7.19 Interventions for special groups
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Every smoker is different, but there are some groups that share social, cultural and personal characteristics to a sufficient degree to benefit from different or targeted approaches to smoking cessation. These include groups with very high smoking rates, where there are significant implications of cessation beyond the smoker, where special barriers exist, or where current mainstream approaches are less successful. Some groups that have received attention in state and national tobacco strategies are described below.
7.19.1 Aboriginal and Torres Strait Islander People
Indigenous people's smoking prevalence is higher than for Australian adult smokers319–321 and is a significant factor in their poorer health status and lower life expectancy.322, 323 An additional issue is the high rate of smoking among health workers in Aboriginal and Torres Strait Islander health services324–326 who have a key role to play in any intervention programs.327, 328 These issues are covered in greater detail in Chapter 8. For further information on smoking, ill health, financial stress and smoking-related poverty among Indigenous communities see Chapter 9 Section 9.6.9.
7.19.2 Low socioeconomic status smokers
The prevalence of smoking is significantly higher among lower socioeconomic groups,12 particularly so in groups facing multiple personal and social difficulties and challenges.106, 329 They are more likely to have a higher level of nicotine dependence and overall they are less confident about their ability to quit and are less likely to intend to quit.106 Among people who have quit, blue collar workers and those with lower levels of income and education are likely to have smoked for longer periods of time prior to quitting.330, 331
Smoking has declined in all social groups over the past two decades. The smoking rate for the highest socioeconomic group (highest quintile) has fallen dramatically, while the decline in smoking among the remaining 80% of the population had not been as marked.12, 329, 332
Addressing social disadvantage associated with smoking is a key area of the National Tobacco Strategy.333 Strategies most likely to reduce disparities between advantaged and disadvantaged groups, or at least benefit all social groups roughly equally include advertising bans, smoking bans in workplaces, removing barriers to smoking cessation therapies, pictorial health warnings, thematically appropriate mass media campaigns, and encouraging greater use of appropriate smoking cessation support services.334–337 Increasing the price of tobacco products has a greater impact in low- than in high-SES populations.337
Chapter 9 explores these issues in more depth.
7.19.3 Pregnant women (and partners)
Stopping smoking before or during pregnancy is clearly an important and worthwhile goal, as smoking is one of the few potentially preventable factors associated with low birth weight, preterm birth and perinatal death.338 The harmful effects of smoking on the health of women and their babies are covered in Chapters 3 , 4 and 9. About 17% of Australian women who gave birth in 2005 reported smoking during their pregnancy.339 Smoking during pregnancy is more common among women without partners, who have a low income and who are socially disadvantaged.338, 340 Women are more likely to quit smoking during pregnancy than at any other time of life because they are concerned not only about their own health, but also the health of their baby.338, 341 About 20 to 30% of women quit after they become pregnant, but about half relapse within six months of their delivery, especially if their partner smokes. Within a year about 70% take up smoking again.340
Smoking cessation programs based on cognitive behavioural therapy are effective at reducing the number of women who smoke while pregnant. These typically include multiple contacts and formats, although there is substantial variation among interventions. Such programs lead to fewer premature babies and higher birth weights. Limited research suggests that interventions that include reward plus social support have resulted in a greater reduction in smoking rates than other strategies. Relapse prevention trials have so far not been successful overall. The Cochrane review states that 'attention to smoking behaviour together with support for smoking cessation and relapse prevention needs to be as routine a part of antenatal care as the measurement of blood pressure.'338
The most obvious point to initiate intervention is in early pregnancy, when women begin their contact with the midwife, GP or obstetrician and other health professionals who will monitor their pregnancy health, birth and postnatal care. Given the time and resource constraints on most health professionals and antenatal services, the brief intervention 5As approach described in this chapter is a workable approach for these settings. This has been presented in several antenatal services on a local and state-wide basis in Australia, and a national smokefree pregnancy project is underway.57, 342–345 This entails integrating a record of 5As interventions into medical records of pregnancy as part of routine practice, training health workers, raising the issues in early consultations, providing printed information on smoking and pregnancy, reviewing quitting intentions and discussing action at each subsequent consultation.57, 343, 345
Intervention should provide positive non-judgemental encouragement to quit that addresses women's concerns about stopping smoking, with referral to the Quitline or other services able to provide tailored support for pregnant women.57, 338, 343 Partner smoking status can also be addressed and referral to extra support provided to encourage them to quit as well.346 Nicotine replacement therapy can be used by pregnant and breastfeeding mothers, however the risks and benefits should be explained by those providing the product and the clinician supervising the pregnancy should be consulted.249, 347
7.19.4 People living with mental illness
People living with mental illness have been considered as a priority group because their smoking rates are higher than those of the general population.12, 333, 348, 349
They include a significant percentage of the smokers in the community.12 US studies estimate that people with mental illness smoke 34-44% of all cigarettes consumed,350, 351 A similar study in Australia found that 35% of all smokers aged 18-39 had a mental health disorder.352 An Australian study of people living with psychotic disorders found 73% of males and 56% of females were smokers with 50% smoking 20 or more cigarettes per day.353 Among people with schizophrenia the rate is especially high. An international review of 42 studies in 20 nations found an average smoking prevalence among people with schizophrenia of 62%.354 Smoking rates are also higher than the general population for people with panic disorder, post traumatic stress disorder (PTSD), agoraphobia and major depression.157, 162, 355–357 There is also a strong relationship between smoking and depression and anxiety.348
High levels of cigarette consumption contribute substantially to the poorer health status and shorter life span of people with mental illness, with ischaemic heart disease being the most common cause of death. Higher rates of respiratory illness and poorer outcomes from cancer also contribute.358 Poverty is often a further consequence of smoking, with those living on welfare benefits spending up to a third of their income on cigarettes. As a result they have little for food, recreation, transport, clothing or health care.359
People with mental illness use tobacco for the same reasons as the general population, but additional factors that contribute to the higher prevalence of smoking include:
- the historical and environmental context in which many mental health institutions have at best condoned and at worst encouraged smoking, with cigarettes used by staff to build rapport, calm, reward or punish clients360, 361
- for patients with schizophrenia, self-medication to relieve cognitive or negative symptoms of the illness or to relieve side effects of medication361
- psychosocial disadvantage of many people living with mental illness362
- strong smoking culture.360
The impact of smoking on the health of their patients is often overlooked by medical and mental health professionals.362 Smoking is often not investigated or recorded as a standard part of psychiatric assessment, and inclusion of smoking cessation in treatment planning is rare.361 This may be partly due to the beliefs held by some mental health workers that smoking is one of the few pleasures clients have, and that smoking is thought to be a way to decrease stress and relax.361, 362
Smokers with mental illness are interested in quitting. In British surveys, about half of smokers with mental illness express an interest in quitting when asked.363 However targeted approaches may increase their quitting success. A pilot study of people with psychiatric disorders in Perth showed that, as with the general population, heavily dependent smokers have less success in quitting, unaided cessation rates are low and more intensive intervention achieves somewhat higher success, so long as symptoms are controlled.365–366 In a larger study of smokers with mental illness in Sydney and Newcastle, participants received eight weekly individual counselling sessions and extended access to NRT. Nineteen percent of those who attended all sessions were abstinent at 12 months, compared to 7% of a comparison group who received self-help materials and usual care.364
As with other health professionals, mental health workers should consider routinely offering people with mental illness advice and support to quit using the 5As framework.367 Given that many of their clients are highly dependent, and are more likely to mix with peers who smoke, more intensive interventions should always be considered if possible. This might involve NRT or other pharmacological help to assist quitting, plus referral to a group program tailored to the needs of people living with mental illness, other specialised individual counselling, or the Quitline.
Quitting does not seem to generally worsen mental illness,364, 368 but the risk of this occurring implies symptoms should be monitored during cessation, especially for people with a history of depression and anxiety.369 Smokers also need higher doses of some antipsychotic medications, and so levels may need to be adjusted after cutting down or quitting.367 Potential interactions of non-nicotine medications and NRT with current medication also need to be considered.
SANE Victoria and Quit South Australia, in collaboration with the Tobacco and Mental Illness project in South Australia, have each developed resources to help long-term psychiatric clients to quit, and resources for carers and mental health workers to use as well as a group program for smoking cessation.370, 371 Similar programs have been run in other states.372 All state and territory Quitline services adhere to protocols for tailoring assistance to callers with mental illness. As well as training Quitline counsellors in the special issues for people with mental illness, they coordinate intervention with the person's health care professionals.373
A further need is for mental health services to develop policy on relevant aspects of tobacco, covering smokefree environments, collecting information about smoking status and quitting intentions on admission, including cessation in care plans where appropriate, and continuing support on discharge. Such a comprehensive approach requires leadership from management, staff training, and a consistent approach across services.361, 374 Some psychiatric services in Victoria and the United Kingdom375 have become smokefree.
For further information on smoking, ill health, financial stress and smoking–related poverty among people with a mental illness see Chapter 9 Section 9.6.4.
7.19.5 People with serious health conditions
Health concerns are a major motivator for smoking cessation, whether experienced personally or through a friend or family member.12 Diagnosis of a smoking-related illness, especially if it results in a period of hospitalisation or intensive treatment, is a good opportunity to promote smoking cessation.376 Treatment of some health problems is substantially improved if clients stop smoking. For example, recovery from heart attack is improved, and the risk of recurrence reduced considerably when smokers quit.377 Cancer patients show reduced response to treatment if they continue to smoke, and have a higher rate of recurrence.378 The management and progression of many chronic and acute diseases including diabetes, asthma, peripheral vascular disease, and emphysema is improved after quitting.3, 27, 379
It is recommended that patients undergoing elective surgery be advised to stop smoking six to eight or more weeks prior to admission to reduce adverse outcomes and improve wound healing, although more research is needed to confirm the long-term benefits.380, 381 There has been a vigorous debate in the medical profession about the ethics, economics, and health effects of refusing some hospital treatments for those who fail to stop.382
There is a strong case for providing high intensity behavioural intervention with at least one month follow-up support to all smokers admitted to hospital, regardless of admitting diagnosis.376 Interventions provided by nurses in a hospital setting, particularly nurses whose main role is health promotion or smoking cessation, help people stop smoking.383 For smokers receiving outpatient treatment, brief or intense interventions by their physician will increase quit rates,240 which may include referral of those interested in quitting to appropriate services. However current practice falls well short of potential.384 In hospital, clients are likely to be more open to help, and they are likely to find it easier to quit in a place where smoking is prohibited.376 At the very least, there is a need to actively manage those who are nicotine dependent by encouraging abstinence, providing NRT to manage withdrawal symptoms, or explaining the necessity of smoking offsite or in a designated area if available. More intensive programs are likely to have greatest success.385 For example referral to the Quitline or in-house support staff for cessation may help improve outcomes, as may consideration of smoking status and intentions for discharge planning, and providing support for continued abstinence or encouragement to consider quitting in the future.
New South Wales Health has developed a good example of a comprehensive policy approach for all inpatient facilities.386
7.19.6 Prisoners
Prisoners and those held on remand have very high smoking rates. For example in NSW reported rates are between 79% and 90%.387–390 The prison population is more likely to be from poorer backgrounds, have a history of mental illness and substance abuse, and be of Aboriginal or Torres Strait Islander background. All of these groups have much higher smoking prevalence than the general population.387, 390, 391
Interest in quitting smoking among prisoners is high. In a Victorian survey, 50% of prisoners wanted to address smoking, drinking, drugs and gambling.392 In a NSW survey, three quarters of smokers reported a desire to quit, but only 58% had an actual plan to give up.387 Among prisoners who relapsed in a pilot smoking cessation intervention, 95% indicated that they were willing to try quitting again with the intervention.391
Barriers to quitting in this population include a strong smoking culture in prison, the role of tobacco as a de facto currency, high levels of nicotine dependence, mental illness, limited access to nicotine replacement therapy and cessation programs, boredom, and stressful events such as prison transfer, family and legal stressors. Further problems include a lack of evidence for best practice for smoking cessation in this group, confusion over the ownership of the problem between the health department and custodial authorities, and poor access by this group to smoking cessation programs while outside of the prison system.387, 390, 391
In some Australian states, smoking cessation groups and telephone support from the Quitline have been provided in some prisons, with variable uptake. For example, NSW and Victoria have developed programs that focus on helping smokers make the decision to quit or to cut down and manage their smoking in smokefree locations.393 In Victoria, the program also makes nicotine replacement therapy available free of charge through a levy fund that has operated in Victoria's public prisons since 1993. Some prisons also sell nicotine patches through prison canteens. However, the expectation that prisoners cover the cost of pharmacotherapies is unrealistic, considering that most inmates have little or no money.391
In recent years, partial or total smoking bans in prisons have been introduced in Australia and other Western countries (see Chapter 15). Total smoking bans appear to have little impact on smoking by prisoners during or after their sentence, and so far they appear to be ineffective in assisting prisoners to quit.387, 390 However, this does not detract from the health issues related to second-hand smoke, for both prisoners and staff.
For further information on smoking, ill health, financial stress and smoking–related poverty among the prison population see Chapter 9 Section 9.6.7.
7.19.7 Drug and alcohol services
Smoking is far more prevalent in people with drug and alcohol problems than in the general population, whether their problems relate to alcohol,394 cannabis395, heroin396, or cocaine.397 For example a smoking prevalence of 92% has been reported among a group of inpatients with drug-related problems in Newcastle, NSW.398 Many health risks for dual use of alcohol and tobacco are multiplicative rather than simply additive. For example oesophageal cancer is postulated to increase among heavy alcohol users as a result of alcohol allowing tobacco toxins to penetrate more deeply to basal layers.399 Similarly, there is evidence that smoking cannabis is a risk factor for many of the same illnesses as tobacco.400–402 Cannabis poses some special problems for users since it is often mixed in cigarettes with tobacco, and 30% of smokers report recent use of cannabis compared to 7% of non-smokers,12 potentially inducing double dependence as a result.
A substantial proportion of clients of drug and alcohol services express interest in quitting when asked.403, 404 By contrast, a study of staff and management attitudes and practices in Australia found smoking received little systematic attention, with concerns about possible negative impact on other treatments, absence of policy and lack of training being major impediments.405 A minority of managers even endorsed at least occasional smoking by staff with clients, and some facilities still permitted smoking inside.406 Rather than compromising the outcome of drug and alcohol treatments, there is some evidence that smoking cessation enhances short-term abstinence.404 As with mental health and correction services, there is a need for policy and training initiatives to address past neglect of tobacco control issues.407 Systematic intervention around the 5As framework tailored to the needs of client groups would provide a good foundation for this work.
7.19.8 Culturally and linguistically diverse communities
Smoking rates vary substantially from one country to another, as does the type of tobacco used and policies to control its use.408
Some smokers in culturally and linguistically diverse community groups in Australia may face extra barriers to stopping smoking, including lack of knowledge of the harm caused by smoking and second-hand smoke, lack of tobacco control measures and norms in their culture of origin, low literacy in English, and lack of community leadership to promote smoking cessation. Despite these potential barriers, average smoking rates in some of these communities are lower than for the rest of the population,409 there is substantial quitting activity,410 and many leaders are aware of issues around tobacco control.411
The Quitline service provides access to many printed resources in a range of community languages, and callers can ask to have their call returned with an interpreter, in a range of languages other than English. Bilingual educators from Quit Victoria conduct information sessions in a number of community languages. Some culturally specific programs have been initiated by various organisations, mostly on a short-term basis, to attempt to address the issues discussed above.412, 413
7.19.9 Younger smokers
Information on smoking cessation among young smokers is limited. In a 2005 survey of school students aged 12 to 17 years, 4% identified themselves as being ex-smokers, around half of the number identified as current smokers.414 In the 2007 National Drug Strategy Household Survey, this proportion was somewhat lower (about a third), with 1.9% of 12 to 19-year-olds being ex-smokers compared to 6.6% of daily or weekly smokers.7 One Australian study of 14 to 16-year-olds found that of current smokers, 64% wanted to stop smoking and 55% had tried to stop smoking in the past year.415 Another Australian study following 14- to 15-year-olds over three years found that about a third of all smokers became ex-smokers in the course of each year. However, close to half of ex-smokers relapsed within 12 months, and the relapse rate was 70% for daily smokers. Female daily smokers were half as likely as males to quit smoking, and smokers with a parent who smoked daily were also half as likely to quit smoking.416 In other studies, factors that influenced the likelihood of quitting among young people included nicotine dependence, age of smoking initiation, perceived peer and parental tolerance of smoking, negative beliefs about the consequences of smoking, and smoking among social networks.417–419
Adult cessation campaigns have been found to impact younger groups. Most focus in Australia's national campaign to promote smoking cessation has been on the 18–40 blue collar demographic, however the impact of such campaigns spreads to younger groups as well. For example, evaluation of the early National Tobacco Campaign media campaigns showed that adolescents learned as much, if not more, than the 18–40 target group from the television advertisements.420
Prevention and cessation are intertwined, but most of the effort with young people to date has focused on preventing uptake rather than promoting cessation. There are a number of issues around promoting cessation and providing support among young people, regardless of whether they are experimenting or have graduated to regular daily smoking.417, 421, 422
There is scant evidence on what works best for teen cessation. A recent review concluded that programs designed to help teens have modest success compared to control conditions, and that programs focusing on motivational enhancement, cognitive behavioural techniques and social influence were most effective.423 School based clinics and programs that extended for at least five sessions were more effective than community-based and single session interventions. Currently 4% of callers to the Victorian Quitline are under 18 years old, and protocols for young callers have been developed as part of the set of national minimum standards.424 These recommend that services focus on the immediate harmful effects, issues of appearance and youth-specific reasons for smoking such as rebellion or aspiring to adulthood. Recognising differences in patterns of smoking to that of adults, for example infrequent and situationally dependent smoking, is important, as is referring young people to youth-specific resources, especially internet sites.425
Some quitting medications can be used by younger smokers. Bupropion and varenicline are not officially approved for use by smokers under 18, and NRT is recommended only with precautions.249, 426, 427 When deciding whether or not to recommend NRT use by an adolescent (12 to 18 years), an individual's nicotine dependence, motivation to quit and willingness to accept counselling all need to be assessed. Counselling is considered to be of vital importance in this age group.57, 428
Schools should establish clear rules banning smoking on school grounds by students, teachers and visitors.429–432 Similarly community youth services have a role in developing policy that addresses smoking by clients and staff, and encouraging and supporting smoking cessation, including use of routine brief intervention.
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