Cold turkey

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:

  • 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.

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:

  • cut down gradually, for example smoke one less each day, butt out when it is only half finished, or make the mornings/evenings a smoke-free zone
  • replace cigarettes with carrot sticks, cassava sticks or fruit, chew on sugar-free gum or brush your teeth instead
  • do something else instead, for example knitting, swimming or gardening, go for a swim, walk or run, or take a shower
  • reward yourself for cutting down.

Material adapted from:

Further reading

Using physical activity to enhance quit rates

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

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:

Further reading

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 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.

Further reading

Counselling

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.

Further reading

Pharmacology

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:

  • difficulties maintaining NRT supplies in remote areas
  • individuals running out of patches because they share with other family members
  • cost, particularly for oral 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.

Other activities to increase the use of NRT in helping Aboriginal and Torres Strait Islander smokers 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

 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).

Box 1: Violet Sheridan and No More Bundah
Violet Sheridan has been an Aboriginal Health Worker at the Winnunga Nimmityjah Health Centre, an Aboriginal Health Service in the Australian Capital Territory, working within a substance abuse project. She has also smoked for most of her teenage and adult years. Seeing her mother-in-law struggle with the effects of emphysema, and similarly experiencing trouble with her own breathing, she decided to take advantage of the No More Bundah program offered by Winnunga Nimmityjah. No More Bundah is an eight-week quit program run by Winnunga that promotes smoking cessation through the use of counselling and group meetings, together with a free two-week supply of nicotine replacement therapy. Violet felt that the initial support provided by the nicotine patches made the difference this time in giving up smoking. Her body no longer craved the nicotine in cigarettes, which in turn made it easier to change her impulse to reach for a cigarette out of habit. ‘When I felt like I wanted a cigarette I knew it wasn’t my body needing the cigarette it was just my mind. So I’d tell myself to wait a couple of minutes or go and have a glass of water, and the urge would have gone’. It is this change in her behaviour around smoking that Violet feels is the key to her successfully giving up. Even though she is with people who smoke all the time she is able to modify what she does when the urge strikes. Even when she no longer attended the support groups, Violet was able to apply the skills that she had learned to get through those times when temptation—or simple habit—would have otherwise weakened her resolve. Now Violet is feeling the benefits of being smoke free for ten months. Her sense of smell and of taste have returned and her energy level has increased so that she is now able to go for long walks. Her doctor has told her that her heavy cough, a result of thirty-seven years of smoking, will take a little longer to clear but her breathing has improved remarkably. Asked what she would say to anyone considering giving up smoking, Violet said: ‘Have a go and just don’t give up hope. It’s the hardest thing I’ve ever done and it took me twenty attempts, but I did it with the help I got through No More Bundah. All my friends and family are really proud of me’.Material adapted from:

Further reading