting smoking. This aligns with the report by Hospital Canselor Tuanku Muhriz UKM, ²⁹ which stated that individuals receiving professional guidance exhibited higher success rates in smoking cessation compared to those attempting to quit independently. These findings underscore the significance of professional support in ensuring the effectiveness of smoking cessation interventions.

Evidence from high-income countries, including the United States and Australia, shows that targeted outreach and supportive counseling effectively improve smoking cessation in rural and underserved populations.^{30 -32} Similarly, this study’s findings on the importance of provider attitudes, trust, and clinic promotion align with other international research highlighting the influence of healthcare workers on treatment uptake. ³³ These emphasize both the contextual uniqueness of rural Malaysia and the universal importance of trust and provider engagement in facilitating cessation behavior.

The findings of this study have relevance beyond Malaysia, offering insights applicable to tobacco control efforts in similar rural and resource-limited settings worldwide. Strengthening clinic promotion, and improving accessibility reflect strategies that have been effective in international contexts. ³⁴ There is also a need to emphasize codesigning tailored smoking cessation pathways for unique populations such as rural smokers. ³⁵ These parallels highlight the broader applicability of Andersen’s Healthcare Utilization Model in guiding tobacco control interventions across diverse populations.

Limitations

There are several limitations in this study. The findings may not be generalizable to all populations in Malaysia since this is a qualitative study conducted in a single rural district. The purposive sampling method may have introduced selection bias, as participants more driven to quit smoking could have been overrepresented. Furthermore, because only 1 female participant was included, the findings primarily reflect men’s cultural, social, and health influences on smoking behavior and healthcare utilization, limiting the applicability of results to women. Participants did not provide feedback on the study’s findings, which may limit the validation of the interpretations presented. Lastly, perspectives from healthcare providers and policymakers were not included, which may have limited the comprehensiveness of the analysis.

Recommendations

To enhance smoking cessation clinic services, several recommendations have been proposed based on informant feedback. These include increasing clinic promotion to raise awareness, establishing dedicated facilities for smokers, and implementing group counseling sessions for peer support. Additionally, informants emphasized the need for stronger government policies, such as banning illicit cigarettes and expanding non-smoking areas, as well as improving treatment approaches through on-the-spot counseling during law enforcement inspections and incorporating pharmacological interventions like Champix. In terms of access, if employees continue to face challenges in accessing smoking cessation clinics that usually operate during working hours, implementing workplace smoking bans could serve as an effective strategy to lower smoking prevalence. ³⁶ Lastly, follow-up studies on former smokers at regular intervals were suggested to assess the long-term effects of smoking cessation.

Conclusion

In conclusion, this study has identified the barriers and facilitators influencing smokers’ decisions to seek treatment at the Smoking Cessation Clinic (QSC) through the lens of Andersen’s Healthcare Utilization Model (HUM). The findings suggest that predisposing, enabling, and need factors play a crucial role in determining smokers’ treatment-seeking behaviors at QSC. Recommendations included increasing clinic promotion, establishing dedicated facilities for smokers, implementing group counseling sessions, strengthening government policies (such as banning illicit cigarettes and expanding non-smoking areas), improving treatment approaches through on-the-spot counseling and pharmacological interventions like Champix, and conducting follow-up studies on former smokers to assess long-term cessation effects. These insights hold implications for clients, healthcare providers, and policymakers in advancing efforts toward a smoke-free nation. Furthermore, this study contributes to the enhancement of QSC services, the development of more effective policies, and the academic discourse in public health and qualitative research.