Psychologists and smoking cessation: Reducing the burden of smoking

Psychologists are likely to see clients who are addicted to tobacco smoking. In Australia, 2.4 million people regularly smoke (AIHW, 2016). Life expectancy for smokers is at least 10 years shorter than for nonsmokers (Prabhat et al., 2013) and up to 20 years shorter for those with a severe mental illness (Callaghan et al., 2014). Many people overcome substance use disorders, only to die from a tobacco-related illness (Mendelsohn & Wodak, 2016). Stopping smoking reduces mortality risk and has numerous other health benefits.

While over 95 per cent of NSW psychologists surveyed (n=72) believed the health benefits of smoking cessation were substantial, less than half assessed smoking status routinely (Bowman et al., 2013). The majority (65%) did not offer treatment for smoking or provide self-help materials (70%). Only 13 per cent advised cessation and only seven per cent provided brief interventions.

Breaking down barriers

Below we provide information to address the most common barriers to addressing smoking cessation identified by psychologists (Bowman et al., 2013).

1. Smoking is a personal choice

Nicotine dependence is a recognised condition in DSM-5. The physical cravings for a cigarette make volitional choice problematic, especially among those with low levels of rewards in their lives or limited self-regulatory capacity, and those living in environments where smoking is the norm. Almost all smokers start regular smoking in adolescence, so it is unlikely to be an informed choice.

2. Clients are not interested in smoking cessation

The average smoker makes at least two failed attempts to quit per year (Borland, Partos, Yong, Cummings, & Hyland, 2012). Evidence suggests that people with mental disorders are just as motivated to quit smoking as the general population (Siru, Hulse, & Tait, 2009).

3. Advising smoking cessation will damage rapport

People with and without a mental illness expect to be given advice to quit. An Australian study of community mental health consumers found that 87 per cent said they would have accepted advice to quit and 89 per cent would have accepted referral for smoking cessation (Bartlem et al., 2015), yet most did not receive either. In a randomised trial demonstrating the effectiveness of Quitline referral for stopping smoking, patients in the Quitline referral condition (versus in-practice management) rated their GP as more supportive of their quitting (Borland et al., 2008).

4. Smoking is not the presenting condition

Smoking may be a predisposing or perpetuating factor. Daily smokers are twice as likely to experience psychological distress as the general population and are twice as likely to be diagnosed with a mental illness (AIHW, 2014). Many clients use smoking to manage stress or chase positive feelings. Much of the perceived ‘benefit’ from smoking is due to the temporary relief of nicotine withdrawal symptoms, which erroneously creates the impression that smoking is relaxing. Talking about smoking is an opportunity to help clients develop and deploy effective stress management strategies.

5. Smoking cessation can worsen a person’s quality of life (QoL)

While getting through nicotine withdrawal can be difficult, systematic reviews have shown that stopping smoking is associated with reduced depression, anxiety, stress and improved QoL for smokers both with and without mental illness (Taylor et al., 2014). If you also consider the cost of smoking – smoking a pack a day costs $8000 a year, the balance of evidence is that quitting enhances QoL rather than compromises it. Patients treated simultaneously for smoking and other drug problems are 25 per cent more likely to achieve long-term abstinence from alcohol and other drugs than those who do not receive a smoking intervention (Mendelsohn & Wodak, 2016).

Smoking cessation: A menu of options

The most effective way to quit smoking, for those with and without a mental illness, is a combination of behavioural interventions (either in person or via telephone) and pharmacotherapy such as nicotine replacement and/or medication (Kotz, Brown, & West, 2014). We present an evidence-based menu of options which psychologists, in all sorts of roles and settings, can use to help their clients who smoke move towards quitting.

Firstly, psychologists should routinely assess smoking status and determine whether smoking has any role in the presenting condition. For clients with mental health conditions, including problematic substance use, consider additional challenges that may interact with their ability to quit smoking (Baker et al., 2017). If smoking is identified and you cannot provide treatment because it is outside your area of expertise or have limited session availability to tackle it yourself, provide a brief intervention (see box) and offer referral to the Quitline or to someone specialising in smoking cessation. If you can provide smoking cessation support within your role, the evidence-based options include the following.

Behavioural interventions

These may involve generic skills in facilitating decision-making, goal setting, maintaining motivation, enhancing self-efficacy and other smoking-specific work. This includes assessment of smoking history and tobacco dependence, identification of triggers to smoke and education about tobacco use. Client education includes outlining:

• the role of nicotine
• how to use nicotine replacement products
• the effects of cessation on medications, alcohol and caffeine levels
• skills to manage cravings and other triggers, including strategies to allow cravings to extinguish (Zwar et al., 2014).

A course of treatment therefore involves several sessions, both before and after quitting.

Smoking can be addressed within the context of psychological counselling sessions while treating mood, substance use and other conditions (Baker et al., 2017) and cessation can assist mood and other outcomes. Monitoring of common nicotine withdrawal symptoms (e.g., depression, anxiety and anger/irritability) can help to distinguish temporary withdrawal symptoms from any relapse of a mental health condition (Segan, Baker, Turner, & Williams, 2017). In addition, a medication review by a doctor may be necessary as smoking cessation can increase the blood levels of alcohol, caffeine and some medications (e.g., clozapine, olanzapine, and fluvoxamine) and dose reduction may be required (Mendelsohn, Kirby, & Castle, 2015).

Quitline

This service provides an effective behavioural intervention via free telephone counselling (Stead, Hartmann-Boyce, Perera, & Lancaster, 2013). Making a referral is shown to increase the likelihood of the person quitting and is preferable to providing Quitline’s phone number (13 78 48) because many smokers, while willing to accept a call, are reticent to call for themselves. Quit specialists will schedule counselling calls with the client. Psychologists can share care by referring to Quitline to address smoking while dealing with the client’s other psychological issues. There is also an Aboriginal and Torres Strait Islanders’ Quitline. Visit www.quitnow.gov.au to see what Quitline offers in your state.

Pharmacotherapy

This includes nicotine replacement therapy products (patches or intermittent forms) and medicines. If the client is using nicotine replacement therapy, the evidence supports the use of patches, which release a steady low-dose of nicotine, with an intermittent product (e.g., gum, lozenge, spray, inhalator) for when cravings hit. While these products can be purchased over-the-counter, support is often needed to use these products correctly. Patches are cheaper if prescribed by a doctor. Nicotine replacement therapy is most effective when the client also engages in behavioural counselling (Kotz et al., 2014). Varenicline (Champix) is a prescription medicine which reduces the pleasurable effects of smoking by preventing stimulation of neural receptors by nicotine. Varenicline is shown to be effective and adverse neuropsychiatric side effects are found to be rare for people with and without mental health conditions (Anthenelli et al., 2016). Under the PBS scheme varenicline is to be prescribed with provision of, or a referral for, behavioural counselling.

Customised self-help

Quit coach is an online program which asks the person questions about their smoking, motivation and past quit attempts, and uses the answers to provide a personalised quitting plan. Quit coach is free and has helped thousands to successfully quit smoking as demonstrated in randomised trials (Borland, Balmford, & Swift, 2015). Quit text which provides motivational messages, advice on coping with cravings and distraction from cravings when needed, is also effective (Borland, Balmford, & Benda, 2013). There is no randomised controlled trial evidence for the effectiveness of smartphone applications but a recent review (Thornton et al., 2017) found some to be of high quality, (e.g., I Quit, My Quit Buddy, QuitStart and Smart Quit) although more research is needed to verify the effectiveness of mobile apps for smoking cessation.

Provide self-help materials

Quitnow.gov.au has a wide range of self-help materials and links to state Quitlines that can be a resource for psychologists.

A call to action for psychologists

This is a call to action for psychologists to address smoking. Psychologists are well placed to deliver smoking cessation interventions. These can be delivered within the context of usual treatment using a menu of evidence-based options. The most effective way to quit smoking is a combination of behavioural interventions and pharmacotherapy. Even a brief intervention can trigger a quit attempt and may results in cessation, especially if it includes referral to evidence-based help.

The first author can be contacted at [email protected]

1. Quit Victoria
2. Cancer Council Victoria
3. University of Newcastle