Smoking cessation for Aboriginal patients

Smoking Cessation for Aboriginal People

Sammi: Good evening everybody and welcome to this evening’s Smoking Cessation for Aboriginal Patients webinar. My name is Samantha and I am your host this evening. Before we start, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work and we pay our respects to Elders past and present.

Okay, so I would like to introduce our presenters for this evening. So we are joined by Dr Rowena Ivers and Dr Lyndon Bauer. Rowena is a GP who works in Illawarra Aboriginal Medical Services and a Clinical Associate Professor at the Graduate School of Medicine at The University of Wollongong. Her interests include tobacco and alcohol interventions for Aboriginal people. And Lyndon is a GP who works on the Central Coast in New South Wales and is a Conjoint Senior Lecturer at The University of Newcastle and has worked part time in health promotion since 1993. Lyndon first started his smoking cessation interest in 1992 and has been working in the area ever since. So, thank you Rowena and Lyndon for joining us this evening.

I will hand over to Lyndon now to take us through our learning outcomes for this evening and then we will move on with the rest of the presentation.

Lyndon: Thank you, Samantha. I would also like to acknowledge the traditional custodians of the land, any Elders that are present and any other First People that are listening in today.

The learning objectives. By the end of this online QI and CPD activity, we should be able to recognise the high smoking rate among Aboriginal people and the health risks associated with tobacco smoking for Aboriginal patients, particularly those for pregnant Aboriginal women. We hope to aware of the issues and barriers faced by Aboriginal people who are quitting smoking. We would want to be able to discuss evidence-based tobacco treatment options including culturally accepted smoking cessation support for Aboriginal patients, and we would like to identify pathways to access additional tobacco cessation support such as the Aboriginal Quitline, the additional PBS availabilities for Aboriginal people. I will hand over to Rowena.

Rowena: Yes again just to acknowledge traditional owners, the 2.22 People as Lyndon and Samantha have done. I guess tonight I am speaking as a GP who has worked a lot in Aboriginal health because I work at the Aboriginal Medical Service in Wollongong, the Illawarra Aboriginal Medical Service, where I actually work with a team of great colleagues including Shane Venables who could not come tonight who runs our tobacco program. And that is one of the things about working in Aboriginal health, is it is generally working in a multidisciplinary team environment. But we do also know that there are a lot of Aboriginal people who attend mainstream practices throughout Australia.

So, what do we know about Aboriginal people in New South Wales? It is about 265 thousand people, about 3.4% of the New South Wales population. About 46% live in major cities. So really the biggest Aboriginal community in Australia is actually Sydney where there is about 90 thousand Aboriginal people. So, in general the Aboriginal community is younger than the general population, and I guess a lot of us know through the Close the Gap campaign that life expectancy is less than that of other Australians, 70.9 years for males and 75.9 years for females. And so of that life expectancy gap, we know that smoking actually contributes about 17% of that drop in life expectancy. So working with people on their tobacco use is a really important part of us closing the gap for all Australians.

So, smoking in terms of how we know it is not a traditional part of Aboriginal culture. Certainly where I used to work in the Northern Territory for a good decade in Arnhem Land, tobacco was brought across by Macassan traders and so people did start smoking tobacco probably about 400 years ago, but it is not a traditional part of culture. Certainly colonisation and dispossession has played a role in tobacco’s uptake and many of my colleagues in the Northern Territory, even prior to 1967 and the Referendum when Aboriginal people could first vote, were actually paid in tobacco. They were paid in flour and blankets and tobacco, so when they were working on cattle stations. So, that was when a lot of people started smoking. If people lived on missions in the Territory they were given tobacco as part of their rations. In some parts of Australia, particularly in Central Australia, people chew pituri. It has a neuroactive component which is different from tobacco and certainly around the Top End people chew normal tobacco. So people use it in different ways. But of course around Australia, most people use roll your own packet tobacco available commercially or the pre-made commercial cigarettes that we know.

So, let us have a think about why smoking rates in the communities that we work with are so high. Basically I think it becomes the norm. So we know that Aboriginal, that all smokers generally will begin smoking as teenagers. And the average age of starting smoking is about 14 or 15 across Australia. So essentially a paediatric condition. But Aboriginal children tend to start smoking a little earlier than mainstream teenagers. So certainly we know that tobacco in general, the smoking rates are higher in communities where there is poverty, when it is linked to leaving school early. It is linked to higher rates of unemployment and I guess people are smoking as a way to relieve boredom in those situations. So I think some people also might smoke to cope with life stressors such as grief and loss. In the communities that we work with, you know there are lots of, there is a housing shortage, there is lots of stress around lack of employment and I think that smoking rates are generally higher in people with mental illness. Some of the highest smoking rates that we see in Aboriginal or non-Aboriginal communities are actually in people with conditions such as chronic schizophrenia. We know that in places like jail, Aboriginal people are over-represented. In the past, the smoking rates in jail have been very high, although due to stop smoking and pharmacotherapy programs in jails, that has now reduced. So, smoking, it does play a role for people in terms of sticking together with family and friends in terms of social cohesion. There is peer pressure to smoke and it is seen as part of sharing and belonging. But of course, pretty soon after smoking, most smokers become addicted. And develop a habit of smoking and without realising they will be experiencing withdrawal symptoms. Often they interpret them as stress or anxiety. In fact, it is often just withdrawal from tobacco that is giving them the most symptoms.

Lyndon: Rowena, can I add my own observations there? Some of my Aboriginal clients and patients have reflected to me that it is not just about the pharmacotherapy, it is not just about quitting, it is about sometimes feeling that they are being rejected or removed from their community and so to recognise in our Aboriginal patients that it is not the same thing to quit smoking that it be for others, that there is a real cultural aspect. Sociocultural. A feeling that in quitting they may be rejected or stepping out from their group.

Rowena: Yes. And certainly with some work we did in the Territory was that people felt that it was easy to quit when they were surrounded by say friends or family who were health conscious and trying to quit at the same time, if they were trying to quit in workplace-based groups with other colleagues who were trying to quit or where there were other social pressures like non-smoking areas that supported them to quit. And in our program at the Aboriginal Medical Service in Wollongong, certainly focussing on family and friends is part of the program as well.

Okay, so barriers to quitting smoking. So, obviously we have to look at dealing with a physical addiction and as medical practitioners that is one of the things that we do need to think about and we probably can over-focus on as you say, but it is also a great time to focus on other aspects of that person’s life and other things that are going on in their life, thinking about other difficult life circumstances, other stressors in their life. And it basically means that people can you know, they might be at risk of social isolation and alienation, and it might be seen as very difficult and that there is not much social support, but it is about focussing on the whole person. So one of the big things we found in the Norther Territory was that when we started working in area of tobacco control there was not actually any stop smoking programs at all available even across the whole country. I think there was only one Aboriginal person working in tobacco control. People did not have access to pharmacotherapies and there were no staff really trained in giving support on quitting smoking. Now that has changed and so sometimes health services are inaccessible. Mainstream health services can be very inaccessible for Aboriginal people, certainly in places like the Northern Territory where the traditional languages are spoken. It is harder to access mainstream services. People might perceive that some services are racist or that there is no other Aboriginal peers who are involved in the delivery of health services. So a lot of local health district programs will now have Aboriginal health information workers or chronic disease workers and certainly in Aboriginal medical services around the country there are Aboriginal chronic disease workers and some specifically in tobacco programs who are involved in giving advice about tobacco and talking to clients about pharmacotherapies. So, the good news is most people, most Aboriginal people who smoke want to quit and lots have made many quit attempts. So, it is actually quite rare now to find someone who really does not want to quit. We still find those real stick in the mud people who really are not interested, but actually most smokers, they really have tried many, many times and it is one of their long term aims.

Lyndon: And I believe you raise this later on, but I also know that another barrier is the feeling of shame in approaching practitioners and so I have heard Aboriginal clients saying this is another shame job. You know, with failing and failing again and so it is very hard to face the practitioner. And so it is really important to have a rapport and acceptance that it is a chronic relapsing illness, and that this is what was expected in the course and there is no shame involved, in fact we really encourage the courage that people have to approach us.

Rowena: Thanks, Lyndon. So, certainly the good news is also, is that the smoking rates in general are trending down. So in the mainstream, from think of the time since the 1940s and 50s when smoking rates in men in Australia were about 70%, very, very high. That has drifted down over the years and certainly through the 80s and 90s with the big national tobacco campaigns a lot of people in Australia gave up smoking. And the good news is, that smoking rates for Aboriginal people are also trending down. So, in some of the communities that I used to work in the Territory, the smoking rate was about 70% or 80%. It is lower in places like New South Wales among communities here, but overall people are tending to give up smoking. With smoking rates in pregnancy, probably reflect that a lot of young people still have higher smoking rates. So smoking rates among pregnant women in communities that we work with are still very high, but again trending down. So, and I think that the reason for this is probably multifactorial. Things like price rises of tobacco and increased taxation make a difference. I think things like the big national advertising campaigns make a difference. Things like the messages on the back of cigarette packets are noticed by people. We do a lot of work in the Territory and people have really noticed those new messages and some of them did give up smoking as a result just of those packet messages. But I think there is a shift in what people see as the norm to some extent.

So, we still have to keep in mind though, the rates among Aboriginal people are much higher, so 22.7% of Aboriginal adults smoke daily compared to 10.6% of non-Aboriginal adults. So, I think that among our pregnant women, 42.4% of Aboriginal mothers reported smoking during their pregnancy, compared to 7.2% of non-Aboriginal mothers. Where I work, our smoking rate among Aboriginal pregnant women is about 50% so we really know that this is an area we need to continue working on. And that involves talking to women before they fall pregnant, while they were pregnant and offering advice and support, but also offering support to their partners and the Elders who maybe live in their house as well.

So, what makes people think about quitting? So for all smokers, the general things that make people think about quitting are family and community. So, we know that non-smokers are positive role models for children and it also means that non-smokers can protect their children and family from the health consequences of second hand smoke. I do know that there are a lot of people who are smokers themselves but take very, very active actions not to have their children exposed to smoke by setting up outdoor smoking areas and obviously not smoking in their car because that is the law now. But it is also about role modelling. So, we do know that smoking, because of the tax rises on tobacco, that actually smoking has become a great, it has had a great impact on people’s household budgets. And I think for a lot of people, those tax rises in the end has been the thing that has shifted their views on smoking. The tax rises and price increases have probably meant that fewer young people have taken up smoking, because we know that young people are the most price sensitive.

So, people give up when up when they have got health concerns, and sometimes people do worry about the health effects of smoking and sometimes they might be diagnosed with a serious illness, particularly having a hospitalisation is a real trigger for people to give up and it provides that motivation. And as doctors, we really need to work with people at those times of change and that is a time to spend a little bit more you know, time and effort and be very supportive of that person around the time that they have been hospitalised. For example, building up to having back surgery or a hip replacement surgery is a good time to really work with people about giving up smoking, or for example after they have after they have just had a hospitalisation for an exacerbation of COPD.

So, with pregnant women that we are working with, the reasons for smoking are pretty much the same. People are addicted. People use it to relax and calm down. I have to say, talking to women over the years, we know that one of the effects of smoking is that women will have smaller babies but unfortunately that is also linked to a much higher risk of perinatal death. Some women will opt for the smaller baby. I tend to downplay that point myself.

Lyndon: The head is no smaller, it is the scrawny body, so the head is the bit that is hard to get out, so…

Rowena: So, but I think it is really about talking to women, you know, non-judgementally but talking through the chances of miscarriage, that there is a higher rate of still birth. There is a much higher chance of prematurity and higher chance of birth defects and we know certainly the much higher rates of perinatal death, that is where the baby is more likely to die within the first 30 days. And even within the first six months or so there is a higher risk of SIDS. And a lot of women are actually not aware of all those things. And it is one of those things, when in terms of giving advice on tobacco, it is probably one of the most effective and cost effective interventions we can do during pregnancy, even compared to all the other antenatal tests that we do, giving smoking and successfully getting someone to quit has the highest benefit for the mother and the baby in terms of prevention of perinatal health problems. So, yes, compared to all the other blood tests and all the other measurements we take during pregnancy, this is by far the most effective antenatal measure.

Lyndon: Yes, I would just like to add as well, that it is a whole next generation problem, because children born that have been exposed to nicotine in the womb become dependent on tobacco much more quickly because their receptors are already primed for it. The small for dates babies end up with more obesity later in life, and that has been shown in a number of studies. Independent of side stream smoke after birth, they have more asthma and lung problems and as well, there is a whole lot of learning difficulties et cetera, attention deficits, that are associated with smoking during pregnancy. So the whole next generation is really affected, it is not just a matter of mortality and then it is passed. It is something that goes on to affect you know, the next generation entirely.

Rowena: Yes, I know some of our other work at the Illawarra AMS is around supporting breast feeding, and for example if you are a smoker, it does affect the baby’s uptake of successful breast feeding as well. So, that again is linked to many of those conditions in terms of obesity and asthma later in life.

Lyndon: Just another point, and I will make an advert for a previous webinar we have done on smoking cessation and mental health, and that is that whilst people who smoke feel that it does relax and calm them down, in fact the majority of that is simply to avoid withdrawal and that the research now very clearly shows that after cessation that anxiety and depression improve substantially as much as using an antidepressant. So, there are really big mental health positive benefits of cessation. There is a period of withdrawal that is best supported by nicotine replacement therapy. It can be done well, but do not feel that having people stop smoking is a risk to their mental health, in the long run it is a big benefit.

Rowena: And I normally spend quite a lot of time, it is a very commonly held myth by people that they are stressed so therefore they cannot give up smoking now. But again, it is really about promoting that those symptoms are actually withdrawal and that overall their mental health will improve because we know that nicotine produces high levels of stress hormones in the end. But after they have got through the withdrawal, the actually will improve.

Lyndon: Yes, there is a meta-analysis looking at whether nicotine itself causes anxiety and depression, and the jury is still out on whether nicotine itself actually does cause depression, although there is a lot of evidence towards that. It is very much well-accepted and a huge meta-analysis that mood improves when smoking cessation is established.

Rowena: Yes, so certainly getting back to smoking among pregnant women, basically cutting down. A lot of the time I will actually just, for some heavy smokers, cutting down might be realistic but I think the aim is to totally quit, and I think that some women are prepared to go cold turkey to quit fairly suddenly. A lot of smokers now instead of in the past where people smoked 20-30 cigarettes a day, you will find a lot of smokers are smoking 5-10 cigarettes a day. And always give people the opportunity to give up smoking themselves, especially when they are pregnant, however we can still use other options as well in terms of pharmacotherapy. So again, it is really, our smoking advice needs to be a very key part of the antenatal care and preferably delivered at every opportunity and we have got some images here of some of the pamphlets to support that. A lot of antenatal programs may have tobacco workers linked to their program as well, or staff who are trained in tobacco control.

Lyndon: Can I just address cutting down and the research around that shows that women report a lot of confusion because there are a lot of mixed messages coming from different health professionals and it is not helpful. The biggest benefit is between stopping altogether and the cut down itself is not proportional. The big result is at that actual stopping altogether. And even people exposed to side stream smoke have effects on their pregnancy. So, be aware that people self-regulate their smoking style very strongly. But if you smoke 25 a day and cut down to 10, you may not have cut down at all. You may be saving money, but people are breathing the smoke in deeper, holding it in longer, and getting just as much out of it. So, cutting down really needs to be a last resort. Advice needs to be at least less than five cigarettes a day and you also need to ask them, well what have other doctors told you? We understand that people get a lot of mixed messages on this, but the true message is, the best is to stop. Only as a last resort if you cannot stop you need to cut down to less than five a day.

Rowena: I will still occasionally get someone who tells me that they have been advised that giving up smoking in pregnancy is risky. It is absolutely not true. That is a myth. Giving up smoking in pregnancy is always as I said one of the main things that is going to improve outcomes during pregnancy. So when we are talking to patients though, I guess be non-judgemental and do not nag. Really be encouraging. And again, I would ask people at every opportunity in terms of asking and recording their smoking status. So it is about motivating people to quit and I guess be aware that that person may have some shame about it. And some people actually deflect a question and will prefer not to talk about it. I still would return to it perhaps at another time, but it is always worth bringing it up.

In some more traditional communities, think about women’s and men’s business. I generally find that in New South Wales that is not really an issue. Smoking is something that everyone can talk about. So it is about personalising the treatment for people and making an approach that is adapted to that particular person and their needs.

Lyndon: With pharmacotherapy for pregnancy, only nicotine replacement therapy is available and there are very clear guidelines with the RACGP. There is potential risk in going outside those guidelines because the child later may find that they have some problems, learning difficulties, whatever and they blame someone for going outside those guidelines. So I would advise you to be aware of the guidelines, the number of months to be used, the type of use et cetera and to follow those guidelines for smoking cessation with pharmacotherapy with pregnancy.

Okay, practical advice for GPs. One of the first things that comes up is the interaction with other drugs, alcohol and caffeine. It is not the nicotine but the smoke itself that induces liver enzymes and the induction of those liver enzymes will mean that people will chew through their caffeine faster, their alcohol faster and a number of other drugs. But probably the most important one is clozapine in schizophrenia which you know, the levels can be between not working at all and fatal between starting and stopping smoking. So what happens when someone stops smoking and continues to have the same amount of caffeine is that they pretty much get a caffeine overdose. They get too much. And the symptoms of too much caffeine can be mistaken for symptoms of nicotine withdrawal. Additionally they potentially need to drink less alcohol. They are not going to metabolise the alcohol as quickly and once again, if they are getting too much alcohol intoxication will probably lead to them smoking again. They need to know those things.

We have talked about the myths around smoking and stress. I think that the other webinar will cover that better. Involve the family members, particularly with the Aboriginal community because that is what is different with the Aboriginal community. The culture of Aboriginal people is so based on the family unit and involving the family, smoke-free homes, finding someone who is going to support the person, those are the sorts of culturally appropriate things for the Aboriginal community.

Talk about finances. That is, we are talking about something that is going to have a big impact on the whole group not just the person smoking because it takes away so much of the financial income.

Encourage a healthy lifestyle of course.

Adjust medication dosage. Once again, this is because of the induction of liver enzymes.

So, smoking cessation advice. The Five A’s are a way of organising and reminding yourself of things that need to be done. There are a number of steps. Pharmacotherapy is critical, one of the cornerstones of smoking cessation and always pharmacotherapy has a better outcome if supported with ongoing support and counselling. Hospital based smoking cessation is a really good opportunity when people are thinking about their health. Quit based smoking groups, referral to Aboriginal Quitline. Did you know that there is a special Aboriginal Quitline manned by people who are either Aboriginal themselves or have cultural training and will give a very culturally appropriate intervention for the person on the line. It is not just sending out someone pamphlets, the person engages with a clinician and has follow up and it is just a fantastic service. I cannot talk highly enough about. The fact that we do not have to pay for it makes us feel like it is not anything special, but it really is something special. So make sure you use the Quitline. I would also like to say at this stage, do not just tell people to ring the Quitline. If you do only a small fraction of them will go through with it. There is a referral process, a fax off and if you actually get their permission and fax that off, then someone will call them back. And you know, that is the way to get it established and really that is the best way to go about it.

Educational interventions, so school, family, community et cetera, NAIDOC et cetera. Tobacco control legislation, smoke free homes et cetera.

Okay, so has I said pharmacotherapy is one of the cornerstones that we really need counselling to get that to work at its maximal level, and Aboriginal Quitline is very important.

So the Five A’s. Everyone needs to be Asked. There is then an Assessment process. You then Advise the person based on their assessment, depending on what stage of cessation they are up to. You then offer them Assistance which may be pharmacotherapy or referral et cetera, and then everyone needs follow up. Without on average four follow ups, the success rate is quite abysmal. So, if you cannot and I know because I cannot get people to come back four times, you have to engage the Quitline to get this number of follow-ups to the level where you are going to have success.

Rowena: At our Aboriginal Medical Service, one of our health workers does call people back. We normally do it a week or so later and we have actually got it set in our recall systems so there is a reminder for staff to call. So you can use your recall system for that, or as Lyndon has said, we also still use the faxed quick referral and that way they can get an automatic call back as well from the Aboriginal worker.

Lyndon: Ask everyone. Now often in your medical notice as a GP it will say non-smoker, but if you do get somebody come up like they are having a screening blood test for cholesterol et cetera, just ask again, you are still a non-smoker aren’t you? People are not offended by that question. Particularly in the Aboriginal community you will find that people have gone back to smoking and unless you ask the question, they are marked down as a non-smoker and they may well be still smoking.

Rowena: We have had a question about smoking cannabis as well as tobacco. Now some people will not state that they are a tobacco smoker, but they are actually a cannabis smoker and mixing tobacco with their cannabis, so it is worth enquiring about that, too.

Lyndon: Absolutely. The Assessment. So, what do we assess? Firstly it is the stages of change, which is either ready, unsure or not ready. For those people who are ready to quit, they are the ones who you spend the time teaching them how to quit, offering them pharmacotherapy et cetera. The majority are unsure. What is the job for the unsure person? For the unsure person you need to find out what are their barriers, why is it that they are not ready to quit smoking and try to make a plan to address their barriers. If you cannot address their barriers trying to push them hard on using pharmacotherapy et cetera is not going to work. And some of the barriers are things like family. It may be something about work. It may be something about weight gain, stress et cetera. So address the barriers in the unsures. The not readies – my students always struggle the most with the not readies because they are hostile, they say I do not want to talk about my smoking. In fact they are the easiest because they are the ones that you simply do personalised medical advice for. Move them one step towards being unsure and ready next time. You are not doing any favours by giving them a very long introduction into how to use pharmacotherapy. They need to get to wanting to quit smoking before you go there. Equally, if you attack the ready person with a whole lot of scare tactics about how they are going to die, they are likely to switch off and never see you again. So the ready person does not need the scare tactics, they need to be helped how to quit.

Time to first cigarette. Now this is our strongest predictor of how strongly nicotine dependent people are. People smoking within the first half hour after waking are the strongest. The number of cigarettes smoked per day is another indicator, but remember that people will change their smoking style and get more out of less cigarettes, particularly if they cannot afford the cigarettes. So, it may be important to ask if you have always smoked that much and are you finding it hard to afford them?

Comorbidity is important and for the non-Aboriginal community, the research is now showing that nearly half of people who continue to smoke have a comorbidity with either a mental health problem or alcohol, and no I missed this one, but pregnancy probably should not be on the line for comorbidity, because pregnancy is not really a morbidity, it is a good thing. But we certainly need to look at pregnancy as well and make it a very special intervention.

Family history. One of the things that is really important in family history is emphysema. Not everyone gets emphysema when they smoke and if you are in a family that does, then you are likely to by the age of 35 with spirometry you can actually measure the early signs. Now we do not do that for everyone because what do you say to the people who do not seem to be going down that path? But they are the people who urgently need to quit smoking.

Environmental context and other medications. So there are lots of things to assess there.

Now, so Advise. Everyone needs to be told that they should stop smoking. The actual advice though depends on whether they are ready to quit, unsure et cetera. It may be that you are giving them most information about their barriers. And then talk about the other sides of the barriers which are some of these problems with their health.

Assist. So, assisting people will be prescribing pharmacotherapy for the majority of people who have evidence of nicotine dependency on their time to first cigarette. If someone only smokes on every other day and the number of cigarettes is small and when they stop smoking they do not have much in the way of withdrawal, then pharmacotherapy may not be terribly helpful to them. Maybe the occasional lozenge et cetera could be helpful but it is certainly not something that you would strongly recommend. On the other side of the occasion, someone who smokes within the first half hour or hour and finds that that is a really important cigarette, they are definitely going to need the pharmacotherapy. Quitline is really important, encourage a healthy lifestyle, the other things such as moderating the drugs and alcohol, caffeine, that are affected by the liver enzyme induction.

There is also the iCanQuit website. Some people like websites, some people do not. Using the Quitline as well, instead of having personal conversations you can have text message support. Does anyone use a phone for other than texting anymore? It is hard to say. But they can certainly opt for that as well.

Okay, so I have spoken about the Aboriginal Quitline and I will not go through all that again, but please, please, please that is so important. Remember you need at least four follow ups and you are not going to do it on your own. You need to fax off a referral to the Aboriginal Quitline.

And then follow-up. Look the follow-up is really important. The cessation rate is abysmal if there is not the follow up. Be prepared though not to do the shame job, because this is something that the majority of people do not succeed in in any one attempt. So, you need to leave the gate open for them to come back and admit that and say look, that is part of the process. We will work up to a time when you are ready to quit again. And look, that is expected and that is not something you should feel shameful about.

Okay, so the relapse. Patients had one or two cigarettes back to smoking. Remind patients that beginning to smoke will increase urges and make relapses more likely and to provide support and to reinforce quitting. Nicotine, and I believe although I am not an expert in it, that cocaine is the other drug which the smallest dose along the way gets you way back to pre-quitting levels of addiction. It is a really profound drug in that cannot afford to have a cigarette. You might as well have a carton. And I think people need to be aware that those receptors all turn on and go crazy with that first dose.

So how do we prevent relapse? So the first couple of weeks to three months are the biggest risk and you need as much support as possible in that time. We will talk a little bit about the pharmacotherapy in that time and the most supportive drug in that time I guess is varenicline. Any smoking in the first two weeks and a person is likely to fail. However it depends on how you are going about it and it is slightly different with varenicline. Total abstinence during a quit attempt is a must. There is some evidence that people finding actually being forced to set a quit date can be a negative thing as well, so a little bit of flexibility but also explaining that you know, once people do go back to smoking, even a puff, that it is a big trigger to just being completely addicted again. Triggers such as workplaces et cetera, I will talk more about those triggers in a minute when we get to varenicline. Caffeine, alcohol, all those things that can trigger those symbiotic feelings in the body. So after relapse, other things I said again, it is not a shame job, it is what is expected, when can we make a time to talk about this again? My door is always open, et cetera.

There is a question about whether medication is on close the gap, so yes it is and there are some more nicotine replacement options becoming available soon I believe. The lozenges and gum are becoming available to the general population. While they were previously available the number of times that you were allowed to have it is basically double in the Aboriginal community, so we can write a script for non-Aboriginal patients for patches, for one month with two repeats. That gives you three months. For Aboriginal patients you can have that done twice in a 12 month period. Now that is not an authority script, that is a script which you do as a restricted script, but you will need to stay within the guidelines of that restriction.

Here are some of the resources for Aboriginal patients. Once again, Aboriginal Quitline. It is then also, if you run a service and you have a number of Aboriginal people it would be well worth grabbing some of these booklets that have got culturally appropriate messages for the Aboriginal community.

So, nicotine replacement therapy. Under-dosing is a big problem with nicotine replacement therapy. The majority of people who smoke a substantial amount need more than just one patch. The Renee Bittoun method which we will be talking about in a minute is really critical to building up the nicotine to a level which basically causes complete satisfaction to the person. And if there are multiple forms of nicotine you do not need to stop them all suddenly, you can wean them back.

So this is the information about the CTG and I think I will just jump over that. You can grab all of that information from the slide later on when you want to do the prescription unless you? Go on.

Rowena: It is Rowena here. Certainly getting the nicotine patches on the CTG is really accessible now, but it is about some of the other oral and so the lozenges and inhalers, that have some of the Aboriginal community control health services have stocked them through grants which have been available through New South Wales Health. But in the long term, that certainly moves to putting all those other supplementary forms of NRT apart from a patch, on to the PBS as well which we really look forward to as well.

Lyndon: Yes, I believe there still may be an issue in not being able to use them as a combination on a script because in the restricted benefit it says that this is the sole of form of treatment. So, yes, if you are cautious about that, read that closely but yes, certainly you will have the choice between patches and lozenges coming up.

This is the combination algorithm for those of you who are not aware of it, this is just gold. In the early days when we started people on nicotine replacement therapy, so often when they quit smoking they thought their patches were causing them side effects and in the majority of the side effects were actually not enough nicotine rather than too much. So, what we do now is let them keep smoking with one patch on and see really how many cigarettes they need to smoke on top of that patch. Essentially it breaks down to if you need to smoke 10 cigarettes a day, you need another patch. So then they go off for another few day and see with two patches, how many cigarettes they need to smoke. Now, they are not going to get side effects from nicotine withdrawal because they can top up their own nicotine with the cigarettes occasionally. My record is one woman who needed four patches plus lozenges and I have a colleague who had a patient who needed five patches. You would never go straight to that sort of level without testing it and building it up. But if the person is able to tolerate 10 cigarettes per day on top of that number of patches, they need another patch. Once you can get them down to be quite satisfied with having less than 10 cigarettes a day, then you can top them up simply with lozenges or gum et cetera.

Now people say, well why does that not cause addiction in itself? It is because nicotine replacement therapy is a steady, slow state which is just stopping people from troughing out and it is not giving them all those big surges. So they are withdrawing away from the nicotine by not having all the surges.

Varenicline is an interesting chemical in that it blocks the receptor, and this is what is different with varenicline from your nicotine replacement therapy. Now it does not work that way for everyone and certainly I would guess that maybe two out of ten of my patients it just does not work for. They start taking the varenicline and they build up the dosage and once it is working, after about a week, they find that when they smoke they do not enjoy it and in fact they feel quite icky about smoking. They are the people that varenicline is working really well for. For some people it just does not work that way. They continue to smoke and they obviously have different receptors that they are enjoying the nicotine through. And for those people, you can add a little nicotine in or you might just say, let us go use the nicotine replacement Renee Bittoun algorithm. Now there previously were questions about whether varenicline can cause mental health problems and the research now shows that it causes no more mental health problems than general smoking cessation. However, I would advise people to be a little careful and prudent with varenicline in that if you have someone with previous suicide attempts or major mental health issues, it is just not an area you want to play with. Even if they do have a bad outcome and the varenicline had nothing to do with it, it is always going to be questioned. So I avoid the varenicline in those patients. Now my own experience also would say that people who are very, very heavy smokers do not do well on varenicline. Now that is just my own experience and I am wondering whether the blockage of their receptors causes them problems where the stimulation is not enough for what they need. Now look, this is just my own experience but that is just another area where I am cautious. For example, I have patients that are smoking 45 cigarettes a day. I would much rather use nicotine replacement therapy and be in control of what is happening.

Rowena: I have had a patient who smokes 60 a day and used varenicline successfully, so you can. But I mean the evidence is also that combining varenicline with NRT has the best rates. The problem is on the PBS, you know it is hard to get them both, you cannot get them both at the same time.

Lyndon: Yes, and the idea there is that varenicline is for one particular receptor and depending on the person, they are enjoying their nicotine to various degrees through various receptors, and perhaps not so much through the varenicline receptor.

And here is your flow chart for varenicline and these are some of the ideas on adding in some nicotine replacement therapy where it is not working and if you go on after a certain amount of time and it is of no effect, then move on to other forms of pharmacotherapy.

Now bupropion is a drug which came out, it was the first of the PBS covered smoking cessation drugs. As a result, a very large number of people were prescribed it and a number of very nasty outcomes were reported. Since then, all of those nasty outcomes have been linked back to people smoking and nothing to do with the bupropion. In other countries where bupropion is used as an antidepressant, none of these nasty effects do occur. There are some effects from bupropion that you need to be aware of. It definitely reduces seizure threshold so I do not use it in people who are commercial drivers and certainly not people who might be withdrawing from alcohol or any history of seizures. Also for some reason, people with eating disorders seem to have more seizures on bupropion, so not used in eating disorders either. However, if you have someone who everything else has failed with, it is definitely worth a try. Something less than half of people get a magical, I do not want to smoke at all once they start on bupropion. If in your history they say they have had that effect but they have gone back to smoking, it may well be the best drug for them. So it is an interesting drug. It has been used now in some other issues, weight control et cetera. It seems to be an addiction drug more than a specific nicotine replacement drug. But quite interesting and definitely worth knowing about.

Okay, so many of you would be aware of the withdrawal symptoms, irritability, anger, difficulty concentrating, increased appetite, restless, depressed mood and insomnia. In that period of time, you can have people with increasing problems with their mood and that is why it is so important to give them good coverage with either nicotine replacement or one of the other pharmacotherapies. I have to stress once again though, that once they have withdrawn from their nicotine, their mood improves as much as more than using an antidepressant. So you also see cravings, tiredness, depression, hunger, mouth ulcers, constipation, cough, nausea and sore throat.

Support. Obviously congratulate people who have done alright and been successful, reinforce the benefits, reinforce the benefits to their whole community. Discuss the problem to solve their high risk situations, relapse issues and stages of change and advice.

Here are some of the resources that are available. The New South Wales Health patient fact sheets with a link to that, and New South Wales Health tools for health professionals. And there is also the RACGP guidelines which are very comprehensive.

I would like to acknowledge Bronwyn Bancroft for the original artworks, and the Aboriginal Quitline artwork by Carissa Paglino.

Sammi: That does bring us back to the learning outcomes for this evening. Before we re-go over them, we do have a couple of minutes left so we can take some questions. We will give you a minute to type them through. Lyndon, we did have someone ask earlier and I did refer them to another webinar, but just around the safety of NRT and pregnancy.

Lyndon: Yes. So I will give a quick run-down of the guidelines for nicotine during pregnancy. Firstly, mostly nicotine replacement therapy doubles quit rates. Unfortunately in the research around pregnancy it has not been quite as useful as that. It seems that nearly half of women quit smoking when they first find out they are pregnant and the remaining women find it very, very difficult to quit smoking altogether. However, it is agreed that for those people that cannot quit smoking for two weeks, that they should be offered nicotine replacement therapy. So you do not just go straight to nicotine replacement. You should get follow up and see if they can possibly quit without the nicotine replacement. The next step is that they should be offered not patches as first line but an intermittent dose to minimise the total dose of nicotine to the baby. There are a number of effects on the unborn baby from nicotine itself and the research is ongoing so whilst stopping smoking is much, much, much better than the risk of nicotine on its own, if it is possible to get both without the nicotine, well that is a better outcome. So while we are trying to minimise the total dose of nicotine we might use lozenges et cetera. However, many women have morning sickness and cannot tolerate lozenges because of nausea, so then you would go on to using patches. But the guidelines say to remove the patches at night, once again to minimise the total dose of nicotine. The guidelines say that you should use the nicotine replacement therapy for two months and then stop. Anything outside of that is outside of the guidelines and I would advise that if you are going to do that, you need to inform the woman very clearly and get clear consent that you are going outside the guidelines because you are not just treating the woman, you are treating her child as well and just to cover yourself in that. But, yes you are supported by guidelines both by the RACGP and also by the National guidelines that you can use nicotine replacement therapy during pregnancy.

Rowena: And of course you can still give general smoking advice and general pharmacotherapy to other non-pregnant members of the family, including the partner, other members of the household as well.

Lyndon: Absolutely. And the other partners et cetera can have all the options of pharmacotherapy. And also, remember that there is a very high rate of relapse back to smoking even in those women who quit during pregnancy, and addressing that, asking if they have gone back to smoking after pregnancy because they are likely to have another pregnancy and also because of the risks of the children and side stream smoke et cetera. So, that is really a big part of the job as well. And remember if they can plan to use that other pharmacotherapy before they fall pregnant again, obviously you have all of those different pharmacotherapies available.

Sammi: Wonderful. Thank you very much for answering that, Lyndon and Rowena. We have not had any more questions come through via the chat box, so we might wrap up for the evening and we will just take a quick look back at our learning outcomes with Lyndon to just re-confirm what we have been over this evening before we leave you.

Lyndon: Yes, so recognise the extraordinarily high smoking rate among Aboriginal people and the health risks associated with tobacco smoking for Aboriginal patients and particularly for pregnant Aboriginal women. The sociocultural change that happened in the general society is just starting to happen in the Aboriginal community now. We need to support that sociocultural change and some of those people with the sociocultural change may be able to quit as happened with the general community without a lot of support, but many of them will need lots of medical pharmacotherapy and counselling to be able to quit. So be aware of the issues and barriers to quitting faced by Aboriginal patients, things like shame, things like the community, feeling outcast et cetera. So we discussed evidence-based treatment. We have talked about counselling. We have talked about different types of pharmacotherapy, and also things that are culturally accepted in smoking cessation support for Aboriginal patients. Identify pathways to access additional tobacco cessation which was the Aboriginal Quitline and closing the gap for Aboriginal people.

It just reminds me of one other thing that we do talk about. You as clinicians would recognise that the foetal haemoglobin has a much higher affinity for oxygen than the maternal haemoglobin, and this is the way the baby drags oxygen off the mother’s blood. However because of that, the foetal haemoglobin also has a much greater affinity for carbon monoxide and one of the real problems for the baby is carbon monoxide poisoning. So whilst the mother is not poisoned by the carbon monoxide particularly from the cigarette, the baby will concentrate that carbon monoxide and it stays stuck to the red cells. So, one of the big problems is that the carbon monoxide is concentrated in the baby. And that is apart from the damage to the placenta and all of the other side effects of nicotine. So yes, that is just some more stuff on pregnancy.

Sammi: That is fantastic. Thank you so much Lyndon and Rowena for joining us this evening and thank you to everybody online as well. We really hope that you enjoyed the session.