Cold turkey

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.

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 people who smoke quit unaided.

Unaided quitting is known as going ‘cold turkey’. People who smoke 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:

  • setting a quit date
  • throwing away smoking gear (e.g. cigarettes, ashtrays, lighters)
  • changing routines linked with smoking (e.g. instead of smoking in a work break go for a walk)
  • avoiding situations where they usually smoke
  • starting new activities (e.g. exercise) to replace smoking.

Using physical activity to enhance quit rates

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.

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 people who smoke 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’.

Smoking and stress factsheet

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. To find out more about strategies for people who are quitting smoking to manage stress read the Key facts about smoking and stress factsheet.

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

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.

Drink water

Sip some water slowly, holding it in the mouth a little longer to savour the taste.

Deep breaths

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:

  • listen to music
  • go for a walk or exercise
  • or talk to a friend.

Material adapted from:

Quitline

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 people who smoke 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.

Key facts about Quitline

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.

The NBPU TIS have produced a Key facts about Quitline factsheet that provides key information about the Quitline service for TIS workers including promotion of Quitline for cessation support, how Aboriginal and Torres Strait Islander Quitline counsellors can help community members and common questions about Quitline.

Counselling

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.

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.

Pharmacology

Regional Grant funding does not cover TIS teams to offer nicotine replacement therapy (NRT) or other stop smoking medication (SSM) to people who smoke. 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 people who smoke (58.5%). However, just under three quarters of those surveyed believed NRT and SSM did help people who smoke to 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 people who smoke 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:

  • difficulties maintaining NRT supplies in remote areas
  • individuals running out of patches because they share with other family members
  • cost, particularly for forms not on the Pharmaceutical Benefits Scheme (PBS).

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:

  • greater discussion around NRT options (e.g. gum, patches or combined therapy)
  • including patients in the decision process
  • providing appropriate regular support.

    NRT factsheet

Other activities to increase the use of NRT in helping Aboriginal and Torres Strait Islander people who smoke to quit are:

  • providing better information about NRT to the community
  • including access to NRT as part of a broader tobacco control program.

Another program which demonstrates the effectiveness of a comprehensive service for supporting quit attempts is the No More Boondah 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.

You can find further information about nicotine replacement therapy in the video and factsheet produced by NBPU TIS which can be downloaded here.

Further reading