Evidence suggests that supported quit attempts (e.g. using nicotine replacement therapy (NRT), having group or individual counselling) are more successful than unaided attempts. However not everyone wants to use medicine such as NRT, or see a counsellor and many smokers quit unaided.
Unaided quitting is known as going ‘cold turkey’. Smokers who want to quit this way should be advised to make a plan. Planning when they will quit and what they will do when cravings strike means they are more likely to succeed. The aim is to change the habits associated with smoking. This means thinking about things such as when and where someone smokes. Planning includes:
The case study in Box 1 provides an example of how someone was able to quit using this method. Support from family and friends was an important part of this process.
Box 1: Quitting Cold Turkey
As a crisis support worker for the Kamunga Aboriginal Health Service working with young homeless people and those in other critical situations, Margie Jackson could have plenty of excuses for continuing to smoke. But after smoking 70-plus cigarettes a day for 26 years, Margie’s body was telling her that it was time to give up.
Margie first took up smoking after the birth of her daughter as a way of coping with postnatal depression. She thought that smoking would be a better way of dealing with the depression than taking medication. Over the years, Margie made many a new year’s resolution to quit smoking but they were always short lived. Wednesday, the 18th February 2004, though was different. After suffering from chest infection every winter, Margie finally decided to quit.
Margie felt the key to success in this quitting attempt was both her strong commitment to doing so, and a sense that the time had come to face up to the damage that smoking was doing both to her health and to her wallet. She was staggered to find that she had smoked her way through $6000 worth of cigarettes every year. But it was watching her mother die of smoking-related illness that finally forced Margie to realise the damage that smoking could do.
After briefly trying nicotine patches and finding that they did not suit her, Margie was able to quit ‘cold turkey’. Support from friends, family and work colleagues, especially other smokers, were an important part of the quitting process. Her partner at the time, out of consideration for Margie, took to smoking outside the house; he soon followed her lead and gave up himself. This positive feedback gave her both a sense of pride in what she was doing and her self esteem a real boost.
Margie says she cannot remember suffering from bad nicotine cravings; instead, she focused on the positives she was experiencing from being smoke-free. She found new joy in her favourite foods and perfumes once her sense of smell and taste quickly recovered. Her skin also felt smoother and her clothes no longer had the odour of tobacco smoke. While Margie did gain a bit of weight, she has since been able to lose most of it. This has been further helped by her increased fitness because of no longer suffering from regular bouts of bronchitis.
Margie feels she encourages other smokers around her to quit – not through giving them lecture but through leading by example. She likes to share her experience with friends and family in the hope that it will inspire them to quit too. Margie is to be congratulated on her success and we would like to thank her for sharing her story with us.
Material adapted from:
Usually when someone quits using the cold turkey method they quit all at once. Evidence shows this is more successful than tapering (cutting down), even if someone chooses to quit using support from pharmacology or a health professional. However not everyone is ready to quit smoking. For anyone not quite ready to quit, but who is starting to think about the benefits of not smoking, cutting down is a good way for people to get more control over their smoking and start to change their smoking habit. Cutting down can give people the confidence to quit. More tips on how to cut down are given in Box 2.
Box 2: How to cut down on the smokes
To get any health benefits it is necessary to stop smoking completely, but some people aren’t ready to do that. They may feel nervous about quitting or feel put off because they have been unsuccessful at quitting in the past. But there are ways to help people get more confident and feel more in control of their smoking. They can practise not smoking in every-day situations where they would normally smoke, as well as cutting down in other ways. By doing this they are taking small steps towards quitting for good. Some suggestions to cut down are:
Other activities can support people to succeed in their attempts to quit. While nicotine addiction plays a big role in maintaining smoking behaviours, factors such as the social interactions that smoking supports, and psychological causes such as habit, also make it hard for smokers to quit.
Giving people new habits and ways of interacting to replace the gap left by not smoking may therefore be helpful. For example, if someone uses ‘going for a smoke’ with friends and family as a way of having a yarn or as an opportunity to debrief or blow off steam with co-workers, then it is important that they find other ways to engage in these important social interactions. So ‘come and have a smoke with me’ might become ‘come and have a cuppa’ or ‘come for a walk/bike ride/swim’.
There is some evidence that exercise can be an aid to smoking cessation. Recent evidence from Canada has shown that including a structured exercise program alongside nicotine replacement therapy (NRT) can increase quit rates and this is sustained over time. Exercise seems to reduce withdrawal and cravings for cigarettes. This may be because physical activity stimulates the reward centres in the brain in a similar way to smoking. The pleasurable ‘high’ that exercise delivers might also provide a distraction from the cravings and negative thoughts experienced during quitting.
Aerobic exercise (e.g. running, swimming, cycling) and some kinds of strength training (isometric) is especially helpful for reducing withdrawal symptoms and cigarette cravings. Effects can last as long as 50 minutes after the exercise session. As well as starting a regular exercise routine, someone trying to quit might use exercise as a distractor when an urge for a cigarette strikes. This might be as simple as going for a short walk. For more tips on coping with cravings see Box 1.
In the longer term, exercise programs might help prevent relapse by boosting self-esteem, feelings of wellbeing and reinforcing a person’s self-image as a non-smoker and physically active individual.
Box 1: The four Ds guide to beat the craving…
Delay acting on the urge to smoke. Don’t open a pack or light a cigarette. After a few minutes, the urge to smoke will weaken.
Sip some water slowly, holding it in the mouth a little longer to savour the taste.
Take deep slow breaths in and out and repeat three times. Deep breathing will take the focus off the cravings.
Do something else
To take your mind off smoking, do something else:
It is important that TIS teams work to improve Aboriginal and Torres Strait Islander people’s access to cessation support services such as Quitline. They can do this by raising awareness and understanding of these support services, addressing any misunderstandings, and promoting service use in their region. This might include referring smokers to Quitline, as well as providing education and information about the service.
There is some evidence that Aboriginal and Torres Strait Islander people may be reluctant to use the mainstream Quitline because of a perception that non-Indigenous counsellors would be unable to relate to them, or that they would talk down to them.
Since 2010 the Department of Health has provided funding to all Quitline services to enhance the capacity and knowledge of Quitline counsellors to enable them to deliver appropriate and culturally sensitive services to the Aboriginal and Torres Strait Islander population. Partnerships with Aboriginal and Torres Strait Islander communities have been built to promote and encourage use of Quitline services. This has included outreach work with counsellors, visiting services, and community events. Some services also employ dedicated Aboriginal and/or Torres Strait Islander counsellors.
Reports from Quitline providers indicate capacity, with most staff having undertaken training, and an increase in referrals to Quitline (both self-referrals and referrals by agencies) being seen across sites.
While uptake of services has clearly benefited from this approach, evidence for the effectiveness of Quitline for supporting cessation attempts by Aboriginal and Torres Strait Islander people is still limited. However, there is no reason to believe that culturally sensitive Quitlines would not be effective, as long as if people are able to access the service.
Behavioural counselling is well established as an effective support mechanism for individuals wishing to quit smoking. Counselling is effective when delivered either on a one-to-one, or in a group setting. There is a relationship between the intensity (length of session contact) and duration (number of sessions) of behavioural smoking cessation counselling and its effectiveness, but even low intensity counselling (3-10 minutes) improves quit rates.
Although the evidence is limited, intensive counselling (more than 10 minutes) has been shown to increase quit rates in some Aboriginal communities. For example, the
included intensive counselling as one component in addition to usual care (quit advice, pharmacotherapy, and patient-initiated follow up). Evidence shows that the program doubled quit rates from 6% to around 12%. This effect was found despite the intervention being implemented with less intensity than originally planned.
Brief intervention (see Box 1) is accepted as an effective approach which increases quit rates in motivated individuals. This approach has been found to be most effective when combined with other interventions such as behavioural support, and nicotine replacement therapy (NRT). Although it is usually delivered in a one-to-one situation, increasing access to brief intervention training is an important and effective part of a population health promotion approach. This is because:
Box 1: What is a brief intervention?
Brief intervention makes the most of any opportunity to raise awareness, share knowledge and get someone to think about making changes to improve their health and behaviours. Brief intervention uses counselling skills such as motivational interviewing and goal setting. An understanding of the stages of behaviour change is also important. Brief intervention takes as little as 3 minutes and is usually carried out in a one-to-one situation. The 5As for smoking cessation for health professionals is an international smoking cessation framework used in brief intervention that has been shown to be very effective in encouraging and supporting smoking cessation. More information about the 5As can be found in this podcast developed for the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people featuring Professor David Thomas.
Specific barriers to the use of brief intervention with Aboriginal and Torres Strait Islander clients have been identified.
Cultural beliefs are particularly important, as they mean that brief intervention is often seen to be inappropriately telling people how to behave.
The Queensland Government developed a brief intervention training program, SmokeCheck, for Aboriginal and Torres Strait Islander Health Workers and other health professionals who work with Aboriginal and Torres Strait Islander health clients and communities, which addressed these barriers. It included culturally sensitive materials and approaches for brief intervention. Evaluation found that SmokeCheck increases health workers confidence when:
Health workers also reported offering more advice about nicotine replacement therapy and reducing tobacco use after training, suggesting a change in behaviour as well as confidence.
A recent study which included SmokeCheck training as part of a multi-component community project, found that while health workers spoke positively about the training. No-one implemented the intervention as they had been shown. Rather they adapted their approach using only some of the components. No evidence is available yet on how this affected client responses to the intervention – it may have been that these adaptations were appropriate responses to individual need.
A guide to the SmokeCheck brief intervention with clients at the various stages of change.
SmokeCheck and other brief intervention training packages designed specifically for working with Aboriginal and Torres Strait Islanders (e.g. Quitskills) are available in most States and Territories. More information on workforce training for brief intervention can be found here.
Because of the opportunistic nature of brief intervention, it is important that anyone who has contact with smokers from Aboriginal and Torres Strait Islander communities has culturally appropriate brief intervention training. In many organisations only health professionals, such as Aboriginal and Torres Strait Islander Health Workers, nurses, doctors, and dentists are trained to do brief interventions. However, because brief intervention is focused on motivation and education, not therapy, you do not need a health background to do this training. They are also opportunistic, meaning that they do not need to take place in a medical setting. This means anyone can do brief intervention training, including:
Regional Grant funding does not cover TIS teams to offer nicotine replacement therapy (NRT) or other stop smoking medication (SSM) to smokers. This is because TIS teams are funded to carry out population health promotion activities, not individual smoking cessation support. However, it is important that TIS workers have up-to-date knowledge of the individual level cessation supports such as NRT and SSM, as these can inform population health promotion activities (e.g community knowledge building).
A number of studies have examined the extent to which NRT is an effective smoking cessation treatment for Aboriginal and Torres Strait Islander populations. Overall NRT is effective, particularly if free/subsidised, and especially if accompanied by good follow-up support services. Evidence about the effectiveness of other SSM such as Varenicline (Champix) and bupropion (Zyban) in Aboriginal and Torres Strait Islander populations is limited. An article from the Talking about the Smokes (TATS) survey,
found that Aboriginal and Torres Strait Islander people are less likely to use NRT or SSM as part of a quit attempt (37%) than non-Indigenous smokers (58.5%). However, just under three quarters of those surveyed believed NRT and SSM did help smokers quit. Cost is probably the main barrier to using pharmacological aids. Nicotine patches – available to Aboriginal and Torres Strait Islander patients at a subsidised cost on an authority script through the Pharmaceutical Benefits Scheme (PBS) – were the most common pharmacological aids used by Aboriginal and Torres Strait Islander smokers and recent ex-smokers (24%). Varenicline was the next most commonly used pharmaceutical at 11% and nicotine gum at 10%.
Observational research in remote Northern Territory communities, found that following recommended treatment for using NRT (compliance) can be limited by factors such as:
However, observation of the successful delivery of NRT in one community by a public health nurse showed how compliance improves when regular support and counselling is provided: NRT was supplied in one week blocks with face-to-face follow-up every week at the client’s home. There is also evidence from the
that combining NRT with intensive counselling and support is effective even in remote settings.
This suggests that focusing on increasing compliance is likely to improve quit attempts. This can be done through:
Other activities to increase the use of NRT in helping Aboriginal and Torres Strait Islander smokers to quit are:
Another program which demonstrates the effectiveness of a comprehensive service for supporting quit attempts is the
smoking cessation program based in ACT. The program combines weekly support groups, access to NRT (through a GP), phone follow-up, and home and workplace outreach (see Box 1).
It is important to provide health promotion for primary and secondary school age people. There is evidence that school-based activities have an increased chance of working if they:
Linking school-based interventions into wider community activities as part of a multi-component program also seems to boost impact. This is thought to be because the effects of school-based smoking prevention programs are sustained when changes in the larger community are also present and when there is reinforcement of the program over time. A review of the evidence also recommended that 15 or more sessions are delivered to young people at school, at least up until the ages of 14 or 15 years.
Evaluated school-based health education activities for Aboriginal and Torres Strait Islander young people, include the
program, an interactive education program of seven weeks which encourages young people to be positive lifestyle role models. Since 2010 this program has been delivered to more than 250 Aboriginal and Torres Strait Islander students across 20 schools and training centres throughout South East Queensland and has been found to have a positive impact in the urban setting on students’ knowledge, attitudes and self-efficacy regarding leadership, chronic disease and the impact of risk factors including smoking. These are recognised as important steps towards reducing the number of young people taking up smoking and increasing the number of young people who quit smoking.
According to data from the Australian Institute of Health and Welfare, almost half of all pregnant Aboriginal and Torres Strait Islander women smoke. Smoking in pregnancy can be supported/encouraged by people’s expectations about what is considered ‘normal’ behaviour, as well as family influences.
Quitting is seen as a difficult thing to do. Despite strong protective attitudes for the unborn baby, continued smoking may be thought of as a necessary response to stressful situations in life. This suggests a need for greater knowledge and understanding of the problems which smoking in pregnancy can cause. The evidence shows that tailoring health promotion social marketing for Aboriginal and Torres Strait Islander pregnant women is more likely to support changes in attitudes and intention to quit for this group.
Regional Grants do not fund TIS teams to offer nicotine replacement therapy (NRT) to smokers. However, it is important that TIS workers have up-to-date knowledge of the individual level cessation supports available to pregnant women, as these can inform population health promotion activities (e.g community knowledge building). While NRT does not always result in smoking cessation by pregnant women, using NRT rather than smoking while pregnant is better for the baby because it removes the other dangerous toxins contained in tobacco smoke. Antenatal smoking guidelines, Management of smoking in pregnant women recommend that pregnant women should first try to quit using counselling and support. If this does not work then the woman should be offered oral short-acting forms of NRT (lozenge or mouth spray). If this is not effective, smoking cessation treatment may progress to nicotine patches, or if necessary combined therapy (i.e. patches plus oral forms). NRT must only be used in pregnancy under the supervision of a suitably qualified health professional. Other stop smoking medicines (varenicline and bupropion) are not safe to use in pregnancy.
Other activities to help pregnant Aboriginal and Torres Strait Islander smokers to quit (with or without NRT) include:
The New South Wales Quit for New Life program provides an example of how these activities might be combined (see Box 1). Once again a systems approach is recommended, linking the woman in with other support that is available either from the community, Aboriginal Medical Services, or even social media such as the Quit for you – quit for two mobile device app.
Box 1: The Quit for New Life program
This program is offered across all Aboriginal Maternal and Infant Health Services (AMIHS) in NSW that provide antenatal care for women having an Aboriginal baby. It combines a number of recommendations for supporting pregnant Aboriginal and Torres Strait Islander women to quit smoking including:
A recent study in Australia has also demonstrated the acceptability of rewards or incentives to encourage pregnant Aboriginal and Torres Strait Islander women to quit or reduce their smoking, while a study in New Zealand has shown that financial and product based rewards can promote quitting in pregnant Maori women.
Second-hand and third-hand smoke are health risk factors, particularly for children. If mothers are not ready to quit, then finding ways of avoiding smoking around their children, such as in the car or at home are important ways of improving child health. For more information on this topic please see the section on reducing second-hand and third-hand smoke.
Social media and social networking tools such as Facebook, Instagram, YouTube and Twitter are increasingly being used to help tackle smoking, particularly with young adults. One of the advantages of these platforms is that they are accessible, low cost and familiar to young people. About 15 million Australians are active users of Facebook – around 63% of the total population.
Research by the McNair Ingenuity Research Institute in 2014 found that Facebook is a popular means of communication among Aboriginal and Torres Strait Islander people. According to this study (which is ongoing), even in remote communities use of Facebook is higher than in mainstream Australian society.
The use of Facebook and Twitter as a way of communicating is a popular approach for many healthcare services. However the value of these tools seems to lie more in their networking functions. Social media is interactive and user-driven, meaning it has the potential to provide real-time peer to peer support and discussion around tobacco use.
There is currently a lack of evidence of the effectiveness of using social media in tobacco control. Studies that do exist tend to be descriptive, with a focus on the acceptability of the medium to support quitting, or an analysis of posts. A recent study from Canada provides some support for the use of social media for extending the reach and impact of more traditional smoking cessation approaches among young adult smokers. The study found that young people engaged through social media were more than twice as likely to have made a successful quit attempt three months into the campaign than those not on social media and using on-line support only.
Menzies School of Health Research has recently produced a tips and tricks resource for people working in health promotion and tobacco control, Social media in health promotion and tobacco control: tips and tricks. An accompanying PowerPoint presentation, Can Facebook help Aboriginal and Torres Strait Islander people to quit smoking? is also available.
Mass media and social marketing campaigns aim to reduce the number of people who smoke by changing attitudes, beliefs and intentions surrounding tobacco use. Mass media campaigns take a traditional marketing approach to this aim, treating the desire to be smoke-free as a product to be sold. In contrast, social marketing uses knowledge of specific community barriers to develop more targeted marketing approaches.
Both approaches use education about the negative consequences of smoking and the benefits of not smoking for two purposes:
It is thought these campaigns help to prevent smoking by changing people’s expectations toward smoking, so that tobacco use is no longer accepted as the ‘usual, cool or necessary thing to do.’
There is evidence that both mass media and social marketing campaigns can help prevent smoking from starting, encourage people to stop smoking, and prevent relapse among recent quitters by reminding them about why they chose to stop smoking. However one of the biggest effects is in relation to promoting access to cessation support services such as Quitline, counselling and other health professionals. Developing capacity to support people who are ready to quit – by taking the systems approach described under Planning, is therefore essential if programs are to be sustainable.
A campaign’s impact is influenced by:
The relevance of the message has been found to be important for audience engagement. The context, characters and role models used in advertising or community activities must seem believable, if smokers are to connect to them. When a campaign does not relate to how people see themselves, they find it hard to become interested in the content. While there is some evidence that mass media campaigns do influence attitudes and beliefs of Aboriginal people and Torres Strait Islanders in regard to smoking, more specific local messages tailored for Aboriginal and Torres Strait Islander people seem to be most effective. Evidence from the
project also supports the importance of using targeted advertising.
The Australian Government’s Don’t Make Smokes Your Story campaign is a good example of how advertising and community-based activities can work together to encourage behaviour change among Aboriginal and Torres Strait islander smokers. You can adapt and use these materials and resources for your own activities.
Reducing second-hand and third-hand smoke is an important aim. This is because second-hand and third-hand smoke can be very harmful. The evidence also shows that if smoking is seen as ‘normal’ at a community level, young people are more likely to start smoking, and current smokers will find it harder to quit. Increasing the extent to which a community is smoke-free is associated with less smoking and more success in quitting. Relevant activities include the following:
To be successful, smoke-free policies need community participation – not just consultation – in their development. Policies that have local ownership and commitment are more likely to be followed. There is also evidence that introducing smoke-free policies in the workplace can lead to increased support for smoke-free spaces in other areas such as smoke-free homes and cars. Successful smoke-free workplace policies also result in more workers wanting to quit.
Combining locally owned smoke-free policies with access to quit support services increases the success of these policies. Working in an environment with a smoke free policy can also encourage individuals to quit.
Here are some quick tips on setting up a smoke-free environment: How to set up a smoke free environment.
The Aboriginal Health and Medical Research Council (AH&MRC) of New South Wales provide a good set of resources to help you support workplaces to set up smoke-free policies. The second module, Workplace smoking policy in the
provides: advice on how to begin the process; templates for worker consultation; and templates to assess how much smoking happens at work.
Second-hand and third-hand smoke is a health risk factor, particularly for children. Children are at greater risk for a number of reasons, including their size, faster breathing rates and less developed respiratory and immune systems. Second-hand smoke is associated with a number of childhood illnesses including:
Second-hand smoke is also believed to contribute to the risk of sudden infant death syndrome (SIDS).
Less well known, but probably just as harmful is third-hand smoke. Third-hand smoke is the tobacco smoke toxins from second-hand smoke that get into a smoker’s hair and clothes and build up on surfaces and dust in areas where people smoke. Evidence shows that these toxins stay in homes and cars for a long time after the cigarette has been extinguished, even several months later. They may even become more toxic over time.
Third-hand smoke is an emerging area of research and we don’t yet understand all the health hazards. However, children (especially infants), are more vulnerable to third-hand smoke toxins. This is because infants crawl over contaminated floors and mouth contaminated surfaces like furniture and toys. We also know that infants consume up to a quarter of a gram of dust every day. That’s twice as much as adults.
There is good evidence that having a smoke-free home and car improves children’s health. There is also some evidence that keeping the home smoke-free helps to prevent uptake of smoking by young people. There are therefore many good reasons to support people to have smoke-free homes and cars.
A recent review found that intensive counselling methods or motivational interviewing with parents to be most effective for reducing children’s tobacco smoke exposure in the home. There is some indication that school-based education, intensive home visits, brief education provided to parents in clinics (including scheduled children’s health checks) and culturally sensitive health promotion brochures may also help reduce second-hand smoke in the home and car.
Menzies School of Health Research has developed Healthy starts: reducing the health effects of smoking around Indigenous babies and children, a resource to support health providers when discussing second-hand tobacco smoke with families, and to encourage families to have smoke-free homes.
Any opportunity to reduce second-hand smoke is a good investment because there is no safe level of exposure to second-hand smoke, and smoke-free events both denormalise smoking and encourage people to think about quitting. Furthermore a recent survey, Talking About The Smokes (TATS) found that support for smoke-free festivals and events is strong in Aboriginal and Torres Strait Islander communities, particularly among those who don’t smoke: for never smokers, support was 71%, for ex-smokers 65%, and for non-daily smokers 70%. Half of all daily smokers were in favour of smoke-free events (51%).
Pledging to be smoke-free demonstrates an active commitment and motivation to change. Evidence shows that when someone makes a public declaration (pledge) they are more likely to follow through with that promise, both for themselves, but also because of what others might think of them if they don’t maintain their promise. We also know that people are more likely to stick with a commitment that has real value, purpose and meaning to them.
Smoke-free pledges are a good population health promotion tool because:
Once you have decided what you want to accomplish through your program, you will need to choose activities that will help you to achieve these aims. It is important that Tackling Indigenous Smoking (TIS) activities are effective for achieving the proposed outcomes of the TIS program (e.g. increasing awareness of the benefits of not smoking, more smoke-free environments, increased quit attempts, reduced uptake of smoking). The best way of ensuring that an activity is effective is to use ones which have been tried and tested, so we have evidence that they work. It is also important that you choose the right activities for your local population needs and your local community context. Your role is to use your understanding of the communities in your region, your professional experience and expertise, along with your knowledge of the evidence to put together a suitable set of activities.
Evidence is the information or knowledge about ‘what works’ which can help you decide which activities you will use. Evidence comes from many different sources including published research, and many professionals value this kind of evidence the most. However published research about TIS activities is not always available. Local evidence that an activity works also has an important role to play in the development of TIS activities.
Figure 1: Using the evidence to develop locally relevant services
This is one reason why the careful monitoring and evaluation of local activities is an essential part of the TIS program. Collecting accurate and thorough local data will help you to see what works best and this information can then be used to improve your activities. You can also share this with other TIS-funded organisations and contribute to the evidence on what works for TIS.
Sometimes collecting data can be challenging – the number of participants in a program may be small, or it may be that it can take a long time to see changes in smoking behaviour in the wider community. The NBPU TIS can support teams to address these and other challenges in order to develop the evidence base for TIS.
It is important to remember that the evidence does not provide a set of fixed solutions (it is not a ‘recipe book’). It is one element in an ongoing process. Your decision making will draw on your professional expertise about TIS and the local community with the evolving local and research evidence to develop a locally relevant service (Figure 1).
Stopping smoking by current smokers is the best way of reducing tobacco-related harm. Individuals may make several quit attempts before successfully stopping smoking for good. This is why health promotion activities and community development to support quitting are so important; it’s about continually reminding people of the importance of quitting and informing them about where to get help. It is important that as well as providing education about tobacco harms, organisations providing health promotion activities are able to refer people who want to quit to smoking cessation support services. Being part of a wider health service system or network is therefore essential for TIS teams.
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