National Guide

Chapter 2 | Healthy living and health risks

Smoking







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      4. Smoking

Healthy living and health risks | Smoking

Prof David Thomas

Key messages

  • The harms of smoking and the benefits of smoking cessation are well established.1
  • National Aboriginal and Torres Strait Islander smoking prevalence is high, but is decreasing.2
  • Health practitioners play an important role in supporting public health approaches to reduce smoking prevalence by delivering screening, medications and behavioural support for smoking cessation.3
  • There is strong support for more culturally appropriate approaches to smoking prevention and cessation.4
  • Although culturally adapted smoking cessation services are preferred, other services are also effective and can be recommended.4
  • There is strong evidence for behavioural support and use of medications to support cessation among adults.5
Type of preventive activity - Screening
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
People aged 10 years and over Ask all patients if they smoke tobacco and record/update smoking status in their clinical record Opportunistically

Review smoking status at least annually for people who smoke or who have recently quit		 Strong National guideline3 A systematic approach to identifying all people who smoke increases the support offered by health practitioners6
Parents and carers of children aged 15 years and under Ask parents and carers if they smoke, and smoke inside the home or car, and advise about harms of second-hand smoke to children Opportunistically Good practice point National guideline3 This may reduce exposure to second-hand smoke, which is especially harmful to children3
Type of preventive activity - Behavioural
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
Adults who smoke Advise all adults who smoke to quit and on the most effective methods to quit Opportunistically, whenever possible Strong National guideline3 Advice from doctors or nurses increases cessation compared to usual care (relative risk (RR) of 1.76 and 1.29 from 26 and 44 trials, respectively)5
Young people aged 11–17 years Advise all young people who do not smoke to not start smoking

There is insufficient evidence to recommend behavioural cessation support to young people		 Opportunistically Strong National guideline3 Behavioural interventions among young people aged 7–17 years reduce initiation compared with controls (RR 0.82 from 13 trials);7 however, no difference was found in a review of nine trials of behavioural interventions to support cessation among young people7
Adults who smoke Help adults to quit by recommending multisession behavioural support using individual or group counselling, Quitline, text messaging (eg QuitTxt), internet programs (eg QuitCoach or iCanQuit) or incentives for cessation support Opportunistically following brief advice Strong National guideline3 Counselling increases cessation compared with no behavioural support (odds ratio 1.44 from 194 studies)8

Calling or being called by a telephone Quitline (RR 1.38 and 1.25 from 14 and 65 trials, respectively), text messaging (RR 1.54 from 13 trials), internet programs (RR 1.15 from eight trials) and financial incentives (RR 1.49 from 30 trials) are effective in increasing successful cessation5
Type of preventive activity - Medication
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
Non-pregnant adults who smoke Help non-pregnant adults to quit by recommending smoking cessation pharmacotherapies

If nicotine-dependent, the most effective pharmacotherapies are combination nicotine replacement therapy (NRT; patch and oral) and varenicline; single-form NRT and bupropion are also effective		 Opportunistically following brief advice Strong National guideline3 NRT (any form; RR 1.55 from 133 trials), varenicline (RR 2.24 from 27 trials) and bupropion (RR 1.64 from 46 trials) increase cessation compared with placebo or no drug5

Combination NRT is more effective than a single NRT (RR 1.25 from 14 trials)5
Non-pregnant adults who smoke If the above pharmacotherapies are unsuccessful, consider the use of nicotine e-cigarettes after discussion of the lack of information about the long term risks of e-cigarettes After unsuccessful use of other smoking cessation pharmacotherapies Conditional National guideline3 Nicotine-containing e-cigarettes increase cessation compared with behavioural or no support (RR 2.66 from seven trials) and compared with non-nicotine e-cigarettes (RR 1.94 from five trials)9
Pregnant and breastfeeding women who smoke If behavioural support is not successful, consider NRT after explaining the risks and benefits. Intermittent use formulations such as gum, lozenges, inhaler or tablets rather than continuous use patches are preferred.

Do not use varenicline or bupropion in pregnant or breastfeeding women		 At each pregnancy care visit Conditional National guideline3 There was no significant difference in cessation in a review of only five placebo-controlled trials of NRT in pregnancy5
Young people aged under 18 years who smoke There is insufficient evidence to recommend the use of NRT in children and young people aged under 18 years who smoke

Do not use varenicline or bupropion in people aged under 18 years		 N/A Good practice point Systematic review7 A recent review found only one trial of NRT in young people (patches versus placebo), which found no difference in cessation
Type of preventive activity - Environmental
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
All people Complement the above individual-based preventive activities with support for comprehensive public health approaches to smoking prevention; for example:
  • marketing and messaging, including posters and displays at the health service, community organisations and events
  • smoke-free rules at the health service, community organisations and events, and smoke-free homes and cars
  • restricting the activities of the tobacco industry
 Opportunistically Strong National strategy10 Mass media campaigns reduce smoking prevalence and increase cessation10

Smoke-free rules reduce exposure to second-hand smoke10
Transnational tobacco corporations have promoted, manipulated and profited from this product they know kills millions every year
  • Ensure training and systems to support the AAH (Ask, Advise, Help) approach to smoking cessation:
    • ensure smoking status is recorded and updated in the patient’s medical record (Ask)
    • ensure staff are trained in brief advice and pathways for referral for behavioural support and medication (Advise and Help).
  • Use Australian guidelines to ensure the appropriate use of smoking cessation medication.3
  • Use the tobacco control continuous quality improvement guide to improve the comprehensive approach to tobacco control at the health service (see Useful resources).11
  • Support and do not stigmatise people who smoke; the blame lies with transnational tobacco corporations, which have promoted, manipulated and profited from this product they know kills millions every year.

Clinical guidelines

Other resources for health professionals

Patient resources

  • Quitline: telephone 13 7848 or 13QUIT or go online to arrange a free call back and follow-up telephone calls
  • QuitTxt: behavioural support to quit by text messages
  • QuitCoach: personalised behavioural support from the internet, supported by Quit Victoria
  • iCanQuit: behavioural support from the internet, supported by the New South Wales Government
  • iSISTAQUIT: resources to support Aboriginal and Torres Strait Islander pregnant women to quit smoking 

Background

The World Health Organization estimates that tobacco causes more than eight million premature deaths globally every year, including the deaths of more than one million non-smokers from second-hand smoke.12 The US Surgeon General has reported that smoking causes many different chronic diseases and cancers, harming almost every organ in the body; smoking in pregnancy causes maternal, fetal and infant deaths and disease, and there is no safe level of exposure to second-hand tobacco smoke.1 The US Surgeon General has also confirmed the early and sustained health benefits of quitting smoking at any age, with quitting before age 40 years preventing 90% of the excess mortality due to continued smoking.13 

Nicotine-containing plants, including pituri, have long been chewed in Aboriginal and Torres Strait Islander communities, especially in Central Australia.14 These plants contain N-nitrosamines, important carcinogens in other chewed and smoked tobacco.15 Chewing smokeless tobacco has been shown to cause cancers of the head and neck, oesophagus and pancreas and worse birth outcomes in other countries.16 Before British invasion and colonisation began in 1788, Indonesian traders introduced smoked tobacco to northern Australia.17 Colonisation led to smoking becoming widespread as tobacco was exploited by the colonisers (eg as rations and payment for labour) and then due to mass marketing by the tobacco industry. 

The Australian Institute of Health and Welfare estimated that smoking caused more than 23% (n=800) of all Aboriginal and Torres Strait Islander deaths in 2018, and accounted for 12% of the total burden of disease and 20% of the health gap with non-Indigenous Australians.18 Using different methods, a longitudinal study estimated that half of all deaths among New South Wales Aboriginal adults aged ≥45 years were due to smoking.19 

Daily smoking prevalence among Aboriginal and Torres Strait Islander adults is high but falling, from 50% in 2004–05 to 40% in 2018–19, demonstrating that further improvements are achievable.2 This improvement in smoking prevalence has not been uniform, and has mainly occurred in towns and cities (decreasing from 49% in 2004–05 to 37% in 2018–19), with no improvement in remote communities (52%).2 However, there have been reductions in smoking initiation among children in both remote and non-remote areas.20 More than half (57%) of Aboriginal and Torres Strait Islander children (aged 0–14 years) in 2018–19 lived in a household with a person who smoked daily, but only 9% lived in a household where someone smoked inside.21 The proportion of Aboriginal and Torres Strait Islander mothers who smoked during pregnancy declined from 52% in 2009 to 44% in 2019.21 

This fourth edition of the National guide to preventive healthcare for Aboriginal and Torres Strait Islander people is structured around the three-step AAH (Ask, Advise, Help) model rather than the 5As (Ask, Assess, Advise, Assist and Arrange) used in the third edition, recognising that the limited time available in consultations can be seen as a barrier to supporting smoking cessation. This is consistent with the current national Australian guidelines and similar long-established three-step approaches in New Zealand and the UK.3,22,23 New recommendations have been added about preventing the uptake of smoking and exposure to second-hand smoke among children. The use of e-cigarettes in smoking cessation remains contentious. Although the fourth edition of the Guide continues to recommend considering e-cigarettes after other smoking cessation pharmacotherapies have been unsuccessful, this edition includes a new chapter about the prevention of e-cigarette use (see Chapter 2: Healthy living and health risks, Vaping). 

Australia has signed the World Health Organization Framework Convention on Tobacco Control, the world’s first public health treaty, committing to a series of evidence-based national policies to reduce smoking and the harm it causes.3 Australia has implemented anti-tobacco mass media campaigns, pack warning labels, restrictions on tobacco advertising, price increases of tobacco through tax rises and smoke-free regulations, and has provided cessation services, contributing to Australia’s low national smoking prevalence.10 There is some evidence that such population health approaches also motivate Aboriginal and Torres Strait Islander people who smoke to quit. Cross-sectional and longitudinal analyses of a large national survey (Talking About The Smokes [TATS]) demonstrated the impacts of noticing anti-tobacco social marketing (eg TV advertisements and posters; with localised material having greater impact) and pack warning labels, as well as the effects of the introduction of plain packaging.24–26 Aboriginal and Torres Strait Islander people who smoked but lived in a smoke-free home not only protected children and other non-smokers from second-hand smoke, but were also more likely to quit smoking than those who did not completely ban smoking in their home.27,28 Annual tobacco tax rises were associated with an decline in tobacco sales in remote Aboriginal communities.29 

Health services can contribute to these evidence-based public health tobacco control activities by promoting anti-tobacco marketing and messaging (eg posters and displays) and smoke-free rules at the health service, community organisations and events.11 Health services should have no contact with the tobacco industry and should support further restrictions on the tobacco industry, such as tobacco endgame proposals. In Aotearoa New Zealand, following Māori advocacy, these restrictions include reducing nicotine in cigarettes to very low levels, significantly reducing the number of outlets where cigarettes can be sold and prohibiting the sale of tobacco products to people born after January 2009, and so creating a smoke-free generation.30 

Health practitioners play a vital role in assisting and supporting smoking cessation and reducing the harms caused by smoking. Although most people successfully quit smoking without the assistance of health practitioners, including most Aboriginal and Torres Strait Islander people, brief advice and behavioural and pharmacological therapies can increase successful cessation.3,28,31 Health practitioners can be encouraged to support smoking cessation knowing that the TATS national survey of Aboriginal and Torres Strait Islander people found that most smokers reported wanting to quit (70%), making a quit attempt in the past year (48%), regretting ever starting to smoke (78%), living in smoke-free homes (56%) and knowing about the most harmful effects of smoking and second-hand smoke.27,32–34 The most common reasons smokers and ex-smokers gave for quitting in the TATS survey were concerns for their health, cost and setting an example for children.26 

Although more socially disadvantaged Aboriginal and Torres Strait Islander people have repeatedly been shown to be more likely to smoke, a longitudinal analysis of the TATS surveys showed that social disadvantage did not appear to predict quitting in the next year.35 Health practitioners can be optimistic about providing smoking cessation support to even the most disadvantaged Aboriginal and Torres Strait Islander people. Conversely, longitudinal analysis of the TATS surveys also found that people whose social circumstances improved (eg getting a job) were more likely to quit than those who did not experience this change, although it is not clear which happened first, getting a job or quitting smoking. The personal empowerment that comes from making one such successful life change can lead to other achievements. 

Although a review of reviews found no evidence of greater effectiveness of culturally adapted smoking cessation compared with other services, it did find strong evidence of community preference for such culturally appropriate services.4 So, although other services can be effective, there is strong support for the importance of more culturally appropriate approaches to reducing Aboriginal and Torres Strait Islander smoking.4,17 

Screening

Ask

Ask all patients whether they smoke and ensure that their current smoking status is recorded in their medical record.3,22,23,36 Regularly (at least annually) update smoking status in the medical records of anyone who smokes or has recently quit.22 A systematic approach to identifying all people who smoke should be used in every health service and has been shown to increase the support offered by health practitioners.6 Almost all (93%) Aboriginal and Torres Strait Islander people who smoke daily who had seen a health professional in the previous year reported being asked whether they smoked, according to the TATS national survey in Aboriginal Community Controlled Health Services.37 Most Aboriginal and Torres Strait Islander cannabis smokers mix cannabis with tobacco, so when asking about one, ask about the other.38 

It is also important to ask all parents and carers of children whether they smoke and smoke inside the home or car.3 It is important to advise them to quit to protect their children, because not smoking inside reduces exposure to second-hand smoke, although it does not provide complete protection.39 

For information about screening people who smoke for lung cancer, see Chapter 19: Cancer prevention and early detection, Lung cancer. 

Behavioural

Advise

Advise all people who smoke to quit in a clear, non-confrontational way; for example, ‘The best thing you can do for your health is to quit the smokes’.3 Reviews of advice from doctors or nurses found increased cessation compared with usual care (RR 1.76 and 1.29 from 26 and 44 trials, respectively).5 This advice can be as brief as 30 seconds, and should be given at every visit and followed by offers of assistance to quit.22 Provide brief advice to all people who smoke, whether they want to quit or not; there is no need to first assess ‘stage of change’.22 More Aboriginal and Torres Strait Islander people who smoke daily and who had seen a health professional in the past year reported that they had been advised to quit (75%) than a similar sample of all Australians (56%).37 These Aboriginal and Torres Strait Islander people were 2.0-fold more likely to have made a quit attempt in the past year than those who did not recall having been advised to quit. 

Advise all children who do not smoke to not start smoking. A review of 13 varied trials found these behavioural interventions among children aged 7–17 years reduced smoking initiation compared with control groups (RR 0.82).7 However, it is important to note that reducing smoking prevalence among parents and carers has the clearest impact of any intervention on preventing youth uptake of smoking.3 Approximately 70% of Aboriginal and Torres Strait Islander adults who have ever smoked daily started smoking before they turned 18 years of age, and approximately 30% started before age 15 years, although the proportion of children taking up smoking is declining.20 

Help

Help all adults to quit by providing or referring to multisession behavioural support using individual or group counselling, Quitline, text messaging (eg QuitTxt), internet programs (eg QuitCoach or iCanQuit) or incentives for cessation support. 

A network meta-analysis was confident that counselling increased cessation compared with no behavioural support (odds ratio 1.44 from 194 studies).8 More sessions of counselling and advice increase successful cessation.6,8 Four or more sessions have been recommended.22 Agree on a quit day, provide strategies for managing smoking triggers, mobilise support from family and friends and, at follow-up visits, provide encouragement and support, reviewing progress and problems.3 Allen Carr Easyway in-person group seminars are also effective.23 A meta-analysis of two randomised controlled trials (RCTs) at Aboriginal Community Controlled Health Services demonstrated that patients who were allocated to more intensive multisession face-to-face counselling and support were more likely to successfully quit than patients who received usual care (RR 2.36).40 

Quitline (telephone 137848 or 13QUIT) offers cessation counselling from trained Aboriginal and Torres Strait Islander counsellors who will call the person who smokes and proactively provide follow-up telephone calls, following direct referral from a health practitioner  or self-referral.3 Calling or being called by a telephone Quitline counsellor increases successful cessation (RR 1.38 and 1.25 from reviews of 14 and 65 trials, respectively). In the national TATS survey, 28% of Aboriginal and Torres Strait Islander people who had been advised to quit by a health professional reported being referred to Quitline, but only 16% of those referred actually talked to Quitline.37

 
Similarly, text messaging (eg QuitTxt), internet programs (eg QuitCoach or iCanQuit) and financial incentives are effective in increasing successful cessation (RR 1.54, 1.15 and 1.49 from reviews of 13, eight and 30 trials, respectively).5 A New Zealand RCT of a text messaging intervention compared with a control (receiving no smoking information) found no significant difference in the greater smoking cessation at six weeks between Māori (RR 2.34) and non-Māori (RR 2.16).41 In the national TATS survey, 27% of Aboriginal and Torres Strait Islander people who had been advised to quit by a health professional reported being referred to a quit-smoking website, but only 22% of those referred actually used the website.37 There is variable interest in using financial incentives to support Aboriginal and Torres Strait Islander pregnant women to quit smoking, which is supported by the acceptability of a trial of incentives combined with other very intensive smoking cessation support for 22 rural Aboriginal women, but as yet no larger or RCTs.42
 
Written self-help material (eg pamphlets) has only a minimal additional effect on successful smoking cessation, even though approximately half (49%) of Aboriginal and Torres Strait Islander people who had been advised to quit by a health professional reported being offered a pamphlet.5,37 Similarly, carbon monoxide monitors (eg Smokerlyzer) are increasingly being used in this setting, but there is no evidence that this biofeedback increases smoking cessation in the pooled results from five trials in other settings.43 Pooled evidence from five trials of smartphone apps found no additional impact on successful cessation compared with low-intensity support.44 A pilot RCT of an app designed to help Aboriginal people to quit smoking only recruited 49 of the planned 200 participants, and only one participant had successfully stayed quit at six months.45 Even though widely used in other settings, reviews have found no effect of acupuncture or hypnotherapy on successful smoking cessation. Exercise programs have many other positive impacts on health, but the pooled evidence from 21 trials found no impact on successful smoking cessation.5 

Medications

Help

Help non-pregnant adults to quit by offering smoking cessation pharmacotherapies to all nicotine-dependent people who smoke. 

Nicotine dependence can be assessed by asking the following three questions:

  • How soon after waking do you have your first cigarette?
  • How many cigarettes do you have each day?
  • Have you had cravings for a cigarette, or urges to smoke and withdrawal symptoms when you have tried to quit?Smoking within 30 minutes of waking, smoking more than 10 cigarettes per day and withdrawal symptoms are indicators of nicotine dependence.3 

Reviews have found that all three smoking cessation pharmacotherapies available in Australia increase cessation compared with placebo or no drug: NRT (any form; RR 1.55 from 133 trials); varenicline (RR 2.24 from 27 trials); and bupropion (RR 1.64 from 46 trials).5 Combination NRT combines a patch with a faster-acting oral form (gum, spray, lozenge or inhaler) that can be used to deal with breakthrough cravings and withdrawal symptoms. Combination NRT is more effective than a single NRT (RR 1.25 from 14 trials).5 Shared decision making can help smokers to decide between the two most effective pharmacotherapies (varenicline and combination NRT) and involves patient preference and their past experience.3 A review of 65 trials found that providing behavioural support increased cessation compared with pharmacotherapy alone (RR 1.15).5 

Aboriginal and Torres Strait Islander people who smoke daily are less likely to use NRT and other smoking cessation therapies than all Australians, even though they are just as likely to believe that these therapies help people quit smoking.46 These medicines can often be dispensed at no or reduced cost to Aboriginal and Torres Strait Islander patients, either through the Remote Area Aboriginal Health Service program in remote areas or elsewhere through the Closing the Gap Pharmaceutical Benefits Scheme co-payment measure.47 

The benefit of vaping nicotine-containing e-cigarettes to help quitting remains contentious (for more information, see Chapter 2: Healthy living and health risks, Vaping). However, if the above pharmacotherapies are unsuccessful, consider the use of nicotine e-cigarettes after discussing the lack of information about the long-term risks of e-cigarettes.3 A review found nicotine-containing e-cigarettes increased cessation compared with behavioural or no support (RR 2.66 from seven trials) compared with non-nicotine e-cigarettes (ie placebo; RR 1.94 from trials), but the certainty of this evidence is limited by imprecision due to the small number of trials.9 The considerable variation between nicotine vaping products (including their nicotine dose) also increases uncertainty. The long-term health effects of vaping are uncertain, so dual use (smoking and vaping) and long-term vaping should be avoided.3 

There is insufficient evidence that NRT is effective in increasing smoking cessation in pregnancy from reviews of only five placebo-controlled trials.5,48 It also remains unclear whether NRT is associated with any increase or decrease in adverse events in pregnancy. In contrast, a review of 97 trials found increased cessation in late pregnancy after behavioural interventions compared with minimal intervention or usual care (RR 1.35), and so behavioural interventions, such as CBT, remain the mainstay of cessation support in pregnancy.5 However, if counselling has not been successful, it is reasonable to consider intermittent-use formulations of NRT, such as gum, lozenges, inhaler or tablets, after explaining the risks and benefits.3 Do not use varenicline or bupropion in women who are pregnant or breastfeeding.3 (For more information about antenatal care, refer to Chapter 5: Preconception and pregnancy care, Pregnancy care). 

There is insufficient evidence that cessation support is effective in children aged under 18 years. In a systematic review of primary care interventions for tobacco use prevention and cessation in children and adolescents, no difference was found between NRT patches and placebo in the nine trials of behavioural interventions and the single published trial.7 NRT may still be used following careful discussion with the patient (aged 12 years and over) and their carer, but varenicline and bupropion are not approved for use in people who smoke who are aged under 18 years.3

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