section 3: helping people quit the smokes

Section 3:Helping People

Quit the Smokes

In this section, we help you to talk to people about giving up the smokes:

We give you all the information you need to run your own quittingcourse and to talk to people about the health effects of smoking, whypeople smoke and how smokers can give it up.We show you how to support people through the quitting process.We look at a few quitting programs being run around the country.We outline a variety of tobacco control training courses run for healthworkers.

What’s in Section 3?Part 1: Information on quitting

Benefits of quittingHow smoking hurts the bodyWhat’s in a cigarette Why people smoke tobaccoNicotine: A hard habit to breakBreaking the cycle of addictionThe 5 stages of change in tobacco smokingTriggers for lighting upTriggers for quittingWithdrawal and cravingsNifty ways to leave your smokes

Part 2: How to talk to people about quittingSuccess stories: Share them aroundListen and learn: Brief interventionSmokeCheck Indigenous Tobacco Brief Intervention ProgramWorking out if people are ready to quitEncourage and motivate: Motivational interviewing Making decisions Coping with withdrawal symptoms

Part 3: Programs to help people quitThe Koori Smoking Cessation ProgramQuit courses for health workers and professionalsQuit services: Available to Australians who smoke

Part 4: Getting the environment rightDeveloping a smoke-free workplace policyHow to set up a smoke-free work environment

AcknowledgmentsThe information in this section is based on the work of Quit Victoria

Part 1: Information on quittingGetting people to think about their smoking is the first step to change. Let themknow what’s in the smokes if they don’t know already, without getting too pushyabout it. Also let them know what they’re in for when they give up the smokes—the good things and the not so good things. Concentrate on the good things, butdon’t leave out the not-so-good things.

Benefits of quittingQuitting smoking is the best thing a smoker can do to improve their health andlive longer. People who stop smoking cut down their chances of developingbreathing problems, lung cancer, and heart disease. Many smokers say thatwhen you give up the smokes, you actually feel better about yourself. Your senseof taste and smell begins to improve. Within a few months your lungs arehealthier, and breathing and exercising becomes easier.

Smokers who give up also find they have more money to spend on things forthemselves and their family. In 2006, the average packet of 20 cigarettes costsabout $8.30. Someone smoking a pack a day would spend more than $3000 ayear on cigarettes.

How smoking hurts the bodyCigarette smoke has many different effects on health. It causes, or is linked to,more than thirty different diseases, including:

breathing problems (emphysema and chronic bronchitis)

stroke

heart disease

diseases in blood vessels (peripheral vascular disease)

cancer

Australian Indigenous Tobacco Control Resource Kit 35

What’s in a cigarette? There is no safe cigarette and no safe level of smoking. Tobacco smoke is amixture of more than 4000 chemicals. Many of these chemicals come fromburning tobacco. The rest come from burning cigarette paper and chemicalsused in growing tobacco, as well as chemicals added when making cigarettes,such as flavouring agents.

Source: Smarter than Smoking Project (based in Western Australia and funded by Healthway)

Tobacco smoke contains:

Tar. This sticky brown mixture of chemicals stains the fingers, teeth andlungs of smokers. It includes a number of cancer-causing substances.

Nicotine. Nicotine is the poisonous drug in tobacco that makes peopleaddicted to smoking.

Toxic gases. Carbon monoxide (also found in car exhaust fumes),hydrogen cyanide (used in gas chambers), ammonia (used in floorcleaners), and many more.

Pesticides and radioactive compounds.

Metals. Arsenic, nickel and cadmium (used in car batteries) amongothers.

Go to CD–ROM: For more information about what’s in cigarettes, see Section 7: Part 1, Quit’s ‘Background Brief—What’s in Cigarettes’

36 Talkin’ Up Good Air

CarbonMonoxide

CarExhausts

PesticideFloor

CleanerWhite Ant

PoisonLighterFluid

Poison used in

gas chambers

MothBallsRocket

FuelCar

BatteriesInsecticide

IndustrialSolvent

Nicotine Ammonia Arsenic Butane HydrogenCyanide

NaphthaleneMethanolCadmiumAcetoneDDT

ToluenePaint

Stripper

Why people smoke tobaccoPeople smoke cigarettes for lots of reasons. Most people start smoking whilethey’re teenagers:

to fit in with their friends—smoking is a way to be accepted;

to look cool and grown up, and experiment with something that isforbidden by older people;

because, maybe, their parents, brothers or sisters smoke; and

because famous people they admire smoke, such as rock stars and sports heroes.

By the time people have reached adulthood they are addicted, and smoking is seen as:

a way to relax, and chill out—a reward;

a habit—something to do;

a pleasurable thing to do that makes them feel good;

a way to deal with stresses and pressures—economic, social and personal;

a way to control body weight;

a way to be social; and

a way to satisfy the craving for nicotine.

Smoking tobacco is not only a habit learned early in life, it also has a physicaland addictive effect on the body.

Nicotine: A hard habit to breakCigarettes and other forms of tobacco are addictive because they contain nicotine.

Nicotine is found naturally in tobacco plants. When tobacco is chewed orsmoked, the nicotine in it sets off chemical or biological changes in the brain,altering the mood of the smoker. Nicotine makes smokers want to keep smoking.

In the beginning, new smokers light up cigarettes in certain situations, such as atsocial gatherings or when they feel angry or down. In relaxed situations, smokingcan perk up a person’s mood, while in stressful times smoking can have a calmingeffect. Before too long, smokers find their day is organised around smoking. Theyfeel anxious when they feel like a smoke and can’t have one. After a while thebody gets used to nicotine, so that the smoker starts smoking more.

Go to CD–ROM: For further information about nicotine addiction, see Section 7: Part 1, Quit’s ‘Background Brief—Addiction’


Many smokers go through nicotine withdrawal symptoms when they stopsmoking. Smokers who are addicted to nicotine have a few tell-tale signs:

smoke within 30 minutes of waking up;

smoke more than 10 cigarettes a day; and

experience withdrawal symptoms when trying to quit.

Knowing a smoker’s level of nicotine dependence will help you work out the bestway to help your client give up the smokes. Most people who are addicted oftendon’t succeed the first time they try to quit: it will probably take a few tries, sobe patient. Encourage people to think of the time they spent smoke-free as anachievement to be proud of, even if it is only for a day or two. Get them to thinkabout what they have learned from quitting in the past and how to use it nexttime.

Go to CD–ROM:For a list of questions to help you work out a smoker’s level ofnicotine dependence, see Section 7: Part 2, Handout #3, ‘Fagerstrom Test for Nicotine Dependence’

Breaking the cycle of addiction Most smokers have been told many times that they should quit smoking. But itis up to them to choose whether they smoke or not. They often know many ofthe risks of continuing to smoke, but believe the good things about smokingoutweigh the bad.

When smokers think hard and long about the good and not so good thingsabout smoking, they can really then decide how they feel about their smoking(and whether they want to keep on with it). They may be happy smokers,not sure about making changes, ready to give up smoking or trying to stayan ex-smoker.

It can take a few attempts to quit, and relapse or going back to smokingis common. But with every attempt, smokers learn more about becoming a non-smoker.

If we can understand what people are thinking and feeling about their smoking,we have a much better chance of helping them to quit. So, when talking to yourclients about smoking, it might be helpful to work out which of the followingfive stages of change they fit in.



The 5 stages of change in tobacco smoking

1. Not ready for change

‘I love smoking.’ ‘I’m not interested in quitting.’ ‘I get a lot out of it!’

They could be:

not concerned about smoking;

not wanting information;

not saying anything at all;

talking about something else or looking uncomfortable;

not aware of the health effects of smoking;

filtering out anti-smoking information; and

in denial.

2. Unsure about changing

‘I’m not sure I’m ready.’ ‘I’m thinking about it.’ ‘Yes, but…’

They will:

have some concerns;

be more aware of pros and cons;

want more information;

seem interested and ask questions;

be thinking about how they need to give up;

not be ready to give up yet;

be more personally vulnerable; and

be unsure.

3. Ready for change

‘I want to stop now!’ ‘I need some help’

They will be:

making decisions;

making some changes now and intend to give up in the near future; and

wanting solutions.

4. Action

‘I’m trying to quit.’

They will be:

showing concern;

happy to have more information;

happy to talk about choices and support;

wanting to plan how to give up;

making active attempts to stop smoking;

making a commitment of time and energy;

finding it hard to make new routines or finding things to replacecigarettes; and

in two minds, or unsure, as to whether they can stay off the smokes.

5. Staying Stopped

‘I want to prevent relapsing.’ ‘I may need a boost to help keep to the changes I’ve made.’

They will:

have given up smoking tobacco;

want to stick to their decision;

be happy to talk about how much better things are;

want to think about how to keep off the smokes through hard times;

be smoke free for over six months;

continue with the change;

maintain gains and work to prevent relapse; and

have established new patterns as a non-smoker.



Stayingstopped

Not readyfor change

Readyfor change

Unsureabout

changingAction

ForeverForeverquitquit

Thinkingabout quitting

Planningto quit

Quit

Staying quit Not thinkingabout quitting

RelapseRelapse

Foreverquit

Relapse

Slip-up and relapse‘I’m smoking again.’ ‘I’ve failed.’ ‘I’ll try again.’

They can:

go back to an earlier stage—retreat to comfort zone; and

learn from past for next attempt.

At the end of the day, your aim as a health worker is to help the smoker quitthe smokes forever. You can help the smoker change their smoking behaviourby travelling with the smoker through these five stages of change (see diagram below).

Source: Adapted from information supplied by Quit Victoria

Triggers for lighting upEvery smoker knows there are ‘triggers’ that will make them want to light up acigarette. Getting smokers to think about the situations they are in and theemotions they are feeling when they light up a smoke can help them quitsuccessfully.

Situations:

having a cup of coffee or an alcoholic drink;

talking on the phone;

driving the car;

at the end of a meal;

relaxing in front of the TV;

when other people smoke; and

having a yarn with friends, and so on.

Emotions, when people are feeling:

sad;

bored;

relaxed;

tired;

angry;

lonely;

stressed; or

happy (making the good times better).

Triggers for quittingSome people give up the smokes because of:

a life-changing experience, such as pregnancy;

a serious health problem, like a heart attack or stroke;

wanting to make a better life for themselves and their community, likenot wanting to smoke in front of the kids; and

changes to workplace policies.


Withdrawal and cravingsGiving up smoking is different for every smoker. Some find it easy to quit, whileothers don’t and may show signs of nicotine withdrawal. Most people only havemild symptoms. People also talk about feeling happy about giving up.

Withdrawal symptoms. The main ones include:

the urge to smoke;

feeling depressed;

difficulty sleeping or interrupted sleep;

irritability, frustration or anger;

anxiety;

difficulty concentrating; and

restlessness.

Withdrawal symptoms usually start within the first 24 hours and are at theirworst in the first week. Most symptoms fade and are gone after one month. Butsome people’s symptoms stay with them for longer. After six months, people feelbetter or at least the same as when they were smoking.

Cravings. These are the urge or desire to smoke. In the first few weeks of giving up thesmokes, cravings will happen as you adjust to living without nicotine. Cravingscan also happen in situations where people are used to smoking. Sometimesthey happen out of the blue, even months after quitting.


Hot Tip #12: You can still keep yourweight down and quit the smokes…

Smokers wanting to quit, who are worried about gaining weight, can:

See a health worker, doctor or dietician and make a sensible eating plan.

Exercise and keep fit, it’s a good way to keep weight down.

Eat healthy snacks, but be realistic, allow some treats every now and then.

Go to CD–ROM: For more information about food and nutrition, see Section 7:Part 2, Handout #4, ‘Enjoy a Wide Variety of Nutritious Foods’

Other signs. When people stop smoking, they can experience other symptoms:

coughing;

other cold symptoms, such as sneezing, headache, earache, sore throat,deafness or feeling off-colour;

mouth ulcers;

bowel disturbance, constipation;

drowsiness or fatigue;

hunger; and

weight gain.

Go to CD–ROM: For further information about withdrawal and cravings, see Section 7: Part 1, Quit’s ‘Stopping Smoking—Withdrawal’


Hot Tip #13: Go find a course forwalking the talk…

The Quit people run the Fresh Start course and the Fresh Start short course.Check out Part 3 of this section for an outline of these two courses tohelp people quit.


Hot Tip #14: 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 controlof their smoking. They can practise not smoking in every-day situationswhere 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:

Leave the smokes at home—don’t carry cigarettes.

Decide not to smoke at work.

Only smoke outside.

Cut down the number of cigarettes smoked by one each day.

Carry carrot sticks, cassava sticks or fruit instead of cigarettes.

At card games have a kitty for the person who smokes least.

Chew on sugar-free gum.

Go for a walk or run.

Change to a disliked brand of cigarettes.

Keep a diary of how many cigarettes smoked each day.

Ask a mate to cut down or stop smoking with you.

Avoid alcohol.

Put an elastic band around the cigarette packet, so it is harder to open.

Each day, put off lighting the first cigarette by five or ten minutes.

Butt out the cigarette when it’s half finished.

Only smoke on even or odd numbered hours, or at certain times of day.

Make the mornings/evenings a smoke-free zone.

Go for a swim or take a shower.

Brush your teeth.

Change the scenery, get up and move about.

Cut drinking straws into cigarette-sized lengths and inhale through them.

If you usually smoke with others, smoke alone. If you smoke alone, spendtime with non-smokers. If you usually sit down when smoking, stand up.Smoke with the other hand or use different fingers to hold your cigarette.

Do something else with your hands—knitting, swimming or gardening.

Reward yourself for cutting down.

Go to CD–ROM: For more ways to give up the smokes, see Section 7: Part 1, Quit’s ‘Stopping Smoking—Quitting Methods and Products’

Nifty ways to leave your smokesDifferent people quit successfully in different ways. It is important for a smokerwho is thinking about quitting to choose a way that is safe and suits them best.Getting extra advice and support from a health professional helps smokers quitsuccessfully. Here are some of the many ways.

Before quitting. Chemicals in cigarettes can change the way some medications work.Quitting can also be stressful. A smoker who is ready to quit should seetheir doctor before quitting if they take medication or suffer (or have suffered)from a mental illness.

Do-it-yourself. Some smokers quit by going ‘cold turkey’, that is stopping completely andsuddenly. This is a good way to start, and there are resources available toincrease a smoker’s chance of success.

One-on-one advice. Discussing quitting with a doctor, health worker, health educator or other healthprofessional can increase the chances of a smoker quitting successfully. Check out Parts 2 and 3 in this section for more information.

Courses. Some people find attending a quit course helpful, as it offers the extra support ofa group, when trying to quit.

Cutting back on the smokes. For those not ready to stop smoking tobacco, changing where and when asmoker lights up can help a person on the way to quitting for good.

Nicotine replacement therapy. All nicotine replacement products—the gum, patches, lozenges, inhaler andtablet (microtab)—are sold at pharmacies and chemists without prescription.Nicotine replacement products work best for people who smoke at least tencigarettes per day and who want to quit.


They help cut down nicotine withdrawal symptoms while people focus onbreaking the smoking habit and learning to live without cigarettes. Nicotineproducts do not contain the dangerous chemicals found in tobacco smoke anddon’t cause cancer, so are much safer than cigarettes. Nicotine products aremade to be less addictive than cigarettes—less nicotine is absorbed, at a slowerrate than smoking.

Go to CD–ROM: For more information on patches, gum, inhalers, tabs and lozenges, see Section 7: Part 2, Handout #5, NSW Health’s ‘Products to Help You’

Prescription medicine. Bupropion is a medicine used to help smokers stop smoking by cutting downsome of the nicotine withdrawal symptoms. It is only available on prescription,and is approved by the Pharmaceutical Benefits Scheme, so it is not tooexpensive. Together with counselling, these pills can increase the chances ofquitting for good.

Go to CD–ROM: For more information on prescription drugs,see Section 7: Part 1, Quit’s ‘Stopping Smoking—Bupropion’

Acupuncture and hypnosis. Some people say they find acupuncture and hypnosis helps them quit. But thejury is still out on whether these ‘alternatives’ work, as so far there is no realevidence one way or the other.

What doesn’t work? It doesn’t help to smoke ‘light’ or weaker tasting cigarettes such as those labelled‘fine’, ‘smooth’ or ‘refined’. These cigarettes have holes in the filter that let in airto dilute the smoke, but the smoker still ends up inhaling the same amount ofchemicals as they do from stronger tasting cigarettes. Because of this they do thesame amount of damage.

Go to CD–ROM: For more on light cigarettes, see Section 7: Part 1, Quit’s ‘Background Brief: ‘Light’ or ‘Low Tar’ Cigarettes’


Part 2: How to talk to peopleabout quittingPeople make their own choices about tobacco. What you, as the health worker,say to them, how you say it, and how you listen will help people give up thesmokes.

Success stories: Share them aroundGetting people to think and talk about giving up smoking can be hard,particularly when they are not ready to quit. Depending on where a person is atwith their smoking, you can provide a range of information and talk up thegood things about being smoke free.

Success stories are a wonderful way to share the experiences of Aboriginal andTorres Strait Islander people who have quit successfully. Your client may knowpeople, or may have heard of people, who have stopped smoking. Ask yourclient to tell the stories they have heard about people who have given up thesmokes for good.

Success stories show Aboriginal and Torres Strait Islander smokers, who may livein communities where most people smoke, that quitting is possible and is achoice they too can make. But remember, it is up to the individual person tochoose whether they try to quit or not.

Sharing positive information in an informal way will hopefully get peoplethinking, and bring them around to being ready to quit (see the following threestories from CEITC’s Galnya Angin newsletter).

To find out more about collecting success stories, see Section 4: Part 1, ‘Personal stories’

Also check out a couple of ‘success story’ projects in Section 2:Part 3, ‘Engaging an Aboriginal Elder in promoting tobacco controlmessages to the Aboriginal and Torres Strait Islander community’project; ‘Say No to Smokes project—success stories campaign’.



Violet Sheridan ‘giving up the smokes’Violet Sheridan has been an Aboriginal Health Worker at the WinnungaNimmityjah Health Centre, an Aboriginal Health Service in the AustralianCapital Territory, working within a substance abuse project. She has alsosmoked for most of her teenage and adult years. Seeing her mother-in-lawstruggle with the effects of emphysema, and similarly experiencing troublewith her own breathing, she decided to take advantage of the ‘No MoreBundah’ program offered by Winnunga Nimmityjah. ‘No More Bundah’ isan eight-week Quit program run by Winnunga that promotes smokingcessation through the use of counselling and group meetings, together witha free two-week supply of nicotine replacement therapy.

Violet felt that the initial support provided by the nicotine patches made thedifference this time in giving up smoking. Her body no longer craved thenicotine in cigarettes, which in turn made it easier to change her impulse toreach for a cigarette out of habit. ‘When I felt like I wanted a cigarette Iknew it wasn’t my body needing the cigarette it was just my mind. So I’d tellmyself to wait a couple of minutes or go and have a glass of water, and theurge would have gone.’ It is this change in her behaviour around smokingthat Violet feels is the key to her successfully giving up. Even though she iswith people who smoke all the time she is able to modify what she doeswhen the urge strikes.

Even when she no longer attended the support groups, Violet was able toapply the skills that she had learned to get through those times whentemptation—or simple habit—would have otherwise weakened her resolve.

Now Violet is feeling the benefits of being smoke free for ten months. Hersense of smell and of taste have returned and her energy level has increasedso that she is now able to go for long walks. Her doctor has told her that herheavy cough, a result of thirty-seven years of smoking, will take a littlelonger to clear but her breathing has improved remarkably. Asked what shewould say to anyone considering giving up smoking, Violet said: ‘Have a goand just don’t give up hope. It’s the hardest thing I’ve ever done and it tookme twenty attempts, but I did it with the help I got through “No MoreBundah”. All my friends and family are really proud of me.’

Story 1:

Newest family member makesgrandma think about quitting againQuitting smoking is a tough job, and not every attempt to do so will be asuccessful one. The arrival of Karen West’s newest grandson, Tarnah, hasmade this grandmother rethink her smoking habit. Karen is from theKalkadoon mob near Mt Isa, and, although not a heavy smoker, she hassmoked about 15 cigarettes a day for nearly 40 years. Karen has tried oncebefore to quit and managed to cut her smoking down to two cigarettes a dayusing the support of Zyban. ‘It was really easy, and I didn’t feel like I neededany more than those two a day’.

While Zyban helped with her cravings, her first attempt at quitting onlylasted a short while. She can’t recall what it was exactly that led to hersmoking again, but remembers feeling that once she had started she mightas well keep going. Apart from the Zyban, she didn’t use any other strategiesto support her quitting attempt and doesn’t know if this would have madeany difference.

Asked what impact smoking has had on her health, Karen feels that herfitness has been affected by breathlessness and she suffers from high bloodpressure. She realises that if she can give up smoking, her fitness and bloodpressure would improve.

It is the impact her smoking has on those around her that concerns hermost. While she doesn’t smoke around her grandchildren, she would like tobe a non-smoking role model for them as well. Her daughter would beKaren’s biggest supporter should she make another quitting attempt, andhas strictly enforced the no-smoking rule around baby Tarnah.

Although Karen does not have a particular quitting strategy in mind as yet,she is beginning to think about how quitting would improve her life and theimportance of having a good reason to motivate her in this difficultchallenge. She doesn’t think that she will qualify to get Zyban on the PBSagain this year, since she has already used it, and will have to think aboutother ways she can cope with the cravings she might feel both physicallyand behaviourally.

We thank Karen for sharing her story and wish her luck and encouragementin making the next step along the road to quitting.


Story 2:

Margie Jackson: A real inspirationAs a crisis support worker for the Kamunga Aboriginal Health Service working withyoung homeless people and those in other critical situations, Margie Jackson couldhave plenty of excuses for continuing to smoke. But after smoking 70-plus cigarettesa 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 copingwith postnatal depression. She thought that smoking would be a better way ofdealing with the depression than taking medication. Over the years, Margie mademany a new year’s resolution to quit smoking but they were always short lived.Wednesday, the 18th of February 2004, though, was different. After suffering fromchest infection after chest infection every winter, Margie finally decided to quit.

Margie felt the key to success in this quitting attempt was both her strongcommitment to doing so, and a sense that the time had come to face up to thedamage that smoking was doing both to her health and to her wallet. She wasstaggered to find that she had smoked her way through $6000 worth of cigarettesevery year. But it was watching her mother die of a smoking-related illness thatfinally forced Margie to realise the damage that smoking could do.

After briefly trying nicotine patches and finding that they did not suit her, Margiewas able to quit ‘cold turkey’. Support from friends, family and work colleagues,especially other smokers, were an important part of the quitting process. Herpartner at the time, out of consideration for Margie, took to smoking outside thehouse; he soon followed her lead and gave up himself. This positive feedback gaveher 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 foundnew joy in her favourite foods and perfumes once her sense of smell and tastequickly recovered. Her skin also felt smoother and her clothes no longer had theodour of tobacco smoke. While Margie did gain a bit of weight, she has since beenable to lose most of it. This has been further helped by her increased fitness becauseof no longer suffering from regular bouts of bronchitis.

Margie feels that she encourages other smokers around her to quit—not throughgiving them a lecture but through leading by example. She likes to share herexperience 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 forsharing her story with us.


Story 3:

Listen and learn: Brief interventionTalking to clients is a big part of your daily health work. You often use yourtalking skills to raise awareness, share information and get a person thinkingabout making changes to their health and lifestyle. In your talks, you arerespectful, sensitive and flexible. In the same way, you can use your naturalskills to talk to people about tobacco smoking

Whenever the opportunity comes along, such as during health assessments,taking a client’s health history or when giving back test results, you can askyour client or patient to talk about their smoking. Anywhere between threeminutes and 20 minutes should do the trick.

Like your other health work, it’s really important to: listen to what people say;notice what they do not say;watch what they do;think about their situation;think about what you know about them;talk with them in a way that is not threatening; andavoid giving a lecture about health behaviour.

SmokeCheck Indigenous TobaccoBrief Intervention ProgramSmokeCheck is a brief intervention program developed in northern Queenslandfor health professionals working with Indigenous clients. A resources kit wasdeveloped that provides information about the health effects of smoking andstrategies for quitting, as well as teaching skills on how to do brief interventionwithin a clinical or community setting. The kit consists of a handbook along withfive pamphlets, a poster, chart and worksheets. Training workshops providehealth professionals with tools in smoking cessation assessment and interventionusing a motivational interviewing approach appropriate for Indigenous clients.

Since the original program was piloted in various clinical settings in northernQueensland, it has been evaluated by the University of Queensland, and350 health workers have subsequently been trained across the State.Recently Western Australia, South Australia and New South Wales have adaptedthe SmokeCheck model for use in their relevant cultural settings.

Go to CD–ROM: See Section 7: Part 7, ‘Training Programs’for SmokeCheck training contacts; and Section 7: Part 2, Handout #6‘SmokeCheck Program: Front Cover Outlines of Several Brochures’


Working out if people are ready to quitIf your client is happy to talk about his or her smoking habit, and wants to quit,you can then work out the person’s readiness to quit smoking. One way of doingthis is through the 5 As—Ask, Assess, Advise, Assist, and Arrange follow-up.

Ask:Talk to your clients about how much they smoke, what they smoke, when theysmoke, why they smoke.

Assess:Work out which stage of change the client is at and his or her level of nicotinedependence.

Advise:Talk to the client about giving up the smokes in a way that is clear, personalisedand does not shame them, and offer some information.

Assist:Talk with the client about what they see as the good and bad things aboutsmoking, provide quitting information, help the client to develop a quit plan,and talk about the ways to prevent relapse.

Arrange follow-up:If the client is thinking about a quitting attempt or has made an attempt,organise a follow-up visit and give support.

Go to CD–ROM: For more on helping people to quit, see Section 7: Part 2, Handout #7, ‘Quit’s 5As for Smoking Cessation for Health Professionals’


Encourage and motivate:Motivational interviewingIf you have gained the trust, confidence and respect of your client, you maythen want to help them think about the good and bad things about theircontinued smoking. Encourage them to talk about their health worries andconcerns, and reasons for wanting to change to a healthier lifestyle. Using yourclient’s own reasons, you may be in a good position to motivate them towardtaking action to give up the smokes.

To encourage, or motivate, a person to give up the smokes, there arefour key things to remember:

Quitting is their choice.

They decide how much of a problem they have.

Don’t argue with or confront them.

You could ask them to think about the good and bad things abouttheir smoking.


Hot Tip #15: Really understanding andsympathising with your client will go a

long way in helping your client stop smoking...Features of good communication skills include:

The interaction between you and your client is private.

Talking often involves the client telling their personal story, in their own words.

Talking includes sharing knowledge and talking about options.

The health worker’s role is to be non-judgmental, not forceful, notconfrontational.

The client’s decision to change, or not to change, is up to them.

Go to CD–ROM: For more information on brief intervention, see Section 7: Part 2, Handout #8, Quit’s ‘Let’s Take a Moment: QuitSmoking Brief Intervention—A Guide for All Health Professionals’Section 7: Part 2, Handout #9, Queensland Health’s ‘SmokeCheck:Indigenous Tobacco Brief Intervention Program’Section 7: Part 2, Handout #10, Quit’s ‘Guidelines for CounsellingIndividuals at Each Stage of Change’

Making decisions Try to work out where your client is at with his or her smoking. This will helppeople to decide whether they want to change their smoking.

If you don’t feel confident talking to your client about their smoking, look atyour other daily work and see where you have successfully talked to clientsabout other health problems. You can also practise your smoking talks withother workers or medical practitioners, as this will build confidence and skills.


Hot Tip #16: Yarning to help your clientopen up about smoking…

Some techniques that encourage and motivate smokers to quit are:

Ask open-ended questions. Get the person to tell you in their own words howthey feel or think about their smoking. Open-ended questions don’t have ayes or no answer. An example is ‘How do you feel about your smoking?’

Actively listen. This means repeating back in your own words what theperson is saying to make sure that you understand them correctly. Anexample is ‘So you’re saying you think gum might be better for you thanpatches?’

Encourage doubts. Help the person to see that it doesn’t make sense forthem to do something they feel is harmful.

Be personal. Provide feedback on the person’s particular situation.

Motivate change. Get the person to tell you why they should change. Matchthe type of action you advise to the client’s stage of change. This isimportant because mismatched interventions can be frustrating anddisappointing for both you and your client.

Record on the client’s file their stage of change and what you advised them.Next time you see them, talk up the positive changes and do another briefintervention if necessary.

Go to CD–ROM: Check out Section 7: Part 2, Handout #11, ‘Ready to Change?SmokeCheck’s Interviewing Guide’

Coping with withdrawal symptomsHelping smokers through the early stages of quitting is really important. If theyget through the tough stuff at the beginning, you are almost halfway there inyour help. In the first month or so of giving up, people can experience severecravings, which generally only last a few minutes at a time. The four Ds—Delay,Drink water, Deep breaths, Do something else—are a way for your clients tocope and to avoid smoking.


Hot Tip #17: The four Ds guide to beatthe craving…

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

Deep breathsTake deep slow breaths in and out and repeat three times. Deep breathing willtake the focus off the cravings.

Do something elseTo take your mind off smoking, do something else:

listen to music;go for a walk or exercise; ortalk to a friend.

Go to CD–ROM: Check out Section 7: Part 2, Handout #12, ‘Quit’s 4Ds Card’

Part 3: Programs to help people quitHere we look at how your organisation can support a tobacco control program.We do this by offering some examples of how other organisations have tackledthe smoking problem in their community.

The Koori Tobacco Cessation Program The Koori Tobacco Cessation Program was developed in partnership with SouthCoast Aboriginal Medical Service, Illawarra Aboriginal Medical Service,Illawarra Health and the National Heart Foundation of Australia (NSWDivision).

The program, run over four weeks, gives participants the option of using freenicotine replacement therapy, or NRT, for this time. Participants are referred tothe program by their doctor, who provides a clearance to use NRT products. Eachparticipant receives a voucher to buy a NRT product, which include patches andgum, from the local pharmacy.

Before and after the program, course participants complete a survey about theirsmoking and how the course has helped them to stop smoking and stay stopped.


The Koori Tobacco Cessation Program—Activities over Four Weeks

Week 1 ActivitiesIntroductions. Everyone introduces themselves.

Participants complete the pre-program survey.

Participants discuss:

Their level of nicotine dependence.

What they hope to achieve from the group andtheir past quit attempts.

The good things and not-so-good things about smoking.The group’s discussion is itemised on a whiteboard oron butcher’s paper.

The good things and not-so-good things about quitting.Again, the group records its discussion.

The health effects of smoking. Participants are asked abouttheir own health.

The benefits of quitting. The immediate and long-term health benefitsare listed.

Past quit attempts and potential withdrawal symptoms andcravings are discussed by the group.

Nicotine replacement therapy, or NRT, and how to use the products.NRT is best discussed before participants try to stop smoking.

Addiction. What is addiction, why do people smoke,and why do people have difficulty quitting?


Example:

Week 2 ActivitiesA discussion summing up Week 1.

Participants discuss:

Whether people tried to stop smoking that week.

Withdrawal symptoms and cravings, and how they are finding NRT.

Quitting smoking methods. This should be discussed before peoplemake a quit attempt.

The side effects of NRT or the prescription drug bupropion andwithdrawal symptoms or craving.

The group looks at ways to plan their quit attempt.

The group discusses things that might trigger or have triggered people tostart smoking again, and ways to deal with these, for example:

stress, alcohol, family illness, death;

having a puff of a cigarette; and

other people smoking in the house or car.

Week 3 ActivitiesThe participants who have made a quit attempt are congratulated.

The participants discuss:

their quit attempt;

withdrawal symptoms;

how people are finding the NRT; and

the things people have done when experiencing withdrawals andcravings.

The group looks at:

what is in a cigarette;

passive smoking, also known as environmental tobacco smoke, orETS, and the effects on kids; and

smoke-free car and home.

Week 4 ActivitiesThe participants who have made a quit attempt are congratulated.

The participants discuss:

how people’s quit attempts are going;

how people are going to stay smoke free;

how people are dealing with triggers; and

if they need to continue to use NRT (for at least eight weeks).

Complete post-program survey.


For further information about the program contact: Health Promotion CoordinatorNational Heart Foundation of AustraliaIllawarra Branch (NSW Division)Kiama Hospital and Community Health ServicePO Box 276, Kiama, NSW 2533Tel: +61 2 4233 1033Fax: +61 2 4232 1005Web: www.heartfoundation.com.au

Resources used in the Koori Tobacco Cessation ProgramNational Heart Foundation Australia NT 2001, The Tobacco Book: A Flip Chart. People Who Are Thinking about Quitting,National Heart Foundation Australia, Darwin

Quit Vic., Ten Steps to Quit for Good video or DVD, T.H.E Videos Pty Ltd


Hot Tip #18: Check out the following resources on

the Koori Tobacco Cessation Program… Go to CD–ROM: Samples of the following four Koori Tobacco Cessation Programdocuments are available in Section 7: Part 2.

Handout #13, Doctor’s Clearance for Nicotine Replacement TherapyProducts

Handout #14, Pre-Course Survey

Handout #15, Post-Course Survey

Handout #16, Nicotine Replacement Therapy Voucher

Quit courses forhealth workers and professionalsAboriginal and Torres Strait Islander health workers might be interested inparticipating in two courses run by Quit:

Fresh Start course

Fresh Start Short course

These two courses were developed largely for non-Indigenous smokers who wantto quit. The Quit courses are programs that are delivered by trained Quiteducators. Unlike programs tailored to the individual community, the Quitprogram includes standardised information that can be delivered to allcommunities in any setting across the country.

Fresh Start. The Fresh Start course is the longer of the two. It is run over eight sessions, twiceweekly, for four weeks with each session running for about an hour. Fresh Starthelps participants understand:

Why they smoke tobacco.

How tobacco smoking affects their lives.

Ways of quitting.

How to stay off the smokes.

The program uses group interaction to encourage and support change, withoutmaking the participants dependent on each other.

Quit Victoria runs educator training courses for health professionals in Victoria,Queensland, Western Australia, Northern Territory, ACT, Tasmania, and parts ofNew South Wales. Quit also delivers an Aboriginal health worker trainingprogram.

Fresh Start—Short.This is run in two three-hour sessions, with at least a week between each session.It is delivered either over a two- to three-week period or in one day. It is no lessdetailed than the longer Fresh Start course, but is simply offered to thoseparticipants unable to attend the longer course.


Fresh Start course outlineSession 1. Understanding smoking and quitting

The participants look at their reasons for smoking and how smoking affectsthem. They also look at why people smoke, the benefits of stopping and howpeople succeed in stopping.

Session 2. Planning to quitThe group talks about the struggle with, and barriers to, quitting, and plansways to avoid smoking, including not drinking alcohol, types of personalsupport and rewards.

Session 3. Health effects of smoking andquitting methods

The group looks at the short-term and long-term health effects of smoking,quitting methods and aids to stop smoking.

Session 4. Coping physically without cigarettesThe group looks at ways to cope with withdrawal symptoms—e.g. relaxationtechniques and tips for weight control—and the first few days without cigarettes.

Session 5. Coping emotionally without cigarettesThe group discusses their sense of loss and grief linked to quitting and looksat how people cope with stress and anger.

Session 6. Staying stopped in the short termAgain participants look at ways to avoid smoking over the first few days,including the benefits of quitting and how to handle slipping up.

Session 7. Staying stopped in the long termThe group looks at ways to stay smoke free in the future and plans for hardsituations.

Session 8. Enjoying being a non-smoker foreverIn the final session, the group again looks at ways to manage stress, andfinds out about further support for stopping and staying stopped once thecourse is finished.


For more information about the Fresh Start courses, contact Quit:Telephone: 13 7848Web: www.quit.org.au

Example :

Quit services: Available to Australians who smoke

Quitline telephone service. Quitline is a confidential, ongoing telephone service offering support toindividuals wishing to give up smoking. Counselling from trained telephoneadvisors is available during business hours from Monday to Friday,with extended hours available in some states and territories. Particularguidelines have been developed to assist Quitline counsellors to advise callersfrom Aboriginal and Torres Strait islander communities in culturallyappropriate ways. The advisors help smokers to understand why they smoke;to help smokers make a plan to quit, and give encouragement and informationduring the attempt to quit. They are never judgmental about smokers;they are just there to help.

Quitline also has a call-back counselling service. An advisor willring back during the attempt to quit at a time that suits the smoker. The service is available across Australia at the cost of a local call. Quitline telephone: 13 7848

Quitline referral service. Quitline referral service is available for GPs and other health professionals.More importantly, it is also available for health workers, who can refer clients tothe service by faxing a referral form to Quitline. A Quitline advisor will thencall the client at the preferred time written on the form.

Go to CD–ROM: For the Quitline referral service fax numbers and forms, see Section 7: Part 8, ‘Key Contacts’ or go to www.quit.org.au/downloads/smoking_cessation_referral.pdf


Part 4: Getting the environment right

Developing a smoke-free workplace policy Australian governments have now introduced laws that require most worksituations to be smoke free. Even workplaces—such as pubs, clubs,restaurants and outdoor dining and drinking areas—which in some stateshave conditional exemption, are to become smoke free over the next yearor so. To find out what the laws are for your particular State or Territory,web search Tobacco Control Supersite.

Making a workplace smoke free is not about shaming workers who smoke orpressuring them to quit. It is about reducing the harm to all workers at, andvisitors to, your workplace.

Smoke-free workplaces improve the quality of the air and, by reducing exposureto second-hand tobacco smoke, also improve the health of all who work there.In addition, smoke-free workplaces reduce the opportunity for people to smokeand encourage workers to think about their smoking habit and about quitting.

The development of a smoke-free policy—by employers and workers—for yourown organisation will help everyone to know how the new laws affect them andwhere smoking is permitted. A smoke-free policy is a formal statement thatoutlines the smoking restrictions in your workplace. It should also state whereworkers are permitted to smoke, as all workplaces should have a designatedoutdoor smoking area.

The policy could also outline:

whether or not workers can smoke outside/in front of the building;

whether or not workers can smoke in front of their patients/clients/serviceusers;

whether or not workers should smoke in a separate area set away fromtheir visitors/patients/clients/service users; and

any disciplinary process that might be applied if workers do not observethe ban.


How to set up a smoke-free work environmentOutlined below are some steps you can take to develop a smoke-free policy inyour workplace:

1. Employers or management should consult andcollaborate with workers by:

informing them of the reason for going smoke free and why the policy isbeing developed;discussing a timeline for phasing in the policy; andgiving everyone an opportunity to discuss their views and concerns.

2. In consultation with workers, a phase-in period, for example, of three months, should be set to helpeveryone adjust to the new conditions.

3. Employers and workers should plan to support andpromote the policy by:

discussing the policy in staff meetings;displaying and circulating information about the changes in theworkplace;providing information sessions about the harm of environmental tobaccosmoke;providing a copy of the policy to all workers;displaying ‘no smoking signs’ throughout the workplace; andmonitoring how the policy has been accepted.

4. Plan to support and educate smokers who maywant to quit. Employers or management couldsupport workers who decide to quit by:

providing in-house quit workplace program seminars;offering to pay for cessation programs;providing nicotine replacement therapy, and one-on-one counselling(applies to health service organisations); andproviding self-help cessation materials.


AcknowledgmentsInformation from the following organisations was used to compile this section:

National Heart Foundation of Australia

NSW Health

Queensland Health

Quit Victoria

Go to CD–ROM: For the complete list of references used in this section, see Section 7: Part 9, ‘References and further reading’


section 3: helping people quit the smokes

Documents