Column 06-2019

Australian Experience: Translating the Science into Clinical Practice

Australia has one of the lowest smoking rates in the world due to aggressive public health policies that include pricing, media education, legislation and heavily state funded pharmacotherapies and I have been involved in this since the 1980s.

We have a very strong no- smoking culture in most social groups and have not introduced electronic/vaping for this reason. Tobacco Treatment Specialists have been addressing the “harder to treat” or heavily nicotine dependent smokers who remain smoking despite the cost, medical consequences and social effects.

 We have seen excellent outcomes addressing smokers with mental health and drug and alcohol comorbidities by changing the language about smoking. I avoid the word “quit” or “stop” and use “manage” your smoking. “Brief Intervention” strategies are not appropriate nor successful in the more dependent smoker. We have developed smoking cessation programmes targeting this group that embraces as less punitive approach, using language that is less intimidating than the imperative “QUIT”.

This small linguistic change has enabled smokers to feel less intimidated and pressured but at the same time acknowledging that something needs to be done for the sake of their health. I have also integrated this language into our state and federal government approaches and recommendations.

 Small factual scientific advances have been introduced into our behavioural recommendations that have also seen the change in the ability to better “manage” smokers.

We teach our smokers about nicotine addiction, pharmacotherapies and valid evidence-based behavioural changes. For example: The evidence that smokers drink more caffeine and alcohol as smoking enhances the metabolising (due to polycyclic aromatic hydrocarbons, PAHs) of both is very informative for smokers. They spend more on caffeine and alcohol because of it, and when they stop smoking they may become a little caffeine toxic if they don’t adjust the level of caffeinated drinks they use. Same effect on alcohol, as alcohol dehydrogenase is induced by smoking. When smokers learn this they are both surprised and angry. These effects are taught in our detox and drug and alcohol units and advice is given regarding the use of NRTs and the safety of concomitant smoking. Smokers see for themselves the reduced need to drink alcohol when they use NRT.

As we have totally smoke-free facilities in all our government institutions we also need to remind our medical colleagues that these PAHs effect many medications, importantly the anti-psychotics, anticoagulants, antidepressants and methadone. Medications such as these to be adjusted down when smokers using them are admitted into hospital as overdose has been reported. I try to educate our medical groups about the current science regarding pharmacotherapies for smoking cessation; the safety of using multiple forms of NRTs, the safety of smoking using NRT and the “gateway” to quitting, the safety of using Varenicline and the safety and efficacy of combining all forms of pharmacotherapies.

We can translate much of the behavioural sciences too into basic advice; such as the cue changes that take place when smokers smoke outside. This small behavioural change is also a “gateway” to quitting. “All smokers smoke outside” is a basic norm in most of Australian households.

 

Renee Bittoun
Consultant; Adjunct Associate Professor
Medical School - University of Notre Dame Australia
Sydney, Australia

Founding Editor in Chief
The Journal of Smoking Cessation, Cambridge UP

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