Section 1 - Lifestyle modifications

Smoking cessation

NOTE: Given established and growing evidence that vaping e-cigarette fluid causes ill-health, the term “smoking” will also include this form of inhaled product as well as tobacco

Recommendations

Cease or prevent commencing smoking ^1–5
- Smoking cessation or not commencing smoking reduces a persons risk of cardiovascular and respiratory diseases and cancers, many other chronic conditions and premature death
- Non-smoking parents, or those who succeed in ceasing to smoke, have the most evident effect on a child abstaining from taking up smoking
Encourage and assist smokers to quit and prevent relapse ^1–5
- Support smokers to access freely available QUIT resources and services
- Assist smokers to quit with evidenced counselling, subsidised medicines and nicotine replacement therapy (NRT)
Eliminate harmful exposure to smoke among children and non-smokers ^1–7
- Do not smoke while pregnant
- Do not smoke indoors, in vehicles, within 10 meters of public buildings or in public spaces
- Do not smoke around children
- Educate children from a young age on the dangers of smoking products
Reduce environmental harms from smoking products ⁸
- Dispose of smoking products legally and responsibly to reduce toxic exposure to infants and animals from ingestion, soil and water contamination and fires

1. The facts ^1–5

11% of Australians smoke
Tobacco smoke contains > 7,000 chemicals with > 69 known carcinogens
E-cigarette liquids contain > 243 chemicals including solvents, nicotine, pesticides and metals
The leading preventable behavioural risk factor for chronic conditions and 8 million premature deaths worldwide annually
Carries the highest burden of drug-related costs on the Australian economy
50% of long-term smokers will die prematurely as a result of smoking related diseases. See Graph 1. and Table 1.

High prevalence populations ^1–5
- Populations that smoke at higher rates than the general population:
  - living in rural and remote areas
  - LGBTQI+
  - unemployed and single parents
  - homeless and prison inmates
  - mental illness and substance use disorders
  - military personnel and veterans

The chart demonstrating risks from smoking, specifically The effect that smoking and ceasing smoking, has on the volume of air that can be forced out of the lungs in one second after taking a deep breath

The effect that smoking and ceasing smoking, has on the volume of air that can be forced out of the lungs in one second after taking a deep breath (FEV₁). Susceptible smokers will have different rates of loss, thus reaching "disability" or "death" at different ages

Table 1. Some health effects from smoking ^1–11
System	Effect
Eyes	Macular degeneration and cataracts
Hair	Loss
Skin	Ageing, wrinkles and wound infections
Brain	Stroke and transient ischaemic attack
Mouth and pharynx	Cancer and gum disease
Lungs	Cancer, chronic bronchitis, Bronchiectasis, emphysema, tuberculosis, Chronic obstructive pulmonary disease, Asthma (adults and children > 12), Asthma (children 1–12 years), and pneumonia
Heart	Coronary heart disease and MI
Stomach	Cancer and ulcers
Pancreas	Cancer Impaired β-cell function and glucose metabolism leading to Diabetes
Bladder and kidney	Cancer
Female reproductive system	Cervical and ovarian cancer, early menopause and irregular and painful periods, reduced fertility, unpleasurable sex, inability to orgasm and bacterial vaginosis Taking oral contraceptive pill while smoking increases risk of MI two fold, and Coronary heart disease twenty fold
Male reproductive system	Erectile dysfunction, decreased sperm quality and sperm DNA damage
Arteries	Peripheral vascular disease
Bones	Osteoporosis cancer
Liver	Cancer
Hands and feet	Persistent pain, gangrene and amputation
Pregnancy	Spontaneous abortion or miscarriage, ectopic pregnancy, premature rupture of the membranes, placenta previa and abruption and preterm delivery
Unborn child and infant	Cardiovascular and musculoskeletal defects, limb reduction defects, missing or extra digits, clubfoot, fused skull sutures, face and eye defects, orofacial clefts, gastrointestinal defects, absent anal opening, hernia, leukaemia, behavioural problems, nicotine dependence, undescended testes

During pregnancy ^1–7
- 8.7% of women smoked during pregnancy at sometime
- 36% of rural and remote mothers smoke during pregnancy at sometime
- Maternal smoking is associated with significant risks to pregnancy, newborn and infant defects. See Table 1.
Infants and children exposed to smoke ^1–5,12
- Infants and children < 5 years are at higher risk of dying if both parents smoke
- Infants exposed to secondhand smoke have double the risk of SIDS due to:
  - thickening and inflammation of the airways
  - increased susceptibility to lung infections
  - the body’s impaired control over respiration and heart rate
  - an impaired autonomic response to begin breathing after an episode of apnoea
- Children exposed to secondhand smoke experience higher rates of:
  - Asthma (children 1–12 years)
  - respiratory tract infections
  - decreased lung function
  - ear infections
  - reduced sense of smell
  - long term developmental effects
  - childhood cancers
- Infants and children are susceptible to the effects of secondhand smoke due to:
  - higher breathing rates
  - greater lung surface area
  - immature lungs
  - inability to control the environment or avoid exposure
- Infants and children most likely to be exposed to secondhand smoke are from:
  - overcrowded households
  - rural and remote locations
  - low socioeconomic households
  - single-parent households
  - households that do not ban indoor smoking
School students and teenagers ^1–5
- The majority of smokers start as teenagers
- In 2017, tobacco smoking rates were the lowest observed since the 1980's at 5%, but vape use is increasing
Aboriginal and Torres Strait Islander populations ^1–5
- 37% of Aboriginal and Torres Strait Islander people > 15 years smoke; highest in rural and remote areas than in urban areas
Vapes (e-cigarettes) ^1–5
- A younger generation of smokers are becoming daily nicotine users since the introduction of vapes to Australia in the mid 2000's
- In 2017, 21.6% of Aboriginal and Torres Strait Islander students reported ever using vapes; significantly higher than non-Indigenous students at 13.5%
- In 2019, the rate of vape use in 18–24 year olds was 26%

2. Intervention and support ^12–14

See Engaging our patients
Determine a person’s willingness to cease smoking
Be nonjudgmental, compassionate, open, honest, sincere and supportive
Do not lecture, threaten or confront:
- listen
- acknowledge the difficult nature of smoking dependence
- many lifestyle changes are required to change smoking behaviours
- outline what can be provided and how the person can be assisted
The only person who can stop smoking is the person themselves. Respect a persons choice not to quit

Behavioural and information based support ^12–14
- Ask:
  - why they smoke?
  - their interest in quitting or cutting down; what stops them?
  - motivations or reasons for quitting? Prompt examples:
    - calculate the annual cost of smoking cigarettes. See Resource 2.
    - calculate how much a patient smokes in pack/years. See Resource 3.
      - refer for lung cancer screening for; a history of > 20 pack/years of smoking, aged 50–79 years or actively smoked within the last 15 years
    - regaining control and being smoke free
    - clean breath, clothes and house
    - being a role model to children and protecting others from secondhand smoke
  - smoking habits and triggers?
- Advise:
  - ceasing smoking is the most beneficial action a person can do for their health and discuss:
    - 1. The facts
    - Table 2. The health benefits of smoking cessation
    - 2.2 Nicotine and dependence
  - the health service is always available when they're ready to take action

Table 2. The health benefits of smoking cessation ^13,14
Time ceased	Health effect
6 hours	Heart rate slows and blood pressure decreases
24 hours	Almost all of the nicotine leaves the bloodstream Venous carbon monoxide levels fall Oxygenation of muscles (including heart muscle) improves Fingertips become warmer and hands steadier
7 days	Sense of taste and smell improves The lungs’ ability to clear secretions, tar and dust begins to recover Higher blood levels of antioxidants such as vitamin C
2 months	Reduced coughing and wheezing The immune system begins to recover Blood flow to hands and feet improves
6 months	Lung function improves, producing less phlegm Stress levels decrease
> 1 year	Lung function improves, breathing easier
2–5 years	A marked reduction in risk of heart attack and stroke The risk of cervical cancer is the same as someone who has never smoked
> 10 years	The risk of contracting lung cancer is lower than that of a continuing smoker
> 15 years	The risk of heart attack, stroke and mortality is close to that of a person who has never smoked

Offer:
- QUIT self-help resources or referral. See Resource 4.
- counselling, psychologist or mental health service referral
- medicine options including NRT
If person wishes to cease smoking provide a clear smoking cessation pathway. See Figure 1.

Nicotine and dependence ^{1–4,8,10,11,13}
- A lethal nerve toxin; the most addictive of tobacco compounds
- Rapidly delivered to and metabolised by the brain, organs and muscles by inhalation resulting in:
  - ↑ heart rate and blood pressure
  - ↓ blood flow in the skin
  - ↓ metabolic rate and appetite
  - vasoconstriction of coronary arteries
  - altered brain wave and endocrine changes
  - ↑ blood flow to and relaxation of skeletal muscle
  - impaired glucose tolerance
- Rapidly triggers release of pleasurable neurotransmitters
- Levels rise quickly after inhalation, accumulates in blood, falling over 6–8 hours
- Accustomed levels in blood is maintained by self-administration
- Inhalation frequency and depth increases to maintain diminishing effects
- Assessing nicotine dependence guides management intensity. See Table 3.

Figure 1. Pathway for smoking cessation

Table 3. The Fagerstrom test for nicotine dependence ^6,12
Questions	Answer	Score
How soon after you wake up do you have your first cigarette/vape?	Within 5 mins.	3
	6–30 mins.	2
	31–60 mins.	1
	After 60 mins.	0
Do you find it difficult to refrain from smoking in places where it is forbidden?	Yes	1
	No	0
Which cigarette/vape would you hate to give up most?	The first one in the morning	1
Which cigarette/vape would you hate to give up most?	All others	0
How many cigarettes/vapes per day do you smoke?	10 or less	0
	11–20	1
	21–30	2
	31 or more	3
Do you smoke more frequently during the first hours after waking than during the rest of the day?	Yes	1
	No	0
Do you smoke if you are so ill that you are in bed most of the day?	Yes	1
	No	0
Answers tallied to give a score > 6 is an indicator of high dependence

3. Develop a Quit plan ^13–15

Assist the person to:
- confirm their readiness to quit
- set goals and steps for quitting e.g. total cessation. Not 'a single puff’
- choose a method to quit and what it entails e.g. counselling, coach, medicines
- set a quit date and begin
- manage triggers, withdrawal and weight gain
- maintain tobacco abstinence, preferably with support

Counselling ^{1–4,8,10,11,13–17}
- Involves mutual problem solving, behavioural skills training, and social support and encouragement
- Smoking cessation with counselling has higher success rates than without
- Refer to a social worker or psychologist for scheduled:
  - phone or face-to-face counselling or
  - group therapy
Choosing a method to quit ^{1–4,8,10,11,13–17}
- The likelihood of quitting tobacco increases with counselling combined with dedication to a chosen method to quit. See Table 4.
- NRT has shown the most success rates of cessation by reducing withdrawal symptoms and blunting the satisfying effects of nicotine
- Combination therapy NRT patches with oral NRT or adjuvant medicines has proven to considerably increase quit rates

Table 4. Methods to quit smoking ^{1,3,4,13–17}
Coaching
Can provide structure, motivation and support to: help organise and remind the person of what and when to do things help develop reasons to quit build confidence and encouragement learn new skills to manage cravings, withdrawal, weight and/or stress Can be a friend, health clinician or a qualified support service. See Resource 2.
Nicotine replacement therapy (NRT) for 8–10 week use or 12 weeks from last smoke
Patches	For those who smoke > 10 cigarettes/day and > 45 kg 25 mg/16 hour patch or 21 mg/24 hour patch	Applied topically. Rotate site to minimise irritation Nicotine is absorbed continuously through the skin to help reduce withdrawal symptoms Subsidised on PBS prescription. Not available at the same time as other PBS subsidised smoking cessation therapies If unsuccessful other medicines can be accessed in the same 12 month period Some QUIT services offer free NRT 24-hour patch useful for those who smoke after waking. Can cause vivid dreams
Patches	For those who smoke < 10 cigarette/day or < 45 kg or with cardiovascular disease 14 mg/24 hour patch or 10 mg/16 hour patch
Gum	First cigarette/vape < 30 mins. after waking 4 mg (6 to 10/day)	Nicotine is digested as gum is chewed or lozenge dissolves in the mouth Taken at intervals to prevent or prior to when cravings are expected Can be used prior to ceasing If unsuccessful other PBS subsidised medicines can be accessed in the same 12 month period No more than 1 piece of gum/hour
Gum	First cigarette/vape > 30 mins. after waking 2 mg (8 to 12/day)
Lozenge	First cigarette/vape < 30 mins. after waking 4 mg (1 every 1–2 hours)
Lozenge	First cigarette/vape > 30 mins. after waking 1.5 mg or 2 mg (1 every 1–2 hours)
Adjuvants
Varenicline A partial agonist of nicotinic acetylcholine receptors that prevents pleasurable effects of smoking and reduces symptoms of nicotine withdrawal May cause mild-to-moderate transient nausea requiring dose reduction
Begin titration as follows: start at least 7 days prior to smoking cessation 0.5 mg PO daily for 1–3 days then 0.5 mg PO bd for the next 4–7 days then from day 8 onwards 1 mg PO bd until the end of week 4 Continue with 1 mg PO bd for a further eight weeks To reduce a relapse for those who successfully quit after 12 weeks continue with 1 mg PO bd for a final 12 weeks
Bupropion A norepinephrine/dopamine-reuptake inhibitor that makes smoking less desirable May cause insomnia, rarely seizures (0.1% risk) and psychotic or manic symptoms, mainly with an existing psychiatric illness Monitor BP if bupropion is used in combination with NRT
Begin titration as follows: start at least 7 days prior to smoking cessation 150 mg PO daily for the first three days then 150 mg PO bd (at least 8 hours between doses) for 7–9 weeks
Quitting abruptly (cold turkey) Quitting cold turkey is most effective with coaching and more effective than cutting down
Cutting down Reducing the number of cigarette/vapes smoked each day over time, to a point of cessation Some people decide to smoke less frequently throughout day until they go without smoking
Other Hypnotherapy (alone), acupuncture or switching to lower strength cigarette/vapes lack evidence to suggest they help to cease smoking Tobacco chemicals increase metabolism of certain medicines e.g. clozapine, theophylline, warfarin and caffeine. Consider adjusting dosages soon after smoking is stopped

Managing triggers^3,4,14-15
- As months pass, cravings can occur when in triggering situations e.g. bad news, arguments, a relationship breakup, car accident
- Brainstorm with person how to avoid triggers by altering smoking habits tied to certain activities, places or people. See Table 5.

Table 5. Smoking triggers and avoidance tips ^13–15
Trigger	Tips
Anytime	Chew sugar free gum, drink water
First thing in the morning	Have a shower first thing, exercise
With tea or coffee	Explore other drinks Use a different cup or drink somewhere other than usual
Morning or afternoon tea	Go for walk, sit with different people
After lunch or dinner	Go for a walk
Straight after work	Listen to music, exercise, cooking or shopping
Before dinner	Play with children, talk with friends
With alcohol	Avoid completely or drink water every second drink Change drink or hold drink in smoking hand
Stress, bad news, argument	Call a friend, go for a walk or play a game on the phone
When living with a smoker	Make smokefree house rules e.g. smoke outside, smoker to not offer cigarette/vape
At night in front of the TV	Do a jigsaw puzzle, use phone, go to bed
Just before bed	Have a warm shower, read a book
When socialising	Socialise with a non-smokers Go to the bathroom, wash face, take some deep breaths Step outside, go somewhere else or go home early If offered cigarette/vape say “no thanks, I don’t smoke”

Managing withdrawal ^3,4,14–15
- For 2–4 weeks after quitting most people will experience withdrawal symptoms which over time will wane. See Table 6.
- Support person to:
  - challenge invasive thoughts e.g. “I really need just one last cigarette/vape”, “just one won’t hurt” or “I could get hit by a bus tomorrow”
  - use self-talk e.g. “I can do this”, “I’m a non-smoker now” or “I won’t let cigarettes/vapes rule my life”
  - accept and avoid dwelling on thoughts of smoking e.g. get back to work, begin that weekend chore etc.
  - resist the temptation, the urge will pass
  - call the nominated coach or friend

Table 6. Tips to overcome nicotine withdrawal symptoms ^3,4,14–15
Withdrawal symptom	Tips to overcome symptoms
Cravings	Last a few mins. Resist and they get less frequent until they’re just memories Exercise
Restlessness, difficulty concentrating and insomnia	Deep breathing and relaxation exercises Smoking increases metabolism of caffeine. Caffeine toxicity is common after quitting. Consider reducing caffeine intake Exercise Hold a straw between fingers as a substitute
Mood changes e.g. depression, sadness, crying, anger, anxiety or irritability	Normal in the early phases of nicotine withdrawal Exercise, use a stress ball After 6 months of quitting, overall altered mood improves
Cold symptoms, constipation, diarrhoea, stomach aches or nausea	Vary diet with plenty of water Refer to MO/NP for symptomatic relief

Managing weight gain^1,3,10,11
- Weight gain is common in the months after quitting nicotine due to:
  - substitution of the hand to mouth action with food and snacks
  - slowing of nicotine free metabolism to a healthier normal rate
  - an increased appetite
  - improved taste and enjoyment of food
- Prepare the person for changes to appetite and eating habits by supporting Physical activity and sleep, and Diet and nutrition
Rewarding the ex-smoker ^1,3,10,11
- Support the person to:
  - embrace being a non-smoker living a smokefree life without smoking
  - celebrate early achievements being healthier, happier and wealthier
  - calculate the savings from quitting and reward themselves e.g. save for a holiday, buy something special, start a new hobby. See Resource 3.
- By rewarding the persistence and dedication to their health and future, the person can continue to motivate themselves

4. References

All Chronic Conditions Manual references are available via the downloadable References PDF

5. Resources

Last updated: November 2024