Profiling hospitalized smokers in Malaysia: Insights into health, tobacco use, and cessation readiness

2.1. Study design

This single-centre, cross-sectional study was conducted at Hospital Tengku Ampuan Afzan, a tertiary government hospital located in Pahang, Malaysia, between October 2022 and 2023. This study adhered to the ethical principles outlined in the Declaration of Helsinki and the Malaysian Good Clinical Practice Guidelines. It was registered with the National Medical Research Register (NMRR) and received ethical approval from the Medical Review & Ethics Committee (MREC), Ministry of Health Malaysia (Approval No.: NMRR ID-22-00820-FOD). In addition, approval was obtained from the Human Research Ethics Committee of Universiti Sains Malaysia (JEPeM) (JEPeM Code: USM/JEPeM/22110680).

2.2. Response rate

All patients admitted to the medical and cardiology wards were asked about their smoking status. The response rate for this study was calculated using the following formula:

A total of 503 eligible patients were screened, and 488 consented and completed the questionnaires, resulting in a response rate of 97.0%. Fifteen patients (3.0%) declined participation, a refusal rate unlikely to introduce significant bias into the study findings.

2.3. Inclusion and exclusion criteria

The study included adult patients aged 18 years and above who were admitted to the cardiology and medical wards of the hospital, where the medical wards covered a wide range of specialties, including nephrology, infectious diseases, endocrinology, pulmonology, neurology, rheumatology, and gastroenterology. Only the medical and cardiology wards were included in this study due to limited resources, particularly the availability of trained personnel, which restricted the study’s scope. Moreover, data from the NHMS and the GATS indicate a higher burden of smoking-related diseases among patients admitted to these wards [3–6], thereby justifying their prioritization.

Only current smokers were included, defined as individuals who had smoked at least one tobacco product per day for a minimum of 1 month before hospital admission. Individuals who were concurrent users of electronic cigarettes or smoking?cessation medications at the time of admission were excluded from the study. This decision was made to maintain a homogeneous study population and to simplify the assessment of nicotine dependence. Including these individuals would have required the use of additional measurement tools, such as the e?Cigarette Dependence Scale, the Vaping Dependence Scale, or modified versions of the Fagerström Test for Nicotine Dependence (FTND) for dual users, thereby complicating the evaluation process. By focusing solely on conventional cigarette smokers and using the FTND as the single measure of nicotine dependence, the study achieved clearer, more consistent results and facilitated more straightforward analysis.

Smokers were excluded from the study if they were clinically unstable or had documented psychiatric conditions, including schizophrenia, depression, bipolar disorder, other psychotic disorders, or anxiety disorders such as panic disorder, generalized anxiety disorder, and post-traumatic stress disorder, due to the practical difficulties in conducting effective communication. These diagnoses were verified through records in the appointment book or the Pharmacist Information System.

2.4. Data collection

Smoking status was determined through direct inquiry with patients upon admission. Eligibility was assessed according to predefined inclusion and exclusion criteria. Informed consent was obtained from all patients before enrolment in the study. A universal sampling method was used, where all smokers who met the eligibility criteria were invited to participate. To ensure comprehension and comfort, interviews were conducted in the patient’s preferred language, which included Malay, Mandarin, or Cantonese. The interviews were conducted by the principal investigator and a co-investigator, both of whom are practising hospital pharmacists and Certified Smoking Cessation Service Providers (CSCSP).

Data were collected using structured questionnaires consisting of three main components. The first component gathered sociodemographic information, including age, gender, ethnicity, education level, religion, marital status, employment status, and living arrangement. The second component focused on health profiles, including calculated body mass index (BMI), medical history, and the primary diagnosis for hospitalization, which were obtained from medical records. For psychological assessment, the Depression Anxiety Stress Scales-21 (DASS-21) [17] was self-administered. Assistance was provided when necessary to support understanding. The third component explored the tobacco use profile. This included age at smoking initiation, duration of smoking, daily cigarette consumption, average daily expenditure on cigarettes, nicotine dependence assessed using the self-administered FTND [18,19], history of previous quit attempts and methods used, tobacco brand preference (legal or illicit), and cessation readiness. Cessation readiness was evaluated using the Transtheoretical Model of Behaviour Change (TTM) as the conceptual framework [20].

A counter-checking procedure was conducted by the principal investigator to address any missing data. All data collection forms were reviewed for completeness and accuracy, and any uncertainties were clarified. Missing or incomplete responses were identified and promptly resolved through same?day follow?up with participants to minimize recall bias. All missing data were fully addressed following this counter-checking process.

2.5. Assessment of cessation readiness

The assessment of cessation readiness was conducted by investigators who had completed the CSCSP training, ensuring consistency and accuracy in data collection. Patients were classified into stages of change based on the operational definitions of the TTM, specifically precontemplation, contemplation, and preparation. Selected items adapted from the GATS Malaysia 2011 [4] were used to guide this classification. Patient responses regarding quit attempts in the past year and intentions to quit smoking were used to determine their stage. Those with no intention to quit within the next 12 months were categorized as being in the precontemplation stage. Patients who intended to quit within 12 months but not within the next month were placed in the contemplation stage. Those planning to quit within the next month were classified under the preparation stage. The action and maintenance stages were excluded, as the study focused exclusively on current smokers.

2.6. Psychological assessment

The DASS-21, a validated instrument developed by Lovibond and Lovibond and later translated for the Malaysian population by Musa et al. [21], was used to assess the psychological profiles of the patients. This self-administered tool measures levels of depression, anxiety, and stress, and is not intended for diagnostic purposes. Permission to use the Malay version of the DASS-21 was obtained from the copyright holder before the commencement of the study. The DASS?21 classifies symptom severity into five categories (normal, mild, moderate, severe, and extremely severe) based on established cutoff scores for each domain. For the depression domain, the cutoff scores are: normal (0–5), mild (6–7), moderate (8–10), severe (11–14), and extremely severe (≥15). In the anxiety domain, the scores are: normal (0–4), mild (5–6), moderate (7–8), severe (9–10), and extremely severe (≥11). The stress domain uses the following cutoff scores: normal (0–7), mild (8–9), moderate (10–13), severe (14–17), and extremely severe (≥18) [21].

Patients who scored beyond normal for any domain will be referred to medical doctors. In consultation with institutional psychiatrists, patients who scored in the moderate or higher categories in any domain were identified and referred to psychological support to facilitate timely diagnosis and intervention. The inclusion of this validated tool was in accordance with ethical board requirements to ensure patient safety and to explore potential psychological factors influencing smoking behaviour and quit attempts. A systematic review and meta-analysis have shown that symptoms of depression and anxiety are associated with poorer smoking cessation outcomes and higher relapse rates [22]. Therefore, addressing these symptoms may significantly improve cessation success.

2.7. Assessment of nicotine dependence

Nicotine dependence was assessed using the Malay version of the FTND, a validated six-item questionnaire with a total score of 10. Scores were obtained through patient’s self-administration and categorized into three levels of dependence: low (0 to 3), moderate (4 to 6), and high (7 to 10). These categories provide predictive value for withdrawal severity and treatment outcomes, which are relevant for tailoring smoking cessation program [23]. Higher FTND scores have been associated with lower success rates in smoking cessation in patients [24] and may require more intensive support, including pharmacotherapy, to effectively manage nicotine dependence.

2.8. Statistical analysis

Data analysis was performed using SPSS version 26. Descriptive statistics were used to summarize all the variables. Categorical variables were presented as frequencies and percentages, while continuous variables that deviated from normal distribution were reported as medians with interquartile ranges (IQR).

Factors associated with illicit cigarette use were examined using univariable and multivariable logistic regression, comparing illicit versus legal tobacco brands. To minimise outcome misclassification and heterogeneity, smokers who reported unspecified cigarette brands or who used other tobacco products were excluded. Univariable and multivariable logistic regression were also conducted to assess the association between readiness to quit smoking (“ready to quit” vs. “not ready to quit”) and sociodemographic, health, and tobacco use factors. Due to small numbers in the precontemplation and contemplation stages, these stages were combined into the “not ready to quit” category, while smokers in the preparation stage were classified as “ready to quit.” Variables with p < 0.25 in univariable analyses were included in the multivariable model. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were reported. Multicollinearity was assessed using Variance Inflation Factors (VIFs), and model fit was evaluated using the Hosmer–Lemeshow goodness-of-fit test.

3.1. Sociodemographic characteristics

A total of 488 hospitalized patients were recruited for the study. The median age of the patients was 50 years (IQR 38–60) and were predominantly male (99.8%). Most of the patients were married (72.5%) and had attained secondary-level education (58.8%). Employment status showed that nearly half were employed (47.5%), while 28.5% were self-employed. The majority of patients (87.9%) were living with family (Table 1).

Table 1. Sociodemographic characteristics of hospitalized smokers.

3.2. Psychological assessment using DASS-21

A total of 488 hospitalized smokers were assessed using the DASS 21. The majority of patients scored within the normal range for depression (88.1%), anxiety (78.1%), and stress (88.3%) (Table 2). The median score for the depression domain was 1 (IQR: 0–3), while the anxiety domain had a median score of 2 (IQR: 1–4). The stress domain showed a slightly higher median score of 3 (IQR: 1–5), indicating a relatively elevated level of stress among hospitalized smokers compared to depression and anxiety. Despite the overall normal scores, a small proportion of patients were classified in the severe or very severe categories for depression (3.0%), anxiety (6.1%), and stress (3.7%). These individuals were referred to medical doctors in the ward for further assessment and appropriate psychological intervention.

Table 2. DASS-21 assessment results of hospitalized smokers.

DASS-21: Depression, Anxiety and Stress Scales.

3.3. Health profile

The data showed that the median BMI among hospitalized smokers was 24.8?kg/m² (IQR: 21–43), which falls within the pre?obese category (BMI: 23–27.4?kg/m²) as defined by the Clinical Practice Guideline for the Management of Obesity in Malaysia [25]. Overall, 63.8% of patients were classified as either pre?obese (BMI: 23–27.4?kg/m²) or obese (BMI?≥?27.5?kg/m²), whereas only 25.8% fell within the normal BMI range (BMI: 18.5–22.9?kg/m²) [25]. The detailed distribution of BMI categories is presented in Table 3.

Table 3. Health-related characteristics of hospitalized smokers.

Notably, 33.8% of patients had no known medical illness. Among those with comorbidities, hypertension was the most prevalent condition (35.7%), followed by diabetes mellitus (23.4%) and chronic obstructive pulmonary disease or asthma (16.4%). The most common reasons for hospital admission were cardiology-related conditions (38.1%), followed by infectious diseases (17.6%) and pulmonary disorders (17.4%) (Table 3). The median length of hospital stay was 3 days (IQR: 2–5), indicating a relatively short duration of hospitalization.

3.4. Cigarette brands preference and illicit cigarette use

Illicit cigarette use was common among the study population, with 53.9% of patients reporting consumption of illicit tobacco products (Table 4). A total of 20 illicit cigarette brands were identified. In comparison, 31.1% of patients reported using legal tobacco brands, comprising 12 distinct brands, while 12.7% indicated no specific brand preference. The three most consumed brands were John D-blend (29.9%), Dunhill (17.0%), and Suria (5.5%). Notably, both John D-blend and Suria are illicit brands, reflecting their significant presence in the market, likely due to their more affordable pricing. In Malaysia, illicit cigarettes typically refer to products that fail to comply with national legal requirements, such as mandatory packaging, labelling, registration, excise duty, and sales restrictions [26].

Table 4. Cigarette choices and brand preferences among hospitalized smokers.

Table 5 presents the factors associated with illicit cigarette use. In the multivariable logistic regression model, lower educational attainment, Malay ethnicity, and younger age were independently associated with higher odds of using illicit cigarettes. Individuals with primary or no formal education had substantially higher odds of illicit cigarette use compared with those with tertiary education (aOR 7.25, 95% CI 3.33–15.80). Similarly, individuals with secondary education had higher odds than those with tertiary education (aOR 2.80, 95% CI 1.56–5.02). Each additional year of age was associated with a 3% reduction in the odds of illicit cigarette use (aOR 0.97, 95% CI 0.95–0.98). Malay smokers had nearly threefold higher odds of illicit cigarette use compared with non-Malay smokers (aOR 2.94, 95% CI 1.56–5.53). The final model showed minimal multicollinearity (VIF 1.05–1.22) and demonstrated good overall fit (Hosmer–Lemeshow p = 0.995).

Table 5. Factors associated with illicit cigarette use: univariable and multivariable logistic regression results.

CI: confidence interval.

3.5. Tobacco use characteristics and cessation readiness

The median duration of smoking history among hospitalized patients was 33 years (IQR: 21–43), with a mean starting age of 16 years (IQR: 13–18). Approximately half (49.4%) of the patients were light smokers, consuming between 1 and 10 cigarettes per day, while 39.5% were moderate smokers and 11.1% were heavy smokers. The median number of cigarettes smoked per day was 12 (IQR: 6–20). The median daily expenditure on tobacco products was RM 6.09 (IQR: 3–10). Slightly more than half of the patients (54.5%) exhibited low nicotine dependence, with a median FTND score of 3 (IQR: 1–5). A substantial proportion of patients (71.7%) had attempted to quit smoking before hospital admission, most commonly through abrupt cessation (64.9%). However, the use of pharmacotherapy during previous quit attempts was low (8.3%), suggesting a willingness to quit but limited access to cessation support. Based on the TTM classification, the majority of patients (78.5%) expressed cessation readiness within 1 month of hospitalization (Table 6).

Table 6. Tobacco use characteristics and cessation readiness among hospitalized smokers.

FTND: Fagerström Test for Nicotine Dependence; TTM: Transtheoretical Model.

The factors associated with cessation readiness are presented in Table 7. In the multivariable logistic regression analysis, Malay smokers were more likely to be ready to quit compared with non-Malay smokers (aOR 1.85, 95% CI 1.07–3.19, p = 0.028). In addition, smokers with a history of previous quit attempts had significantly higher odds of being ready to quit (aOR 1.73, 95% CI 1.09–2.74, p = 0.019). Collinearity diagnostics indicated the absence of multicollinearity (VIF = 1.005). Model calibration was satisfactory, as demonstrated by the Hosmer–Lemeshow test (χ² = 0.181, p = 0.914).

Table 7. Factors associated with cessation readiness: univariable and multivariable logistic regression analysis.

CI: confidence interval; DASS-21: Depression, Anxiety and Stress Scales; FTND: Fagerström Test for Nicotine Dependence.

4.1. Sociodemographic characteristics

This study examined the sociodemographic, health, and tobacco use profiles of hospitalized smokers, providing valuable insights into a vulnerable population that is often overlooked in smoking cessation services in Malaysia. The majority of hospitalized smokers were male, of whom only one female smoker was identified. This trend aligned with the findings from the NHMS (5,6), in which 43.0% of males and 1.4% of females were current smokers within their respective gender groups in 2015, decreasing slightly to 40.5% and 1.2% in 2019 (5,6). In this study, the age group of 50–59 years demonstrated the highest prevalence among hospitalized smokers (25.2%), while only 7.4% of smokers were above 70 years. This age distribution reflects the long-term health effects of chronic smoking, which increase the risk of premature death [27,28]. These findings contrasted with the NHMS results, in which the age group of 25–44 years had the highest smoking prevalence (28.3%) [5]. This discrepancy may be due to NHMS covering a broader age range among the general population, whereas hospitalized smokers tend to be older and affected by health consequences of cumulative tobacco use.

In this study, 15.4% of smokers had attained tertiary education, while more than half had completed secondary education. This notable level of educational attainment underscores the importance of tailoring smoking cessation materials to be accessible and comprehensible for individuals with varying educational backgrounds. Higher education is linked to greater success in smoking cessation, while educational disparities contribute to unequal outcomes [6,29]. In addition, most smokers in this study were married and lived with their families, highlighting the potential value of incorporating family?based behavioural approaches into smoking cessation interventions. This notion was supported by recent systematic evidence, particularly when combined with counselling and pharmacotherapy, which can significantly increase cessation rates among low-income households [30].

Among hospitalized smokers in this study, 23.4% were unemployed and might have relied on others for their tobacco supply and daily living needs. This socioeconomic vulnerability suggests that cessation strategies should incorporate financial assistance and psychosocial support, including subsidized pharmacotherapy and transportation to healthcare facilities. It was further supported by research showing that unemployment is associated with higher smoking prevalence and lower quit rates, highlighting the importance of workplace supports [31]. Nearly half of the smokers in this study were employed in either the government or private sector, indicating a need to strengthen workplace-based smoking cessation programmes. Meta-analysis showed that workplace interventions combining behavioural counselling, digital tools, and financial incentives have demonstrated significant short-term impacts on smoking cessation [32].

4.2. Health profile

In the present study, the majority of smokers exhibited normal scores on the DASS-21 assessment. However, a small proportion were classified as experiencing severe to very severe levels of depression, anxiety, and stress. These findings warrant further investigation. Evidence suggests that individuals with psychiatric disorders are more likely to engage in smoking [33]. These smokers tend to have higher levels of nicotine dependence, which makes quitting more difficult. These individuals also experience more intense withdrawal symptoms, contributing to lower success rates in smoking cessation efforts [33]. Previous studies have also identified several barriers to smoking cessation. These include the high prevalence of smoking within social networks, lack of social support, limited motivation, and restricted access to healthcare services [33,34]. In contrast, pharmacotherapy has demonstrated significantly improved outcomes in smoking cessation, particularly when combined with behavioural therapy [35,36]. These findings underscore the importance of evaluating the mental health of hospitalized patients and integrating behavioural therapies with appropriate mental health support for those in need.

It is concerning that 63.8% of hospitalized smokers in this study were classified as either overweight or obese. This trend is consistent with findings from the NHMS, which reported that more than 60% of smokers in Malaysia fall into these categories [6]. These observations challenge the conventional belief that smoking contributes to lower body weight through mechanisms such as increased metabolic rate, estimated between 3.3% and 10%, and nicotine-induced appetite suppression [37,38]. However, emerging evidence suggests that smoking may lead to visceral fat accumulation, insulin resistance, and an increased risk of metabolic diseases [37]. In addition, the coexistence of smoking and obesity has been shown to worsen cardiovascular risk factors, including reduced levels of HDL-cholesterol and elevated concentrations of C-reactive protein [39]. This dual burden of smoking and obesity presents a significant public health concern and underscores the need for integrated policies that target smoking cessation alongside weight management. Incorporating lifestyle modifications, healthy dietary practices, and regular physical activity may enhance the overall effectiveness of these interventions. In addition, providing targeted support to address weight gain following smoking cessation may further improve their impact.

In this study, cardiology, pulmonary, and infectious diseases were among the most common reasons for hospital admission among smokers. These findings are consistent with both global and local public health data [40,41]. The U. S. Centers for Disease Control and Prevention has reported that smoking and exposure to second-hand smoke contribute to approximately one-third of deaths from coronary heart disease, lung cancer, and chronic obstructive pulmonary disease [40]. Similarly, Malaysian public health data from 2021 identified smoking as a leading cause of mortality, particularly due to cardiovascular disease and lung cancer [41]. A retrospective cohort study further confirmed a significant association between smoking and all-cause mortality in the Malaysian adult population [27]. Smokers are also at increased risk of contracting tuberculosis [42] and COVID-19, with evidence indicating that smoking negatively affects treatment outcomes for these conditions [43,44].

Notably, 33.8% of smokers in this study reported no known prior medical illness. Although these individuals may not have been formally diagnosed or have exhibited overt symptoms, this does not rule out the presence of underlying pathology. Subclinical or unrecognized health conditions associated with chronic smoking may still have been present. Routine health screenings are essential for the early detection of such conditions and can play a pivotal role in reinforcing the importance of smoking cessation [45]. Policymakers should address misconceptions about the perceived safety of smoking in the absence of apparent illness through targeted public health campaigns, alongside comprehensive health assessments and preventive health education. Evidence-based strategies, including mass media interventions and community education, have proven effective in correcting such misconceptions and promoting cessation efforts [46]. These findings provide a strong foundation for understanding the extensive impact of smoking on cardiovascular, respiratory, and infectious diseases. In Malaysia, smoking-related illnesses remain among the top causes of death in Ministry of Health hospitals, accounting for more than 15% of mortality [47].

In this study, 21.7% of hospitalized smokers reported using over-the-counter (OTC) products. Among Malaysians, OTC use is mainly for minor ailments, with common products including supplements, vitamins, analgesics, and flu remedies [48]. Although data on OTC use specifically among smokers is limited, the findings from this study raise important safety concerns. Self-medication without professional guidance may lead to misuse or delayed treatment, particularly in managing smoking-related symptoms or addressing barriers to healthcare access. However, the availability of OTC products offers an opportunity to broaden the uptake of nicotine replacement therapy (NRT). This includes nicotine patches and gums, which became accessible OTC in Malaysia following recent regulatory changes by the Ministry of Health [49]. These products have been shown to effectively manage withdrawal symptoms and support smoking cessation when used appropriately [50]. This underscores the importance of a multifaceted public health approach. Improving awareness and access to cessation treatments, along with equipping healthcare providers with appropriate skills, is vital for enhancing smoking cessation outcomes. These findings support Malaysia’s National Strategic Plan for the Control of Tobacco and Smoking Products 2021–2030. The plan advocates integrating smoking cessation services into hospital care to improve the reach and effectiveness of treatment [7,8].

4.3. Tobacco use characteristics

The median smoking initiation age in this study was 16 years, with a median smoking duration of 33 years. This aligns with GATS 2023, which reported a median initiation age of 18 and noted that nearly half of smokers started before 18 years [2]. This underscores the critical need for early and sustained tobacco education and prevention programmes targeting both adolescents and adults. Regarding nicotine dependence, the median FTND score among hospitalized smokers in this study was 3, indicating low nicotine dependence in the majority of patients. Specifically, 54.5% of smokers fell into the low dependence category. This aligns with findings from an outpatient smoking cessation clinic, where 73.9% of smokers were classified as having low to moderate nicotine addiction [12]. While the FTND is a valuable measure of nicotine dependence, it does not independently predict cessation success. Effective smoking cessation typically requires a combination of pharmacotherapy and behavioural interventions, especially among smokers with higher FTND scores [51,52]. A thorough understanding of an individual’s level of nicotine dependence is essential for tailoring appropriate and effective cessation strategies.

In this study, most patients had attempted to quit smoking within the past year, mainly through abrupt cessation. Many were ready to quit within the same month, likely due to immediate health concerns. Evidence shows that interventions during hospitalization are more effective than those at later stages [53]. However, in Malaysia, inpatient cessation counselling is often unstructured, with patients typically referred to external services like clinics or quitlines [7] and left to seek help independently. The availability of pharmacotherapy during hospitalization remains unclear. In this study, only 8.3% of patients used cessation pharmacotherapy during their most recent quit attempt, underscoring substantial gaps in awareness, access, and support. These findings reinforce the need to enhance the availability of cessation pharmacotherapies such as NRT within hospital settings, particularly for low-income populations, as emphasized in the National Strategic Plan for the Control of Tobacco and Smoking Products 2021–2030 [7]. No pharmacotherapy was initiated in the ward due to limited resources, including staff shortages and NRT supply issues. For post-myocardial infarction patients, NRT should be used with caution or deferred during the immediate 1–2-week post-event period, in line with contemporary cardiology guidance [54]. Therefore, behavioural approaches were prioritised in this study.

A low median daily smoking expenditure was reported (RM 6.09, IQR: 3–10) among hospitalized smokers in this study, which might partly be attributable to the high prevalence of illicit cigarette use among them. 53.9% of patients reported to consume illicit cigarettes, which were generally cheaper. This aligns with national data showing illicit cigarettes account for 38.2%–52.5% of the market share in Malaysia [55]. The affordability and easy access to unregulated tobacco products hinder cessation efforts, especially when compared to the higher cost of legal cigarettes due to taxation. This affordability may also contribute to increased youth smoking, a concerning public health issue.

4.4. Association factors for illicit cigarette use

While previous research has focused primarily on predictors of general tobacco use [2–6], studies specifically examining the determinants of illicit cigarette consumption remain limited. The present study found that lower education levels, Malay ethnicity, and younger age were all significantly associated with illicit cigarette use. Smokers with lower educational attainment may have reduced exposure to health campaigns, resulting in lower health awareness and literacy [2–6,29]. This may increase their vulnerability to cheaper, unregulated, and potentially adulterated illicit cigarette products [26,55]. Differences in residential settings may also contribute to varying levels of access to illicit products, particularly in rural areas where regulatory enforcement tends to be weaker [26,55]. Younger smokers are additionally more likely to consume illicit cigarettes, potentially due to economic constraints, limited health awareness, and peer influence [2,5,6,16]. Future research should incorporate measures of income and geographical location to provide a more comprehensive understanding of how affordability and place-based factors influence illicit cigarette use.

The present study underscores the need for policy interventions within the education sector to mandate smoking prevention and cessation education in schools. This should include lessons on the risks associated with illicit tobacco, such as unknown additives, inconsistent nicotine levels, and potential contaminants. In addition, the findings call for stronger collaboration between public health and regulatory sectors to enhance enforcement against illicit cigarette trade, as outlined in Strategy 2.3 of the National Strategic Plan for the Control of Tobacco and Smoking Products 2021–2030 [7]. Providing incentives for evidence-based cessation pharmacotherapy may also encourage smokers to transition away from cheaper, harmful alternatives.

4.5. Association factor for cessation readiness

Cessation readiness reflects smokers’ motivation to quit and is shaped by sociodemographic, psychological, and environmental factors. However, high readiness alone does not ensure sustained abstinence, which typically requires integrated behavioural and pharmacological support [51,52]. Hospitalization due to acute illness may further increase motivation to quit [9]. Hospitalization often heightens patients’ awareness of their health risks, which enhances their motivation to quit smoking. The acute nature of illness and enforced abstinence during hospital stay can prompt smokers to re-evaluate their smoking habits and increase their readiness to attempt cessation [10].

The higher cessation readiness observed among Malay smokers is consistent with findings by Hasan et al. [56] who reported greater quit likelihood among Malays compared with other ethnic groups. Cultural and religious influences, including increased self-discipline during Ramadan, may strengthen motivation to quit [57]. These factors, combined with perceived vulnerability during illness [9,10], likely enhance cessation readiness. Nonetheless, the lower readiness observed among non-Malay groups warrants further investigation. Future research should examine cultural differences in health beliefs to inform more culturally and religiously sensitive cessation interventions.

The multivariable logistic regression analysis in this study showed that previous quit attempts were significantly associated with higher readiness to quit again. This finding is consistent with Hyland et al. [58] who reported that smokers with prior cessation experiences are generally more prepared for subsequent quit attempts. Previous attempts may enhance smokers’ insight into cessation strategies and strengthen their self-efficacy, in addition to increasing their exposure to health campaigns and support services. However, experiences of failure, relapse, or withdrawal symptoms can also diminish motivation and reduce readiness to try again [58]. Interventions should therefore acknowledge both the positive and negative aspects of past quit attempts to better support smokers in future cessation efforts.

4.6. Strengths and limitations of the study

This study’s strength lies in its focus on hospitalized smokers, a population often overlooked yet offering a critical window for cessation interventions. Universal sampling across medical and cardiology wards enhanced representativeness, while the use of validated tools (DASS-21 and FTND) and the application of TTM framework ensured reliable assessments. The large sample size (n = 488) adds robustness, providing meaningful insights into smoking behaviour and cessation readiness. Importantly, the study highlights strong motivation to quit smoking among hospitalized smokers, low access of pharmacotherapy, and offers valuable evidence to guide hospital-based cessation strategies in Malaysia.

This study was conducted in a single tertiary hospital in Pahang, located on the east coast of Malaysia, in cardiology and medical wards and among medically and psychologically stable patients, which may limit the generalizability of findings due to potential differences in sociodemographic, health-seeking behaviour, and smoking behaviours in other states, wards, and medical status. Besides, the findings may not capture the full spectrum of cigarette?use patterns, particularly among patients admitted to orthopaedic, surgical, or emergency wards. The exclusion of medically or psychologically unstable individuals may have resulted in the omission of heavier smokers or those with greater psychological morbidity, potentially introducing selection bias and limiting generalisability.

Data on smoking history, quit attempts, DASS scores, and nicotine dependence may be subject to recall bias, particularly as patients were unwell during data collection. In addition, social stigma surrounding smoking, especially among women, may have led to underreporting, as smokers often conceal their habits. This stigma can also negatively impact motivation to quit and willingness to seek help.