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Roles, experiences and perspectives of the stakeholders of “10,000 Lives” smoking cessation initiative in Central Queensland: Findings from an online survey during COVID‐19 situation

Abstract Issue addressed The “10,000 Lives” initiative was launched in Central Queensland in November 2017 to reduce daily smoking prevalence to 9.5% by 2030 by promoting available smoking cessation interventions. One of the main strategies was to identify and engage possible stakeholders (local champions for the program) from hospitals and community organisations to increase conversations about smoking cessation and referrals to Quitline. We aimed to understand the roles, experiences and perceptions of stakeholders (possible champions for delivering smoking cessation support) of the “10,000 Lives” initiative in Central Queensland, Australia. Methods We conducted a mixed‐method online survey during the COVID‐19 situation (23 June 2020 to 22 August 2020) with a cross‐section of possible stakeholders who were targeted for involvement in “10, 000 Lives” using a structured questionnaire with mostly closed‐ended questions. Questions were asked regarding their roles, experiences and perceptions about smoking cessation and “10,000 Lives”. Results Among the 110 respondents, 52 (47.3%) reported having provided smoking cessation support, including referral to Quitline, brief intervention and promoting existing interventions. Among them (n = 52), 31 (59.6%) were from hospitals and health services, 14 (26.9%) were from community services and three (5.8%) were from private medical practices while four of them did not report their setting. Twenty‐five respondents (22.7%) self‐identified as being directly involved with the “10, 000 Lives” initiative, which significantly predicted provision of smoking cessation support (OR 6.0, 95% CI: 2.1‐19.8). However, a substantial proportion (63.5%) of those (n = 52) who reported delivering cessation support did not identify as contributing to “10,000 Lives”. Conclusions Stakeholders from hospitals, health services and community services are the main providers of smoking cessation support in Central Queensland. More could be done to support other stakeholders to feel confident about providing cessation support and to feel included in the initiative. So what? Engaging with a range of stakeholders is critical for health promotion program success, to further develop the program and to ensure its sustainability. As such, funding needs to be allocated to the activities that enable this process to occur.


| BACKG ROU N D
Globally, tobacco smoking remains one of the leading preventable causes of premature morbidity and mortality, 1 and considerable challenges remain in ending this non-communicable disease pandemic.
While smoking prevalence has declined in many countries, gaps remain in implementing evidence-based interventions for smoking cessation. 1 Alongside the global tobacco epidemic, 2 the world has been facing one of the largest communicable disease pandemics in history which has had a significant impact on people's health and health behaviours. Evidence of smoking as a risk for greater disease severity or dying from COVID-19 is now established. [3][4][5][6][7] Experts have recommended increasing promotion and implementation of smoking cessation interventions during this crucial time. [8][9][10] The prevalence of smoking in regional and rural Australia remains considerably higher than in cities and metropolitan areas. 11,12 In Central Queensland (CQ), a regional district of Queensland, Australia located in the central east region, 16.7% of adults smoked daily in 2016 compared with the state average of 14.5%. 13,14 To address this higher smoking prevalence, Central Queensland Public Health Unit (CQPHU) launched a public health initiative called "10,000 Lives" in November 2017. 15 The initiative's objective was to reduce daily smoking to 9.5% in CQ region by 2030 by promoting available smoking cessation interventions and advocating smoke-free policies and programs. A detailed description of "10,000 Lives" is reported elsewhere. 15 Briefly, the initiative employed a senior project officer (SPO) to coordinate the program's activities. The activities included promoting smoking cessation in hospitals, medical practices, educational institutes, community organisations, businesses, mining and other industries and corporate organisations, and via local radio and social media. One of the innovative and major strategies of the initiative was to identify and engage possible stakeholders (local champions for the program) from hospitals and community organisations to increase conversations about smoking cessation, referrals to smoking cessation services and overall promotion of smoking cessation in CQ.
CQ region, with a population of ~220 000, had only 61 confirmed cases of COVID-19 (30.9 cases per 100,000 population) up to 26 December 2021. 16 The region had only 1 week long major lockdown in April 2020 and several infrequent and minor area lockdowns (eg restriction of visits in hospitals and aged care facilities) after that. Decreased use of smoking cessation programs due to COVID-19 has been observed in regions like Ontario, Canada (4594.3 cases per 100 000 population), where the incidence of COVID-19 was relatively higher than in regional Australia during the first 2 years of the pandemic. 17,18 However, research suggests that motivation to quit smoking increased in countries highly affected by COVID-19 like the United States of America and Germany in this pandemic situation. 19,20 Other research in Australia, New Zealand and the United Kingdom found that messaging about the risk of COVID-19 among people who smoke was effective at stimulating quit intentions and behaviours. 21 In Australia, quitting activities (eg downloading smoking cessation apps) increased substantially since the beginning of the pandemic. 9,22 However, we are unaware of any Australian study that evaluated the stakeholder's view of smoking cessation programs like "10,000 Lives" during the COVID-19 pandemic.
We evaluated the process of "10,000 Lives" based on a standard health promotion framework and reported the inputs, activities, outputs and immediate impacts elsewhere. 15,23 We found that "10,000 Lives" successfully increased the uptake of smoking cessation interventions like Quitline by engaging stakeholders in hospitals and community services. In the first 2 years since its launch, the initiative contacted 536 stakeholders, conducted 20 educations sessions and held two summits on smoking cessation and trained nine champions to provide smoking cessation support to their clients and colleagues. 15 Thus, "10,000 Lives" substantially increased the referrals to (by 3.8 times) and participation in (by 3.4 times) the Quitline program in the CQ region. 23 As the campaign activities of "10,000 Lives" continued during the COVID-19 pandemic throughout 2020, it also provided a unique opportunity to understand the stakeholder's perspective about the potential impact of the pandemic on the use of smoking cessation support in a regional area in Australia like CQ that had experienced few COVID-19 cases at that time. Understanding the perspectives of the stakeholders who deliver and recommend smoking cessation interventions is an essential element of the process evaluation to identify potential areas for improvement and build sustainability into the program. Therefore, we conducted a cross-sectional survey from June to August 2020 to explore the demography and employment status of Conclusions: Stakeholders from hospitals, health services and community services are the main providers of smoking cessation support in Central Queensland. More could be done to support other stakeholders to feel confident about providing cessation support and to feel included in the initiative.
So what?: Engaging with a range of stakeholders is critical for health promotion program success, to further develop the program and to ensure its sustainability. As such, funding needs to be allocated to the activities that enable this process to occur.

K E Y W O R D S
COVID-19, health promotion, smoking cessation, stakeholder's perspective program's stakeholders, and assess their roles, experiences and perceptions about smoking cessation and "10,000 Lives".

| Study design
We conducted a mixed-method online survey among the possible stakeholders of the "10,000 Lives" initiative using a structured questionnaire with closed and open-ended questions.

| Study setting and population
The survey population were possible stakeholders for the "10,000 Lives" program. Possible stakeholder included employees of the hospital and health services, community services, educational institutions, business, mining or other industry, or a corporate organisation who can provide smoking cessation support to clients or colleagues, thus supporting the mission of "10,000 Lives". 15 Five hundred and thirty-six possible stakeholders (among whom 171 were local champions from hospitals and community services) were identified in the first 2 years of the program by the SPO, who maintained a database of possible stakeholders for the initiative's activities (eg summits, workshops, exhibitions, meeting, phone and email communication). 15

| Online survey
The survey was created in the CQ Health consultation hub (https:// cqhea lth.citiz enspa ce.com/) using a digital platform (Citizen Space of Delib Ltd). 24 The survey link was emailed to the 536 possible stakeholders inviting them to complete the survey. The link was shared in the staff news bulletin of Central Queensland Hospital and Health Service (CQHHS) and staff portal email groups of council and business industries. An email reminder was sent fortnightly. The survey link was live for 2 months (23 June 2020 to 22 August 2020).

The study was approved by the CQHHS Human Research Ethics
Committee (HREC/2019/QCQ/50602). Participants were presented with a Participant Information Sheet outlining the study, which was approved by CQHHS Communications Department. Participants were required to confirm they had read the information and consented to participate before commencing the survey.
The survey (see Table S1) included 38 questions: three demo- smoking cessation support), 25 eight that related to "10,000 Lives", and three on COVID-19 and smoking cessation. Most questions were multiple-choice format including few dichotomous (eg involved with "10,000 Lives": yes, coded as '1' and no, coded as '0'). A fivepoint Likert scale response option was used for the questions related to roles (eg smoking cessation support provided: never, rarely, sometimes, often and always), experience (usefulness of Quitline: useless, slightly useful, moderately useful, useful and very useful) and perception (how important the role of "10,000 Lives": not important, slightly important, moderately important, important and very important). Additionally, participants were asked three openended questions about resources/support needed from the initiative to perform or promote smoking cessation, and for any further comments on "10,000 Lives" or suggestions for additional action related to smoking cessation and the COVID-19 pandemic. Responses to open-ended questions were coded based on the interview guide to produce deductive themes (ie roles, experience, perception about smoking cessation and any comment or suggestion for "10,000 Lives") and inductive themes, if any, by one researcher (AK) using NVivo version 12.0. 27 We used Braun and Clarke's process for thematic analysis of the qualitative data to identify any new theme that had not been captured by the quantitative questions. 28  period. There were no differences in most demographic and employment characteristics between the respondents who reported providing smoking cessation support and those who did not (Table 1).

| Roles and experience
Fifty-two participants (47.3%) reported providing smoking cessation support (see Table 2) and 43 (82.7%) of them (n = 52) provided information on how frequently they provided the support. Nearly half (n = 21, 48.8%) of them (n = 43) reported providing this support at least once or twice a month, with over one-third (n = 15; 34.9%) providing support several times a week. Most (n = 40; 76.9%) of the respondents (n = 52) provided support as part of their job role and/ or self-motivation (n = 16; 30.8%) and/or motivation from the Senior Project Officer (n = 10; 19.2%) (see Table 2).

| Perceptions
Overall, the respondents supported the smoking cessation activities promoted by "10,000 Lives" (see Table 3). These activities included referral to the Quitline service, delivering brief interventions, and completing the SCCP for the patients who smoke. The majority of respondents (n = 75; 68.2%), especially those who work for hospital and health services (43 of 75; 72.9%), strongly acknowledged the important role of "10,000 Lives" for increasing smoking cessation in CQ. More than half (n = 63; 57.3%) of the respondents believed that people feel supported by the "10,000 Lives" initiative even during the COVID-19 pandemic (n = 55; 50%). However, a substantial portion (n = 42; 40%) perceived that this was not always true.
Most survey participants (n = 68; 61.8%) indicated that they did not observe any changes in smoking cessation behaviour during the COVID-19 pandemic. However, some (n = 24; 21.8%) observed an increased interest in quitting smoking. *Two respondents did not answer this question,; **Forty-five respondents did not answer this question,; ***Twelve respondents did not answer this question,; ****Four respondents did not answer this question,; *****Ten respondents did not answer this question,; ******Sixteen respondents did not answer this question. # p value is significant if <.05.
included financial issues (n = 30; 27.3%) and/or changes in people's circumstances in the pandemic (eg worried about developing severe COVID-19 and life-threatening condition, staying at home: n = 20; 18.2%) provided a good opportunity to quit. These perceptions were comparable across the respondents from hospital and health service and other organisations. The findings related to respondent perceptions are presented in Table 3.

| Involvement with "10,000 Lives"
We asked participants if they were involved with the "10,000 Lives" initiative as a stakeholder (local champion) for smoking cessation.  Table S2 demonstrates the differences in demographics and current roles of the respondents who perceived themselves involved with "10,000 Lives" and who did not. Table S3 describes their involvement and experience with "10,000 Lives".

| Predictors of providing smoking cessation support
Using a logistic regression model, we found that reporting involvement in "10,000 Lives" was the strongest predictor (compared with indicated they were not involved) of providing smoking cessation support in the last year; odds ratio (OR) = 6.0 (95% CI: 2.1-19.8).
We also included the demographic variables and employer of the respondent in the model and did not find any other predictors except being aged between 45 and 54 years age; OR = 3.7 (95% CI: 1.5-9.4).
Respondents aged 45-54 years made up 35% of the full respondent list. The estimates of effect are demonstrated in Figure 1.

Analysis of open-ended questions
Findings from the open-ended questions are summarised in Table 4.
Three questions were asked regarding: overall comments on the activities of "10,000 Lives", suggestions for new activities during COVID-19 and further resources required from the initiative. We deductively identified the three themes: an overall perspective on "10,000 Lives", further advice concerning '10,000' and any resource required from "10,000 Lives". Overall, the activities and impact of "10,000 Lives" were appraised positively by stakeholders from the different organisations. However, suggestions included enhancing the promotional activities of the initiative to raise the CQ population awareness. To do this, respondents suggested supplying promotional material that embeds information about the increased harmful effects of smoking on COVID-19 outcomes.
We also analysed the comments inductively to identify any new themes that were not covered by deductive coding. We observed a range of attitudes towards people who smoke reflected in the comments, with only one comment indicating a negative view of people who smoke: "Until rules and regulations are strongly enforced and large fines etc and bought down smokers will still continue to be self-centred and uncaring of the rest of the population".
However, other comments demonstrated a caring attitude towards people who smoke, suggesting that additional staff training in motivational interviewing could improve the ability of the champions to support people to quit smoking with greater care and empathy.

| Interpretation of the key findings
In the current study, we sought to understand the stakeholder's roles, experiences and perceptions of the "10,000 Lives" initiative.
The findings indicate that among the respondents, "10,000 Lives" had been largely successful in building a good rapport with the stakeholders from the hospitals and community, and to encourage smoking cessation activities including referrals to Quitline and brief intervention. Our previous research using an interrupted time series analysis has shown that "10,000 Lives" increased referrals to, and use of Quitline services in the CQ region. 23 We also previously re- were not confident about the "10,000 Lives" initiative supporting people to quit smoking during this COVID-19 pandemic situation. Also, a negative view of people who smoke demonstrated in one respondent comment may indicate the need to provide education and interventions that increase empathy towards people who smoke, because delivering smoking cessation support in an empathetic, non-stigmatising way is crucial to help people who smoke to successfully quit. [29][30][31] This information can support the "10,000 Lives" team in arranging further training and support for the stakeholders to have empathy and support of their clients to quit smoking.
A recent systematic review analysed data from a number of studies (majority from USA) that evaluated brief interventions and referral programs for substance use, where engagement of champions was found to be a key component. 32 The review identified that good collaboration with local champions is one of the essential factors in facilitating interventions for addiction. The "10,000 Lives" initiative sought to engage champions from hospital, community and corporate services. 15 Previous studies that evaluated smoking cessation programs from the perspective of champions/clinicians found that champions/clinicians were good sources of information on how implementation strategies of a program should be prioritised.

| Limitation of the study
We acknowledge that the surveyed sample was relatively small, and response rate was at one-fifth of the estimated total possible stake- implementing a standardised process. 34 For example, the "10,000 Lives" initiative intensively promotes the SCCP 25 tool to support clinicians in routinely identifying patients who smoke and in delivering a brief intervention.

| Implications and recommendations
Our study provides important recommendations for the "10,000 Lives" initiative and health promotion programs more generally. The initiative should find ways to increase engagement with possible stakeholders to ensure those who are yet to be involved are encouraged to participate. This could be done by employing additional program staff to contact and engage stakeholders more frequently.
Engaging with the range of possible stakeholders that have interests in promoting health interventions is critical for its success, and to support iterative development of the program. As such, funding needs to be allocated to the activities that enable this process to occur. A regional smoking cessation initiative like "10,000 Lives" can be replicated by public health services in other geographic areas with appropriate local tailoring to increase smoking cessation activities in the region.