Episode 51: Quit smoking. What makes a difference?

Dr. Caroline West:
Hello, and welcome to the podcast. I'm Dr. Caroline West, and I'm a GP and medical advisor to NPS MedicineWise. When it comes to factors that make an enormous difference to your health, it could be argued that smoking or not smoking should be at the top of the list. Smoking is still the leading single cause of preventable death and disease in Australia. And although, in general, smoking rates are coming down, they remain stubbornly high with certain risk groups. More on that later. The positive news, though, is that health professionals are in an excellent position to make a real difference. Joining me today on the podcast are three specialists who work with the National Best Practice Support Service for Nicotine and Smoking Cessation, also known as the Quit Centre, which is supported by funding from the Australian Government Department of Health and Aged Care, under the Alcohol, Tobacco, and Other Drugs program. I'd like to start with Dr. Eileen Cole, who's the GP lead at Quit. Welcome, Eileen.

Dr. Eileen Cole:
Thanks, Carolyn. How are you?

Dr. Caroline West:
Good.

Dr. Eileen Cole
Thanks very much for having us on the podcast today.

Dr. Caroline West:
It's nice to be with you all. And I'm also joined with Associate Professor Cathy Segan, who's a behavioural scientist who's done research and evaluation of Quitline... Hi, Cathy.

Cathy Segan:
Hi, Caroline.

Dr. Caroline West:
And Emma Dean, who has a background as a pharmacist, and a special interest in smoking cessation.

Emma Dean:
Good morning. Hi.

Dr. Caroline West:
Thanks for being with us, and no conflicts of interest have been declared. Now, if I can turn to you, Eileen, first, you're a practicing GP, I wondered if you could set the scene for us in terms of what is the current situation with people who smoke in Australia?

Dr. Eileen Cole:
Well, Caroline, as you were mentioning earlier, this is a very important topic because smoking is the single largest preventable cause of disease and death in Australia. And we know from figures that came out in the Australian Burden of Disease study from 2018, that tobacco use contributed to 13% of all deaths. That's more than 20,000 deaths, and cigarette smoking was linked to at least 41 different diseases. So, this does make tobacco use the leading risk factor that contributed to disease burden. And just typically, a disease burden implies this is healthy years of life lost due to tobacco smoking. So, in terms of the type of disease, we think about the large number of chronic diseases that tobacco causes, as well as affecting reproductive health and impacting on medical care, including medicines and recovery from surgery. And just to extend that a little bit further, it also refers to second-hand smoke. So, we know that not only active smoking, but exposure to second-hand smoke, causes disease across all age groups.

Dr. Caroline West:
I mean, that historically has been such a problem. I mean, I remember growing up as a kid and people were smoking in cars, and people would smoke in the classroom, or on airplanes. And, I mean, luckily, we've shifted the dial in terms of what's now accepted, but there are still a lot of people who get exposed incidentally to smoke.

Dr. Eileen Cole:
Yes, that's right. And in particular, children are impacted, but we do know now that it impacts across all age groups. And just to qualify a little bit further about the burden of disease, we also know that, compared to urban centers, remote and very remote populations are more significantly impacted by the disease burden. So, there's not only the overall disease burden, but the inequity associated with cigarette smoking that we think is really important for GPs and all health practitioners to consider.

Dr. Caroline West:
I'd love to come back to that in a moment because I think that's really important for us to keep at the top of our minds. But you were talking about the impact it has on your health, and I guess amongst the general public, people sort of get that there's this strong association between lung cancer, for example, or lung disease and smoking. But there's a whole range of other things that you know... When I talk to my patients about the opportunity to stop smoking, they often don't realize that there are associations with things like chronic pain, with vision loss as you get older, with dementia risk. So, it's one of those things that affects your whole body. Dental, with receding gums and tooth loss, even, with smoking is a big one in certain populations. So, do you find that yourself that a lot of people don't realise how extensive the influence is?

Dr. Eileen Cole:
Absolutely, Carolyn. Yeah. And I really think that's where we as health professionals have this fantastic opportunity to individualise the advice that we give to patients, so that the relevance of the conversation is immediate and direct, we're not just asking you about your smoking because we care, or we want to judge you. It's really, we know for you individually, that if you stop smoking, this will benefit your health in so many ways and prevent you becoming unwell. And you're right, people often don't realise. So, that discussion with the health professional that individualises the messaging for that particular patient is very powerful, and I don't think we can underestimate that.

Dr. Caroline West:
And I often, when I'm talking to my patients about it, if they are smoking, I'll say, "Look, if we look at the bigger picture in terms of all your risk factors", I say, "look, the one thing that's going to make the biggest difference straight off the bat, and in terms of your future, is whether you smoke or not. And so, here's an opportunity for us to really zone in on that." And I keep just dripping that message through, because I find that sometimes the process of becoming a non-smoker... I shouldn't use that word, "non-smoker," should I? I have to get out of that habit, but it's people who smoke or don't smoke, isn't it?

Dr. Eileen Cole:
That's right. Yep.

Dr. Caroline West:
But the opportunity is often present over multiple appointments.

Dr. Eileen Cole:
Yes, that's right. And as health professionals, we can sometimes think, "I don't want to be a nag," or "I don't want to be annoying the patients." Whereas, if we can reframe the conversation in our own head as, "This is a positive, active step that I'm making to improve the health of my patient," then it really puts us in a position where we're doing something that's positive. And bringing the patient along with that messaging is more likely to influence their behaviour. And I think this is really, really important when we think about priority populations, that we might find it's much more difficult to have the conversation, or because we perceive that smoking is not something that this population or particular person may want to deal with right now. And I'm talking in particular about subpopulation, or groups within the population, where the prevalence is stubbornly high and disproportionately high to the general population. -

Dr. Caroline West:
Which of those groups? Can you take us through which groups are most affected?

Dr. Eileen Cole:
Yeah. So, in particular, people who suffer from substance use disorder, so alcohol and other drugs have a very high rate of also smoking; and people with mental illness, including low- and high-prevalence mental illnesses, they can be as high as 50%; people who identify as Aboriginal and Torres Strait Islander still have smoking rates that are up around 38%; and people who are socially and economically disadvantaged.
And it's really important that when we encounter people within these priority populations... Which we often do. We know that we see people regularly, and we find that we may be hesitant to have the conversation about smoking because we think that it's not something they can manage right now. Whereas, if we reframe it to say, "This is," as you said earlier, "one of the most important things that you can do for your health," and talking the patient through that, then I think we're really doing them a service.

Dr. Caroline West:
I know a lot of GPs, especially during COVID, we've had this incredible sense of being overwhelmed. Things have been up in the air, we're doing telehealth, we are trying to manage people with COVID in the home. And I guess that a lot of those preventative risk factors and management of those have been parked a little bit. But GPs will say, "Look, I'm so time poor. How can I have time to spend on counselling for things like smoking risk?" But you are a busy GP yourself. I mean, what could we be doing differently there that would make a difference?

Dr. Eileen Cole:
My care has been revolutionised or completely changed by this understanding of the Ask Advise help model, which is as a way of structuring a conversation that will connect patients who smoke to best-practice or evidence-based cessation care. And that evidence-based care is a combination of behavioural counselling over multiple sessions, in combination with pharmacotherapy for patients where that's clinically appropriate. So, that would be for patients who have evidence of nicotine dependence. And like you, I think, "Well, how can I assess motivation? How can I change behaviour? I don't even have time to get through my day." Whereas, for that purpose, I think Quitline is fantastic, and I've essentially now seen my role as supporting patients into smoking cessation program, and supporting their use of pharmacotherapy, including a prescription where that's appropriate. But really, outsourcing the behavioural support and counselling to Quitline because they just do it so well.

Dr. Caroline West:
And fantastic resource. And if I can just bring Cathy into this part of the conversation. Now Cathy, you work as a behavioural scientist. You've done a lot in this area. If somebody actually contacts Quitline, what service is actually provided for those who are unclear about how it works?

Cathy Segan:
Sure. So, we'd introduce the service to people. So, say that we offer four to six call-backs over a period of about a month to help people work out what they want to do with their smoking, to help them manage withdrawal, and then also to adjust with life without smoking. So, the whole point of a behavioural intervention is it gives that more intensive support and helps people through those stages of trying to quit.

Dr. Caroline West:
And what's the evidence of that actually makes a big difference?

Cathy Segan:
So, there's very clear evidence from multiple reviews, that providing that behavioural counselling, the multi-session counselling, does make a difference. So, it makes a difference just on its own. If you actually combine it as well with the stop smoking medicines where they're indicated, then it has an additive effect. So, it's much more powerful. So, if people receive that k personalised advice from a GP or other health professional to stop, and if they use the medicines were indicated plus Quitline, we know that they're about two-and-a-half times more likely to stop smoking.

Dr. Caroline West:
That's really impressive. So, if you go through that individualised approach, I guess that part of that is really understanding the context of someone's smoking. So, what sort of things do you go through? Triggers? Take me through that.

Cathy Segan:
Sure. So, what would happen in the first call is the first part of it would be doing an assessment with the person. So, first of all, looking at what they want to do about their smoking. So, for some people the idea of quitting smoking is absolutely terrifying, and actually not on the agenda for people with severe mental illness. They're like, "I can't do that. That's not possible." So, in those kinds of cases, we'd be looking to help people to cut down their smoking and support them with that, because we know that if people do cut down that can build their confidence to then make a quit attempt later on. So, we can certainly help people with that cutting down. But we also need to let people know that, as Eileen was describing before, there's kind of no safe level of smoking as well, so there can be a misperception among people who smoke that, "Oh, if I cut it down to less than five cigarettes a day, that'll be fine." But actually, the evidence is sadly, for them, that there is no safe level of smoking, and that stopping smoking is really what's needed to give those health benefits. Having said that, cutting down can really have a big financial benefit for people, and that can be really important focus as well, and a key motivator for people to cut down. So, having done a bit of assessment about where people are at, we can look at building motivation and confidence if that's needed. If people are ready to quit, then it would be more about making a plan about potentially setting a quit day, or working out if they are going to cut down and then quit, how's that going to exactly work in practice? And then, yes, as you mentioned, we would be looking definitely at identifying people's triggers to smoke and working out different strategies that they can use. So, obviously, with the addiction to smoking, there can be lots of situational triggers, so if you're out at dinner with people who are smoking, you'll feel like smoking. So, people need a range of strategies to deal with that. Refusal skills, teaching people refusal skills. Practicing with them how they're actually going to refuse a cigarette when they go out to that dinner party on Saturday night is really important. And then, there's also a lot of work just on those daily routines. People will often get up; they'll have a coffee and a cigarette. So, what are they going to do instead of that coffee and cigarette? Are they going to change to an orange juice instead of a coffee so that they don't get that trigger from having the coffee to want to.It doesn't trigger a craving to smoke.

Dr. Caroline West:
Yeah. I mean, if I could just talk about the triggers a little more because, I guess, that, as you say, can be a great way to understand the pattern of somebody's association. And there are common triggers. I mean, you've talked about the coffee one, and getting up in the morning, and off you go with a cigarette and a coffee. And obviously stress is another one, boredom. Alcohol's a biggie. But what are some of the more unusual triggers that can occur for people? Is it very individual?

Cathy Segan:
So, people can have quite individual triggers. So, there can be things like, driving on the way home, there might be a certain set of traffic lights that trigger people each time to then have a cigarette. But, for the most part, there are lots of very common ones. But we encourage people to perhaps take a day, and for a day just write down what those different situations were that they were in that they were smoking, just so that they can start to get a handle on the different situations, and better awareness of when they're smoking. Because for a lot of people, especially people who are more addicted, smoking can become quite automatic. So, even things like just putting an elastic band around their cigarette pack so they have to think twice before they open it, can make a difference. Small changes like that.

Dr. Caroline West:
Do you still use that four D's thing, that delay, do something else, drink water. deep breathe?

Cathy Segan:
Yeah, absolutely. So, yeah. Delay, deep breathe, drink water, and do something else. I think it's important for people to have some portable strategies that they can use wherever they're going. So, often people will have a water bottle with them, and then the other things they can also do as well. I used to love when mandarins were in season, it's a great thing. It's portable, it's small, it's something people have to use with their hands to open it up, and it's... But people often have tried to quit before, and they will have views on what they know will work for them. So, it's really important. A lot of the Quitline counselling is a focus on this personalized support, and I'm helping people to work out what actually works for them.

Dr. Caroline West:
I've often found that patients will come in and they'll say, "Oh I've been talking to the pharmacist." And I'd like to bring you in here, Emma, because I've found that a lot of the time people will actually approach a pharmacist for trusted advice on what they should be doing with their quit smoking, particularly since there are an array of things that can help. What do we need to think about with that medicinal side of things, in terms of the line-up to help people with quitting? Is that an important thing to consider?

Emma Dean:
Definitely. So, I echo Cathy's comments earlier around that we do know that combining the behavioural counselling together with the stop smoking medicines, as appropriate, is going to increase the likelihood of a person successfully quitting. And when it comes to TGA-approved medicines that are available in Australia, we have nicotine replacement therapy, which people often know as NRT, and then we have two prescribed stop smoking tablets, or medicines, bupropion and varenicline. But there are certain things that should be considered when choosing which of those medicines may be best, and that's things like clinical suitability. So, depending on a person's medical history or, for example, if they're taking any medications. What I find is really, really helpful is understanding a little bit about whether the patient has used any of them before, so their experiences with those, and were they helpful or not helpful, or experienced adverse effects? That can be a really, really crucial part. Then, it's also what is PBS subsidised? So, we do have the nicotine patch, the nicotine gum and the lozenge that are all on the PBS, or pharmaceutical benefit scheme. And the prescription medicines, varenicline and bupropion, are also on the pharmaceutical benefit scheme. So, that can be important, because costs can factor in here. I think that the pharmacists can have a really key role here. So, one thing we do know is that correct use of the different nicotine replacement therapy types or forms is really important. So, there's nicotine patch, there's nicotine gum, lozenge, mini lozenge, inhalator and mouth spray. So, there's a few different forms, and unfortunately they're not as easy to use as you may think they are, and quite often people who may have tried them before may have not used them correctly, and either found them ineffective or not as effective as they hoped, or experienced adverse effects. So, I really think pharmacists can have a really key role in supporting the medications.

Dr. Caroline West:
And just going back to you, Eileen. I know that quite a lot of my patients who are interested in becoming people who don't smoke, they ask about vaping. "Should I actually be vaping as a quit smoking tool?" I mean, what do you say to people around that?

Dr. Eileen Cole:
Yeah. So, certainly it is a hot topic of conversation, isn't it, at the moment among us health professionals, and GPs in particular. And I think we can look at vaping and nicotine vaping products in two ways. So, within our Quit Center team, we really look at them and talk about them in the context of smoking cessation, and acknowledging that broader public health discussion. But in terms of using nicotine vaping products for smoking cessation, we really look towards the RACGP guidelines – the Supporting Smoking Cessation guidelines for health professionals, in that nicotine vaping products are recommended for people who've tried to achieve smoking cessation with first-line therapies. So, they're very much second line therapies.And when a GP is considering having a discussion with a patient about the use of nicotine vaping products for cessation, they really need to have a good chat with the patient about the caveats around using the medications. We know that there's a lack of evidence about the long-term health effects of nicotine vaping products at the moment, and that currently in Australia, nicotine vaping products are not registered therapeutic goods. So, their safety, efficacy and quality have not yet been established. And the other complicating factor for GPs and for patients is that there isn't a uniform product. So, there's lack of uniformity around the vaping devices and the products. So, with that in mind, acknowledging that there may be a role as second line, there is quite still a lot of complexity and things to work through with individual patients, if they're choosing nicotine vaping products to support their cessation.

Dr. Caroline West:
And that's probably one of the things I get asked about most, which is the vaping. But the other thing that I get asked about, which is, I guess, a point at which you explore barriers to becoming a person that doesn't smoke, they're around things like... and I'll throw this to you Cathy because you may know the answers of how we can respond to this... "Oh, I don't really want to quit smoking because I'm worried about gaining weight." That's a biggie. So, what sort of conversations can we have around that?

Cathy Segan:
"So, it's true that people who quit smoking do gain some weight, but the health benefits from quitting smoking far outweigh the risks of that extra weight," would be my bottom-line message around that. And I think, yeah, so then Quitline can help people to then look at managing. So, part of looking at healthy options for what they're eating, and looking at general wellbeing in terms of getting enough sleep and eating well is certainly part of the help that we provide to people. That's where the healthy eating stuff and the drinking water being part of the four D's is really, really important.

Dr. Caroline West:
I mean, I'll maybe go back to you, Eileen. I mean, I often talk to people about it and say, "Look, there can be changes in the way you choose foods, but there are opportunities to actually address that preventatively, so that you don't swap the oral thing of the cigarette for the oral thing of lollies, for example."

Dr. Eileen Cole:
Yeah. I think it-

Dr. Caroline West:
What do you say to people when they ask about that? Because they do ask about it.

Dr. Eileen Cole:
I agree, and it's often one of the first things that people ask. And I think, again, trying to reframe the conversation to say more about, moving away from the weight gain and saying, "Well, what will happen if you keep smoking? So, what is the alternative if you choose this behaviour?" And then enabling them to reframe any weight gain as a temporary blip. So, if you're choosing to engage in a smoking cessation program, now you're choosing to make a positive difference in your own health, and that positive focus can be on all areas of your life. So, the main focus will be on smoking cessation, but really looking at the broader impacts of eating healthy, getting enough exercise, the things that we all know work to make us feel better. If the short-term cost is a few kilos of weight gain, then letting the patients know that you're with them there through that and you'll be able to focus on other healthy lifestyle elements, then it just puts things into perspective again. So, that's the approach that I take.

Dr. Caroline West:
Yeah. I like that phrase, the temporary blip. I think I'll use that. That's a good one. The other one I hear a lot about is, and this gets back to triggers and of behavioural stuff, is, "I like to have a cigarette when I drink alcohol. If I am not going to smoke anymore, does this mean I have to stop alcohol, or do I have to stop it for a while?" What's usually recommended from the point of view of Quitline?

Dr Cathy Segan:
So, I suppose there is an issue with alcohol and smoking relapse. So, particularly if people have quite a few drinks, then it can be very easy to give in to temptation and start smoking again. So, we might recommend for people that, say, perhaps for that first week or so...Because we know that about 60% of people will relapse actually within that first week of stopping smoking, which is, I suppose, another important reason to refer to a service like Quitline, because we've got the flexibility to be able to provide more intensive calls over that first period when people are likely to relapse. So, we might recommend, over that first period, that people... Perhaps they might drink less, or they might avoid certain social situations where they know they're going to be really, really tempted to smoke. But eventually, the longer term goal is that people do need to face all of those situations that they used to smoke in, and to try to extinguish that habit. So, it's only, again, a short-term blip in terms of alcohol. And my understanding as well is that if you smoke, when you stop smoking, you may not need as much alcohol to actually get the same effect. Similarly with caffeine. So, it's also really important for if people stop smoking, that they don't replace all of their cigarettes with coffees because they'll end up with the jitters.

Dr. Caroline West:
Oh, yeah. I find that. Because people say, "Oh, I've quit, and I've just feel terrible. I have my coffee, and I feel like I'm jumping out of my skin." And it's not actually the withdrawal from nicotine, it's the added effect of the caffeine in their system. So, I think that's a really important thing for us to flag with people as they go through that transition. And do you think, Emma, that we are doing enough as health professionals, or should we be encouraging these conversations more frequently? What could we be doing?

Emma Dean:
I think it's something that we all know that we should be doing as health professionals, that we should be having these conversations. But going back to Eileen's comments earlier, I think sometimes we rationalise in our heads why we don't, and not really realise what impact that could have, that the patient may then think, "Oh, they haven't asked about smoking. Is that because it's actually not an issue? Is it because they don't care?" So, we don't want to be giving these kind of inadvertent messages from not doing it. And I also do think that, perhaps, on occasion we don't have these conversations because we're not sure what the help looks like. So, we're not sure what Quitline offers, so we think, oh, if we raise it and the patient says, "Oh, can you tell me about what will happen when Quitline calls?" and I can't answer, then I'm going to look a bit silly. So, I think part of it is that as well. But, yeah, I think that we certainly can do more, and it's not just about asking. That's the important first step, finding out if the person does smoke, and we like to say, "Are you currently smoking or do you smoke?" And then provide that advice around quitting that is individualised, so it's more likely to resonate with the patient, and then connecting them to that help.So, if medicines are clinically appropriate, if the person's nicotine dependent, exploring that and prescribing or facilitating access to the pharmacotherapy, and then referring them through to multi-session counselling through Quitline. So, it's the AAH model, the Ask, Advise, Help, is that way that can kind of guide that conversation so that you get those three steps in. But yeah, I certainly think there's definitely more that we should be doing, and really consider if we don't raise it, what we might be telling our patients. I think that's important.

Dr. Caroline West:
Our medicine insight data just came out by NPS MedicineWise, and it was interesting to see that I think it's around 15% of people still don't have their smoking status recorded. So, that's probably a worry, and then they're probably not having it updated as frequently as it could be. So, there's a chance right there to at least document it, and start that conversation. You talked a bit about nicotine dependence. How does a GP triage, if you like, somebody's risk in terms of dependence? Where's the line drawn, in terms of crossing that line to being nicotine dependent or just an occasional user? Or is everybody who smokes indeed nicotine dependent?

Emma Dean:
Look, there are some tools that can be used to help assess a level of nicotine dependence. So, there's something called the Heaviness of Smoking Index, which is two questions: how soon after waking in the morning do you have your first cigarette of the day, and how many cigarettes a day do you smoke? So, they're certainly really good indicators. And also whether someone's had experiences of withdrawal on previous quit attempts can be a good indicator if they are dependent. Obviously these are tools that help us, but as with everything that we do in clinical care, in the RACGP guidelines that Eileen mentioned earlier, there is an algorithm that is specifically for nicotine replacement therapy, and looking at guiding a prescriber around what might be best, depending on how soon after someone wakes they have their first cigarette and number of cigarettes a day. But if it isn't sufficient, and the person is still experiencing withdrawal symptoms, we need to essentially titrate the nicotine replacement therapy to get the clinical response that we want, just like we would in pain control, or whatever else we were doing, that there is an initial algorithm there to guide what might be appropriate. But obviously, if we need to use more, that we can do that as well. So, I think that's really important.

Dr. Caroline West:
When I was GP, I think I've used, "Do you smoke in the first 30 minutes after you've woken up?" I don't know if that's the right or the wrong metric. Maybe one of you could tell me whether that's the arbitrary line of dependence, or is it longer than that?

Emma Dean:
So, certainly, time to first cigarette is a good indicator of dependence, and obviously the sooner you have your first cigarette of the day after you wake up, the more likely you are to be dependent. So, I do think it's a good indicator, in that if you are familiar, Carolyn, with the algorithm that's in the guidelines, it certainly does have within 30 minutes and after 30 minutes there as one of the considerations. And I think the other thing, reflecting on some conversations that the Quit Centre team have had with health professionals over probably the last six months or so, because that's how long our team has been around in the Quit Centre, we do find that still, some health professionals are not familiar with the concept of combination therapy. And that is using a nicotine patch together with one of the faster-acting types or forms. So, nicotine patch and lozenge, or nicotine patch and gum. And really what that does is it takes the best of both of the forms, so to speak. So, you've got the patch that is slow acting and long acting, and takes the edge off those background cravings through a relatively steady dose of nicotine being provided. And then, the faster-acting forms provide that quicker and more flexible relief in response to cues or triggers. That is certainly something that the guidelines have now, is a real consideration with respect to nicotine replacement therapy, if that is deemed most appropriate for the patient.

Dr. Caroline West:
So, that's interesting. So, what you're saying is, you can pop somebody on a patch and then they can almost have top-up gum or anything else to get them through a sticky bit-

Emma Dean:
That's right.

Dr. Caroline West:
... like going to a party or a stressful part of the day. Oh, okay. I don't think a lot of people would've been aware of that, so that's good to know. And then, does anybody combine the oral medications with patches as well? What's the thinking around that?

Emma Dean:
So, there is some evidence that varenicline can be used with nicotine replacement therapy patch. You are more likely to experience some adverse effects with that, but there is some evidence, and the clinical guidelines do make a recommendation that that can be considered as an option. And Carolyn, going back to the comment around combination therapy, I say it's a little bit like a preventer and a reliever. And people are quite familiar with that type of concept. A lot of people know someone who has asthma, or they might have asthma or COPD themselves, so they're quite familiar with this concept of a preventer, which I kind of say is a little bit like the patch because you use it regardless, and then you've got that reliever or that top up. So, the concept is not unfamiliar, either to health professionals or to patients. And I think framing it in that way can be really helpful for people to understand why the two. And for those of us that are health professionals, certainly the way that the nicotine works, and the pharmacokinetics, it makes sense, the patch plus one of those faster-acting forms.

Dr. Caroline West:
It gets back to this central thing of just starting the conversation and getting the ball rolling, doesn't it? Because I think, going back to Eileen's original comment around time-poor GPs, is that an intervention that makes a difference doesn't have to be a laborious huge one. It can sometimes be a nudge, and then what you're saying is get in touch with Quitline, and Quitline can then initiate these multiple counselling sessions, which can address all the behavioural side of things.

Emma Dean:
Absolutely.

Dr. Caroline West:
And that can be a great way of, even in a busy timetable, getting it started. And sometimes, I think we can be encouraged as health professionals that a little intervention can make a big difference. I'm always incredibly chuffed when somebody comes back and they've stopped smoking, and they say, "Oh, it's that little conversation we had a year ago about my general health, or the fact my dad had a heart attack at a young age. And that made all the difference to getting it." So, it was that little personal little inquiry with curiosity around what was important to that person, and then just using that as a little nudge point. And sometimes that's all it takes to get it started. And then, returning to that same theme at subsequent appointments to just check in and see how somebody's going. Somebody mentioned the nag before. It might have been you, Cathy. But it was, I guess, partners of those people who smoke are often so tempted to just stay on the case, i.e. nag. Is there any benefit in doing that? Can that at least get people to change, or do they just dig their heels in?

Cathy Segan:
I think those kinds of messages from partners, while there might be nagging, are kind of coming from a good place. They want the best for their loved ones. But yes, we know that nagging is not really effective, and it's likely to just make the person who smokes more stressed and then they may be more likely to smoke to deal with that. But coming back to what you were saying earlier... I just wanted to make one point about the referral to Quitline. And sometimes when we talk about referral to Quitline, people can interpret that as, "Oh, I'll just tell my patient to give Quitline a call." But we know that because people are ambivalent about their smoking. There's a reason people smoke. It helps them to get going in the morning and to deal with the stress, and to manage their weight, and to do all these things. So, that ambivalence about their smoking behaviour can stop people from reaching out to Quitline. So, we know that if health professionals actually make an electronic or a fax referral to Quitline, we know that their patients are much more likely to actually end up using the service, and that they're also much more likely to be quit six months later.

Dr. Caroline West:
And that's a really great point. I guess when we look across the board, there are some target groups that still we are trying to, I guess, focus on to assist with the smoking rates in certain communities. You've touched on rural and remote, people with substance abuse, mental health conditions, people from an Aboriginal, Torres Strait Islander background. Are there certain approaches or resources that are culturally sensitive, or really address things in a slightly different way?

Cathy Segan:
Quitline does have tailored services for those groups, so there is actually an Aboriginal Quitline on the same number, and the quit number is actually on all the cigarette packets, just for reference, as well. And so, there's an Aboriginal Quitline staffed by Aboriginal counsellors, and then there's also  tailored counselling for people with mental health or alcohol and other drug issues. So, often there'll be potentially more counselling calls, or potentially over a longer period for people with mental health issues. There can also be an issue sometimes with interactions with some of the medications that they take, so we'd be covering some of that. And people with mental health issues can often be really concerned about their mood, so a key role of Quitline is kind of checking in through that withdrawal phase, because withdrawal can make your mood temporarily a bit worse. But we want to make sure that if it's just that nicotine withdrawal, and that there's nothing else going on that needs to be addressed.

Dr. Caroline West:
And focusing, I guess, all the time on the positive opportunities.

Cathy Segan:
Exactly.

Dr. Caroline West:
You will make a difference to your health immediately. It's not something where you have to wait one month-

Cathy Segan:
That's right.

Dr. Caroline West:
... three months, six months.

Cathy Segan:
I was also just going to say, some of the tailoring as well as around those key benefits. So, we know for people with mental health issues, actually up to six weeks and onwards, often people report improved mood, or that their mood is not any worse than what it was before they stopped. And similarly, we know that if people are trying to stop other drugs of addiction, that stopping smoking actually helps with stopping those other drugs. Whereas it used to be thought that, oh, if you stop smoking as well, that it would lead to failure in trying to treat those other addictions. But that actually, the opposite is true.

Dr. Caroline West:
Oh, that's fantastic news.

Cathy Segan:
The other tailoring that we have as well is for people who are pregnant. The call back service, then actually follows them up right through their pregnancy, as well as into the period after they've given birth, because we know that's a common time for relapse. We can have, quite commonly, people who are pregnant who stop smoking for the baby, and one of our key roles is to try and build that intrinsic motivation for them to keep off the cigarettes for themselves and the health benefits for themselves as well.

Dr. Caroline West:
So, if I can finish up with you, Eileen. If you have to encourage someone to have a think about becoming a non-smoker, how do you frame the positives? What are the things that you do to really encourage them to think about smoking in a different way?

Dr. Eileen Cole:
Well, I really use the AAH model. So, as you said earlier, I always ask a patient who smoke, and look for an active opportunity within a consultation to ask about smoking status that's linked to the consultation. So even, for example, someone who might be going into surgery, to say, "I need to update your records. We'll get you prepared for surgery. Do you smoke?" And then documenting that. And then, using that as an opportunity to say, "Smoking increases the risk of complications, wound complications and trouble during the anaesthetic, so let's take this opportunity to connect you to some smoking cessation help." You then need to tailor the subsequent conversation according to the response that you get back. So, I previously thought I needed to assess motivation, whereas I now go in boots and all saying, "Here's the positives." And that gives the patient the opportunity to say, "Well, I'm not really ready." But I know, at that stage, even if I offer to make a referral to Quitline, the patient is thinking about it. If I can make the offer, and Quitline proactively contacts the patient, so it takes the motivation to contact Quitline away, and then that initial conversation, the patient may not engage, but the door's open. And so, then I can have subsequent chats with the patient, and they know that I will talk to them about it in a way that's not judgemental. It's framed as positive, and that they can come back at any time.

Dr. Caroline West:
Fantastic. And how can health professionals get more information?

Dr. Eileen Cole:
So, if we go online, we've got our Quit Centre website, which is a new website. It's particularly for health professionals. And that will link all health professionals to training and resources and tools, guidelines. There's an option there to sign up to a newsletter, which you'll receive directly into your mailbox. And it's a fantastic resource.

Dr. Caroline West:
Okay, so that's quitcenter.org.au? That's right. Fantastic.

Dr. Eileen Cole:
And the other fantastic spot on that is you can make a referral to Quitline directly from that site.

Dr. Caroline West:
Brilliant. Well, thank you so much to all of you, to Emma, Cathy and Eileen. It's been fantastic, and it's certainly encouraged me to always put smoking and becoming a non-smoker at the top of my list when I'm talking with people. And certainly, to use the Quit Center, the Quitline, to assist in that process, and wonderful resource. It's free, that's right?

Cathy Segan:
That's right.

Dr. Caroline West:
No cost to patients, so that's always a great thing to let them know about as well. So, thank you so much for being with us. That's all we have time for today, but if you'd like any more information on this podcast, please go to nps.org.au, or if you'd like information on the CPD points that are attached to this podcast. It's been wonderful having you with us. I'm Dr. Caroline West. Bye for now.