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A Pragmatic Guide for Smoking Cessation Counselling and the Initiation of Nicotine Replacement Therapy for Pregnant Aboriginal and Torres Strait Islander Smokers

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Smoking prevalence of pregnant Aboriginal and Torres Strait Islander women is quadruple that of pregnant women in the Australian population, and is associated with significant adverse outcomes in pregnancy. While cessation is a priority, there is as yet little evidence for effective interventions. This paper provides a pragmatic approach to addressing the complexities of smoking in pregnant Aboriginal and Torres Strait Islander peoples and informs clinicians about the initiation of nicotine replacement therapy (NRT) in pregnancy. Experts agree that nicotine replacement is safer than continuing to smoke in pregnancy. Although a pharmacotherapy-free attempt is initially recommended, if abstinence is not able to be achieved in the first few days, the women should be offered an accelerated option of NRT starting with oral forms and then, if required, progressing to nicotine patch or combined oral and transdermal therapy. Support should be offered for at least 12 weeks and post-partum. Offering counselling and cessation support to partners and family is also important, as is linking the woman in with appropriate social and community support and Aboriginal specific services. As long as oral forms of NRT are not included in the Pharmaceutical Benefit Scheme for Aboriginal and Torres Strait Islander women a significant and inequitable barrier will remain.
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A Pragmatic Guide for Smoking Cessation Counselling and the Initiation
of Nicotine Replacement Therapy for Pregnant Aboriginal and Torres
Strait Islander Smokers
Gillian S. Gould, Renee Bittoun and Marilyn J. Clarke
Journal of Smoking Cessation / FirstView Article / March 2014, pp 1 - 10
DOI: 10.1017/jsc.2014.3, Published online: 31 March 2014
Link to this article: http://journals.cambridge.org/abstract_S1834261214000036
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Gillian S. Gould, Renee Bittoun and Marilyn J. Clarke A Pragmatic Guide for Smoking Cessation Counselling and the
Initiation of Nicotine Replacement Therapy for Pregnant Aboriginal and Torres Strait Islander Smokers . Journal of Smoking
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A Pragmatic Guide for Smoking Cessation
Counselling and the Initiation of Nicotine
Replacement Therapy for Pregnant Aboriginal
and Torres Strait Islander Smokers
Gillian S. Gould,1,2 Renee Bittoun,3and Marilyn J. Clarke4
1School of Public Health, Tropical Medicine and Rehabilitation Science, James Cook University, Cairns, Queensland
2School of Health and Human Sciences, Southern Cross University, Coffs Harbour, New South Wales
3Brain & Mind Research Institute, Sydney University, New South Wales
4Northern NSW Local Health District, Grafton, New South Wales
Smoking prevalence of pregnant Aboriginal and Torres Strait Islander women is quadruple that of
pregnant women in the Australian population, and is associated with significant adverse outcomes
in pregnancy. While cessation is a priority, there is as yet little evidence for effective interventions. This
paper provides a pragmatic approach to addressing the complexities of smoking in pregnant Aboriginal
and Torres Strait Islander peoples and informs clinicians about the initiation of nicotine replacement
therapy (NRT) in pregnancy. Experts agree that nicotine replacement is safer than continuing to smoke
in pregnancy. Although a pharmacotherapy-free attempt is initially recommended, if abstinence is
not able to be achieved in the first few days, the women should be offered an accelerated option
of NRT starting with oral forms and then, if required, progressing to nicotine patch or combined oral
and transdermal therapy. Support should be offered for at least 12 weeks and post-partum. Offering
counselling and cessation support to partners and family is also important, as is linking the woman in
with appropriate social and community support and Aboriginal specific services. As long as oral forms
of NRT are not included in the Pharmaceutical Benefit Scheme for Aboriginal and Torres Strait Islander
women a significant and inequitable barrier will remain.
Keywords: tobacco smoking, Aborigines, Australian, smoking cessation, nicotine replacement products,
prenatal care
Introduction
Smoking prevalence of pregnant Aboriginal and Torres
Strait Islander women (49.3%) is quadruple that of preg-
nant women in the general population (12.1%) (Li, Zeki,
Hilder & Sullivan, 2012). Only 9.6% of Aboriginal and Tor-
res Strait Islander women who smoke quit in pregnancy
compared with 18.4% of pregnant smokers generally (Li
et al., 2012). Pre- and perinatal smoking, as well as expo-
sure to second hand smoke in childhood, are major factors
associated with adverse outcomes for both mother and
child, including miscarriage, stillbirth, low birth weight,
birth defects, Sudden Unexpected Death in Infancy, res-
piratory problems, glue ears, cognitive-behavioural prob-
lems, and early smoking initiation (Hofhuis, de Jongste,
Address for correspondence: Dr Gillian S. Gould PO Box 9077, Moonee Beach 2450, NSW Email: gillian.gould1@my.jcu.edu.au
&Merkus,2003). The benefits of quitting on birth weight
are maximised with cessation before 20 weeks gestation,
but only 3% of pregnant Aboriginal and Torres Strait Is-
lander smokers are reported to achieve this (Wills & Coory,
2008).
Aboriginal and Torres Strait Islander peoples belong to
culturally and geographically diverse communities. Local
factors need to be taken into consideration when inter-
preting tobacco control and cessation research in other
populations and other Indigenous communities. Trans-
lational issues may arise for example if applying findings
from an urban population to a remote community, and
across different Aboriginal Nations. Prevalence of smok-
ing varies by remoteness in Australia and can be over
1
Gillian S. Gould, Renee Bittoun and Marilyn J. Clarke
80% (Robertson, Conigrave, Ivers, Hindmarsh & Clough,
2013), with diverse patterns of use amongst Aboriginal
and Torres Strait Islander remote communities (Clough,
Guyula, Yunupingu & Burns, 2002).
Despite an overall decrease in daily smoking in Aborig-
inal and Torres Strait Islander peoples over the last decade
from 53% to 43%, there have been no significant changes
in rates in remote communities, nor a significant drop in
the rates in the peak reproductive age group of 25–34 years
foreithergender(>50%) (Australian Bureau of Statistics,
2013).
A systematic review on smoking in pregnant Aborig-
inal and Torres Strait Islander women synthesised seven
papers, covering five urban, two rural and two remote
communities (Gould, Munn, Watters, McEwen & Clough,
2013a). The synthesis revealed complex factors that foster
maternal smoking such as sociocultural norms, family in-
fluences and stressors. Quitting is perceived as hard, and
smoking is often justified in the face of challenging life
circumstances, and existing anti-tobacco messages lack
relevance. Conversely, women express strong protective
attitudes to the foetus and look up to positive role mod-
els. Women have limited knowledge about harms from
tobacco use and treatment options, such as nicotine re-
placement therapy (NRT) (Gould et al., 2013a;Gould
et al., 2013b). Attitudes of Aboriginal and Torres Strait
Islander communities to NRT have not been satisfactorily
explored (Eades, Sanson-Fisher & Panaretto, 2013;Gould
et al., 2013b).
Additional systemic barriers have been identified that
may affect the health practitioner’s ability to provide eq-
uitable therapy, such as the lack of subsidy for oral forms
of NRT (Gould, McEwen & Munn, 2011) and excessive
caution in prescribing NRT (Gould & McEwen, 2013).
While the oral forms of NRT are not subsidised by the
Pharmaceutical Benefit Scheme (PBS) in Australia, the
costs are likely to be prohibitive for low socio-economic
smokers, including pregnant Aboriginal and Torres Strait
Islander women. NRT is the only option for assisted cessa-
tion as other pharmacotherapies, such as Varenicline and
Bupropion, are contra-indicated in pregnancy in Australia
(Zwar et al., 2011), although a cohort study is underway
to explore the effects of these medications in pregnancy
(Havard et al., 2013).
Guidelines for treatment of smoking in pregnancy
vary internationally. The UK NICE guidelines recommend
NRT patches for women who cannot quit unaided (NHS,
2010) and NRT (both oral and patches, often combined)
are offered to pregnant smokers if they wish to use them.
The Australian RACGP guidelines suggest an initial at-
tempt unassisted by NRT, then offering oral forms of NRT
if a woman is unable to quit; if this is not successful patches
can be used (Zwar et al., 2011).
Health professionals may be reticent to initiate NRT
in pregnant smokers, and the issue remains controver-
sial because of the concerns about the use of nicotine
on the foetus (Forest, 2010;Osadchy,Kazmin&Koren,
2009). A recent Cochrane review determined that there is
as yet insufficient evidence that NRT is effective or safe
in pregnancy (Coleman, Chamberlain, Davey, Cooper &
Leonardi-Bee, 2012), but the review reported there were
no statistically significant adverse foetal outcomes when
comparing NRT to controls. Experts however have con-
cluded that using NRT is generally safer than smoking
in pregnancy (Bittoun, 2010; Forinash, Pitlick, Clark &
Alstat, 2010). Surveyed UK general practitioners (GPs)
reported being unsure about the safety of NRT in preg-
nancy, and low confidence in their ability to prescribe NRT
in pregnancy, despite the majority also believing that NRT
in pregnancy was likely to be safer than smoking (Herbert,
Coleman & Britton, 2005). Price et al. report the major-
ity of US obstetricians in their study did not prescribe
NRTbecauseofalackofcondenceandlackofsmok-
ing cessation training (Price, Jordan & Dake, 2006). In
Australia healthcare providers who have better knowledge
about NRT were more likely also to assess smoking status
in pregnant Aboriginal and Torres Strait Islander clients
(Passey, D’Este & Sanson-Fisher, 2012).
NRT patches have been shown to produce higher absti-
nence rates than placebo at one-month follow up (21.3%
vs. 11.7%), but in the long-term were not efficacious in
pregnancy (Coleman et al., 2012): however adherence was
a major issue, with most of the women not taking the
medication for more than 4 weeks (Oncken, 2012).
Another issue is that higher than normal NRT doses
may be needed due to increased nicotine metabolism
in pregnancy (Dempsey, Jacob & Benowitz, 2002). The
Cochrane review recommends using higher doses of NRT
in future research (Coleman et al., 2012). A recent UK
study of over 3000 pregnant smokers showed that when
two forms of NRT were used concurrently (i.e. combined
NRT patch and an intermittent form) there was a signifi-
cant increase in abstinence compared with no treatment,
(OR =1.93, 95% CI =1.13 to 3.29, p =0.016) while
monotherapy with a NRT patch showed no significant
benefit (OR =1.06, 95% CI =0.60 to 1.86, p =0.838)
(Brose, McEwen & West, 2013). Safety issues of combined
NRT could not be addressed in this type of study design,
however authors make the case that combination NRT de-
livers nicotine without carbon monoxide and the multi-
tude of other reproductive toxins absorbed from cigarette
smoke.
Comprehensive and often intensive interventions are
recommended for pregnant Aboriginal and Torres Strait
Islander women (Lumley et al., 2009) but so far evidence
to guide successful interventions by health practitioners
and policy makers is lacking (Eades et al., 2012;Lumley,
2009).
In the absence of evidence for approaches to man-
aging smoking in pregnant Aboriginal and Torres Strait
Islander women, this paper offers pragmatic guidance for
the practitioner to enable the timely initiation of NRT and
supportive counselling. The guidance is based on a syn-
thesis of available literature, expert opinion and clinical
2JOURNAL OF SMOKING CESSATION
Smoking cessation for pregnant Indigenous smokers
experience and speculates on how these may be applied
in the Aboriginal context. Consideration will be given to
some of the issues a GP, obstetrician or other clinician may
be likely to encounter during management.
Screening the patient
Practices should pay attention to cultural safety for Abo-
riginal and Torres Strait Islander clients, so women feel
encouraged to attend for follow-up healthcare (Belfrage,
2007). Access issues are important and financial burdens
should not become a barrier to attending.
All pregnant women should be routinely asked about
their smoking in a non-threatening way, and nicotine de-
pendence assessed. Smoking may be under-reported in
this population. Using a written multiple-choice format
aids disclosure in the general population, but literacy is-
sues may need to be taken into account, in this popula-
tion (Australian Government Department of Health and
Ageing, 2012). Box 1 suggests a simplified verbal version.
Using a conversational style of history taking has merit
in the Aboriginal context, asking the woman to tell her
smoking story.
Midwifery approaches recommend a sensitive woman-
centred dialogue building on trust and a long-term re-
lationship (Ebert, Van Der Riet & Fahy, 2009). A full
smoking and cessation history should be taken. His-
tory includes age of initiation, length of smoking his-
tory, cigarette consumption, previous quit attempts and
duration of smoke-free episodes, and whether cessation
aids have been used previously, their effectiveness and
anysideeffects.Cigaretteconsumptionmaybehardto
quantify if cigarettes are shared and household finances
prevent supply for the whole week (Gould et al., 2013b).
Ask whether other household members smoke and assess
smoking locations such as at indoor/outdoor smoking at
home, in the car and at work. Initial engagement is vi-
tal to encourage the woman to be comfortable to come
back and see you a second time, and not feel shamed
about her smoking or that she is a ‘bad mother’ for
smoking.
Several drugs, including caffeine, interact with the liver
metabolism of polycyclic aromatic hydrocarbons (pro-
duced by tobacco smoke), resulting in higher bioavailabil-
ity of the drugs, so the usage of caffeine and other drugs
should be assessed. On smoking cessation, caffeine ef-
fects may result in increased anxiety and restlessness, and
therefore be confused with nicotine withdrawal symptoms
(Bittoun, 2010). This effect is independent of NRT use. A
reduction in caffeine intake should be advised, and other
drugs may need monitoring.
The question arises as to what is the best measure of
nicotine dependence in pregnancy?
rAddiction levels are believed to be low in Aboriginal
and Torres Strait Islanders during pregnancy (Panaretto,
2009; Robertson et al., 2013), based on the Fagerstr¨
om
Test for Nicotine Dependence (FTND) or Heaviness
of Smoking Index (HSI). However clinical experience
suggests the full range of dependence.
rAs the above measures depend on the number of
cigarettes smoked per day and many pregnant women
try to reduce their smoking when pregnant, such mea-
sures may not accurately reflect their addiction level.
rDependence scales (i.e. FTND and HSI) do not capture
the potential for compensatory smoking or the high lev-
els of discomfort from craving that a pregnant woman
may experience when reducing.
rThe Strength of Urges to Smoke (SUTS) scale may there-
fore give additional information about dependence (Fi-
dler, Shahab & West, 2011), and should be measured at
each visit (Tab l e 1).
rCarbon monoxide (CO) can be measured by the health-
care provider with a hand held expired breath CO moni-
tor, available in Australia, easy to operate and reasonably
priced.
rThe CO monitor can be used to estimate the foetal car-
boxyhaemoglobin (FCOHb%) in the pregnant smoker
and partner (if smoking). These measures may serve as
opportunities to educate about the effects of smoking
on the foetus (Tab l e 1).
rPregnant women may also be using cannabis and the
clinician should ask about and address this issue in a
non-judgemental way. Cannabis smoking can cause a
high CO reading.
Counselling
Pregnancy is a teachable moment for smoking cessa-
tion (Gould et al., 2013b; McBride, Emmons & Lipkus,
2003). Aboriginal and Torres Strait Islander women are
conscious about wanting to do the best for their baby
and have protective instincts about shielding them from
smoke (Gould et al., 2013a; Gould et al., 2013b): they
are more likely to reduce cigarette consumption than quit
(Gould et al., 2013a; Gould et al., 2013b), however this
is similar for pregnant women internationally (Graham,
Flemming, Fox, Heirs & Sowden, 2013). A study in re-
gional NSW revealed that some Aboriginal and Torres
Strait Islander women may question the importance of
the harmful effects from smoking in pregnancy, if others
around them have not been seen to be affected by to-
bacco smoking and may be adverse to an authoritative or
judgemental approach (Gould et al., 2013b). Counselling
techniques based on the stages of change, and motiva-
tional interviewing, have been shown to be less effec-
tive in pregnancy (Hettema & Hendricks, 2010; Lumley
et al., 2009).Howeverseveralotherbehaviourchangetech-
niques for pregnant smokers have been associated with
successful programmes internationally, including increas-
ing self-efficacy and goal-setting, and facilitating coping
(Lorencatto, West & Michie, 2012). Box 1 shows a recom-
mended approach to counselling. Even brief counselling
JOURNAL OF SMOKING CESSATION 3
Gillian S. Gould, Renee Bittoun and Marilyn J. Clarke
Table 1
Suggested assessment tools for pregnant smokers
Heaviness of Smoking Index (HSI)
Strength of Urges to Smoke
Scale (SUTS) Carbon Monoxide and FCOHb%
How soon after waking do you smoke
your first cigarette? (TTFC)
0. 60+minutes
1. 31 60 minutes
2. 6 30 minutes
3. Within 5 minutes
How many cigarettes do you usually
smoke each day? (CPD)
0. 10
1. 11–20
2. 21–30
3. 31
Total Score Interpretation:
0–2 =very low dependence
3=low dependence
4=moderate dependence
5=high dependence
6=very high dependence
In general how strong have the
urges to smoke been?
1. Slight
2. Moderate
3. Strong
4. Very strong
5. Extremely strong
COppm FCOHb%
>20 5.66
19 5.38
18 5.09
17 4.81
16 4.53
15 4.25
14 3.96
13 3.68
12 3.40
11 3.11
10 2.83
92.55
82.26
71.98
61.70
51.42
41.13
1–3 <0.85
CO levels of 6 or less indicate
non-smoker
Adapted from Smokerlyser Chart
Bedfont Scientific Ltd. Issue 11 -
January 2011, Part No: LAB261
HSI score: SUTS Score: CO reading: FCOHb%:
can have a beneficial effect on cessation in a clinical setting.
Understanding the sociocultural context is essential – for
an overview of potential factors see Gould et al.’s review
(2013a).
In preparation for quitting the woman is advised to
start extracting herself from environmental cues as this
will result in less urges to smoke. It is helpful if she smokes
outside even if the household is not yet smoke-free (Mills,
Messer, Gilpin & Pierce, 2009) Other cues can be sepa-
rated, such as not smoking with coffee or when on the
phone. In areas of very high smoking prevalence, constant
cueexposurewillbeproblematic,andshouldbesensitively
addressed.
To capitalise on the teachable moment we recommend
encouraging a trial of cessation in the following week,
aiming for abstinence of at least 2 days. Make a quit plan
with your patient (see Box 2) and encourage her to fill it
out with your help (being mindful of literacy issues). The
sample quit plan has sections to assist with problem solv-
ing of challenges for smoking cessation and encourages
the use of self-rewards. It is important to build a sense of
self-efficacy, and emphasise choice.
Linkages with local Aboriginal Medical Services and
Aboriginal Maternity Services are recommended, if the
client wishes to use them. Some Aboriginal communities
have Tackling Indigenous Smoking and Healthy Lifestyle
teams with Aboriginal smoking cessation counsellors, but
these do not cover every remote community. Where avail-
able these teams can be accessed for additional support
and follow up. The Ministry of Health NSW, through the
Aboriginal Maternal & Infant Heath Services (AMIHS)
have started the Quit For New Life programme, which
provides counselling and free oral forms of NRT, and ces-
sation services for family members. It is recommended to
be proactive in helping the woman and her family link in
with social and community services, including Aboriginal
specific health and community services that can assist in
addressing her environmental stressors such as financial
or housing issues, and specific problems such as domestic
violence, and mental health concerns.
4JOURNAL OF SMOKING CESSATION
Smoking cessation for pregnant Indigenous smokers
Box 1.
Counselling pregnant Aboriginal and Torres Strait Islander women
rDevelop your own non-judgemental way of introducing the topic of smoking e.g. “Some things we can do to
help you and baby have a healthy pregnancy, like regular check-ups; some things you can do yourself like eating
well and resting, and some things we can do together, like helping reduce your and the baby’s exposure to tobacco
smoke”. To elicit knowledge level you may ask an open ended question “What do you think/know about tobacco
smoke and pregnancy?”
rUse the ABCD approach to structure counselling:
A – Ask about smoking – “I hope you don’t mind me asking, but does anyone at home smoke?” Followed by “do
you smoke?” then take a smoking history. “Some women smoke more when pregnant, some smoke the same, or
some smoke less – what’s been your experience?”
B – Brief advice to quit and offer all pregnant smokers assistance with quitting. “Have you had a time in this
pregnancy or in the past when you tried to go a whole day without smoking? How did you go?” If appropriate
suggest a trial of stopping smoking in the next few days for 1–3 days. Emphasise importance of taking one day at
a time. Explain withdrawal effects and link with stress (see below).
C – Cessation aids. “One of the things we can really help you with is to quit smoking. If you cannot manage it
alone, we can use nicotine to help the cravings.” Introduce the idea of NRT and explain risks and benefits. Discuss
previous experiences with NRT and address myths. Explain also in context to the other chemicals in cigarettes.
Measure CO reading and explain implications. If indicated offer samples of oral NRT for the current or following
week, and follow-up in a few days to a week.
D – Discuss family, social and cultural context for smoking, and challenges for quitting. It may be helpful to find
out what salient others in the family have said about smoking in pregnancy.
General Points:
rEncourage quitting early in pregnancy
rEncourage quitting rather than cutting down consumption
rProvide foundation knowledge by using simple educational materials to explain about smoking in pregnancy,
e.g. “what’s in a cigarette”
rStress is a common reason for smoking in Aboriginal and Torres Strait Islander communities, and is cited as a
barrier to quitting. The ‘stress’ caused by not smoking may not be understood as a nicotine withdrawal effects. A
simple way of educating about this is to use a visual guide.
rThe patient-education diagram below (figure 1) shows how nicotine levels go up with each cigarette smoked
and go down in between cigarettes. This has a yo-yo effect all day on the feel-good chemicals (dopamine) and a
smoker is in and out of withdrawal all day. These symptoms of withdrawal are often perceived as ‘stress’. For a
full list see DSM V.
Initiation of NRT
Discuss the potential of using NRT (see Figure 2)from
the first visit. Explain the risks and benefits of using NRT
replacement in pregnancy, so the client can make an in-
formed decision. Plan to see the pregnant smoker weekly
or earlier. If the initial attempt is not successful (i.e. the
patient is unable to abstain for 2–3 days), with the client’s
consent, move swiftly onto pharmacotherapy so as not to
lose momentum with the quit attempt (Gould & McEwen,
2013). Discuss options of different forms of oral NRT. As
nicotine metabolism is faster in pregnancy higher doses
than usual may be required (Dempsey et al., 2002), and
4mg oral intermittent forms can be used as required for
cravings.
As intermittent oral NRT is not subsidised on PBS, it
will need to be bought over the counter. Cost may be a
prohibitive factor for many Aboriginal and Torres Strait
Islander smokers. In remote areas oral forms of NRT may
not be available at retail outlets. The argument about costs
saved by not purchasing cigarettes may not be so applica-
ble because of the way supplies of cigarettes are purchased
and shared as a family (Gould et al., 2013b). Consider
obtaining your own supplies of oral NRT from sources
such as Cancer Council or the local health district who
sometimes have funding for low socio-economic popu-
lations, or from pharmaceutical companies. Some Abo-
riginal Medical Services may also have oral NRT supplies
JOURNAL OF SMOKING CESSATION 5
Gillian S. Gould, Renee Bittoun and Marilyn J. Clarke
Figure 1
(Colour online) Patient education guide for nicotine levels, withdrawal and stress
Source: Gould, G. Give Up The Smokes Aboriginal Quit Caf´
e - a new concept
in intensive quit smoking support for Aboriginal and Torres Strait Islander people. Coffs Harbour: The Mid North Coast (NSW) Division of General Practice,
Galambila Aboriginal Health Service and Dr Gillian Gould. 2012, page 35. ISBN 978-0-9873410-0-6. Creative Commons Attribution-NonCommercial-NoDerivs
3.0 Unported License. A more detailed version may also be found in Bittoun R, Stop Smoking - Beating Nicotine Addiction Sydney:Random House,1993, p48.ISBN
0-09-182795-7
Figure 2
(Colour online) Flow chart for initiation of nicotine replacement therapy
6JOURNAL OF SMOKING CESSATION
Smoking cessation for pregnant Indigenous smokers
to distribute. Clinicians in NSW may consider linking the
client in with the Quit for New Life program via AMIHS,
to gain access to oral NRT.
Box 2.
Example of a quit plan for pregnancy
MAKING A PERSONAL QUIT PLAN
My Quit Method
Cold Turkey
Nicotine Gum
Nicotine Lozenges
Nicotine Inhaler
Nicotine Spray
Nicotine Patches
My Quit Date_________________________
My Quit Strategies
Exercise ______________ ______________
Quitline 13QUIT or 13 7848
Group Support
Other support _________________________
Reduce caffeine
Make the home & car smoke-free
Key Challenges
Challenge How I will address this
My rewards for not smoking
Adapted from: Gould, G. Give Up The Smokes Aboriginal Quit Café - a new concept in intensive quit smoking
support for Aboriginal and Torres Strait Islander people. Coffs Harbour: The Mid North Coast (NSW) Division of
General Practice, Galambila Aboriginal Health Service and Dr Gillian Gould. 2012, pages 108-110. ISBN 978-0-
9873410-0-6. Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.
If oral forms of NRT are not suitable, move swiftly on
to 16-hour patches (removed at night). The 16-hour patch
comes in two strengths: 15 mg and a recently released 25
mg: the latter will be included in the PBS this year, and is
suitable for those smoking more than 10 cigarettes per day.
Although guidelines caution that the NRT dose should be
less than smoking, NRT products are not as bio-available
as cigarettes, and there are differences between the lev-
els of absorption of the products (Fant, Henningfield,
Shiffman, Strahs & Reitberg, 2000; McEwen, West &
Gaiger, 2008). Anticipate in this population that there
may be some ‘weaning off’ of cigarettes. Although pre-
cessation NRT is not recommended in pregnancy, it is
suggested that clinicians take a balanced view with indi-
vidual cases. For example if a woman normally smokes 10
JOURNAL OF SMOKING CESSATION 7
Gillian S. Gould, Renee Bittoun and Marilyn J. Clarke
cigarettes a day and is now smoking 2 cigarettes a day and
using 6 lozenges, encourage complete cessation within 2
weeks by increasing dose of lozenges, and assisting her to
set a definite quit date. Clinicians should consider that it
would be worse if she went back to full smoking, and need
to continue to build efficacy.
Combination therapy (NRT patch and an oral form)
may be required for more dependant smokers. Ther-
apy should be encouraged for 12 weeks, but antici-
pate adherence may be an issue as encountered in clin-
ical trials (Onken 2012). However, even short peri-
ods of abstinence in pregnancy may have beneficial ef-
fectsonfoetalgrowth(Heiletal.,2008). Women reg-
istered under the PBS Closing the Gap Co-payment
measure can receive prescribed NRT patches at no
cost, providing the prescription is appropriately anno-
tated (Australian Government Department of Human
Services - Medicare, 2013).
Follow-up support
Encourage the pregnant smoker to return no matter how
successful or unsuccessful the quit attempts have been.
Give positive feedback and help build on successes and
strengths. Each visit, check SUTS and CO readings. Con-
sider a faxed referral to the Quitline for their call-back ser-
vice as an adjunct. Most Quitlines have Aboriginal coun-
sellors, and if the woman identifies as Aboriginal or a
Torres Strait Islander a culturally appropriate service can
be provided.
Partners and family members may not be supportive
of the pregnant woman quitting, and may undermine her
quit attempts (Gould et al., 2013b). Suggest that part-
ners and family may attend with the patient or separately
for consultation regarding their own smoking and learn-
ing how they can best support the quitter. Encourage
smoke-free home and cars. You may promote the notion
of preparing the environment for the baby as an additional
rationale. Support should be offered for at least 12 weeks
and post-partum. Initial sessions may need to be fairly
intensive to cover all the issues that are important in the
context of smoking in pregnancy. If the clinicians prac-
tice does not allow for this then referral options need to
be considered. It is recommended to adapt approaches to
the individual community and work in partnership with
local Indigenous staff and Aboriginal Medical Services es-
pecially in rural and remote settings.
Many pregnant mothers relapse or may not intend
to stay abstinent after the birth, yet there is currently no
evidence-based strategy for relapse prevention (Lumley
et al., 2009). However mothers who quit for themselves
and not just their baby may have a higher intention to
remain abstinent post-partum. As visits with the pregnant
mother progress ask her to reflect on what she will gain
from remaining smoke-free after the birth.
Ancillary resources
At least half of the Australian programmes aimed at Abo-
riginal and Torres Strait Islander communities focus on
smoke-free pregnancies (Gould et al., 2014). There may
be quit groups at the local Aboriginal Medical Service that
you can refer to. Several sources of support that you may
pass on to your clients involve new media, although not
all ‘smart phones’ operate in remote areas:
rQuit for You, Quit for Two phone App for ma-
ternal smoking https://itunes.apple.com/au/app/quit-
for-you-quit-for-two/id549772042
rBlow Away The Smokes DVD – a guide to quitting
cigarettes for Aboriginal & Torres Strait Islander smok-
ers www.blowawaythesmokes.com.au
rSticking It Up The Smokes Facebook site
http://www.facebook.com/StickinituptheSmokes
Policy changes required
The National Tobacco Strategy, the Closing the Gap strate-
gies and the National Aboriginal and Torres Strait Islander
Health Plan all recommend comprehensive approaches
(Australian Government Department of Health, 2012;
Commonwealth of Australia, 2012; Council of Australian
Governments, 2008). These should include Aboriginal and
Torres Strait Islander specific smoking cessation and sup-
port services, family-based programmes, and strategies to
improve delivery of smoking cessation services, including
NRT.
Access to oral forms of NRT is essential to effectively
initiate treatment for pregnant women. Application needs
to be made to the Pharmaceutical Benefits Advisory Com-
mittee to place a range of oral forms of NRT on the PBS.
Without equitable access to suitable forms of NRT preg-
nant women from low socio-economic backgrounds are
further disadvantaged.
Better education is required for medical professionals
and specialists in how to counsel Aboriginal and Torres
Strait Islander smokers, initiate NRT and how to work
with the smoking cessation guidelines for pregnancy. It
is important for training to address both the opportuni-
ties and barriers that a clinician may experience in trying
to tackle smoking with a pregnant woman. The training
needs to include culturally safety issues, and the important
role that partners and family members can play in helping
support the woman quit smoking.
Conclusion
The prevalence of smoking by pregnant Aboriginal and
Torres Strait Islander peoples is slow to decline. There
is a clear need for comprehensive approaches which in-
clude improved access,cultur ally safe practices, supportive
counselling and the incremental use of NRT. All clinicians
should be able to raise the issue of smoking with preg-
nant Aboriginal and Torres Strait Islander women, and
become more familiar with how to initiate NRT in a timely
8JOURNAL OF SMOKING CESSATION
Smoking cessation for pregnant Indigenous smokers
manner for Aboriginal and Torres Strait Islander popula-
tions. This paper provides a pragmatic approach to smok-
ing cessation for pregnant Aboriginal and Torres Strait
Islander smokers and their families and hopes to address
some of the educational needs of health professionals to
become more adept at tacking smoking in these disadvan-
taged and marginalised groups.
Acknowledgements
None
Financial Support
Dr Gillian S. Gould is in receipt of a National Health
& Medical Research Council Post-Graduate Indigenous
Research Training Scholarship co-funded by the National
Heart Foundation (Grant number APP 1039759)
Conflict of Interest
None
Ethical Standards
Not Applicable
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10 JOURNAL OF SMOKING CESSATION
... The high worth of r suggested that consumers feared self of landfill awareness is strongly linked together. As a result, the H3 result is consistent with the findings of many studies (Woo & Au, 2008;Gould et al., 2015). H4 had a significant finding of β = 0.512 and p = 0.000, indicating that the congruity between feared self and landfill awareness has affected cigarette butts littering behaviour. ...
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... The high value of r meant that consumer feared self and environmental awareness have strong correlation between each other. Therefore, H3 result is consistent with several studies (Gould, Bittoun, & Clarke, 2015;Woo & Au, 2008). The result of H4 was also significant at β = .42 ...
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Background Maternal smoking during pregnancy (MSDP) is an important public health concern because of potential adverse health effects to the woman, fetus, and child after birth. Prevalence rates are high among groups with socioeconomic disadvantage, including Indigenous women. Purpose This study was conducted to understand experiences of MSDP for Indigenous women. Methods The study was conducted using phenomenology. Data were collected through interviews with 15 pregnant and postnatal Indigenous women who had smoked during pregnancy. The data were analyzed for themes using phenomenological methods. Results The women's narratives revealed four experiences: quitting smoking during pregnancy to protect the unborn baby from harm; quitting smoking during pregnancy because of personal adverse health effects; cutting down smoking during pregnancy and feeling remorse for not quitting; and keeping on smoking during pregnancy and not planning to try to quit. The women's experiences also indicated several impediments to quitting smoking. Conclusions There is need for health care policy to ensure adequate smoking cessation services and support for Indigenous women who smoke in pregnancy. Health care professionals should provide individualized interventions that take into account the challenges to quitting that pregnant women experience and that are in accordance with clinical practice guidelines for MSDP.
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Introduction While tobacco smoking prevalence is falling in many western societies, it remains elevated among high-priority cohorts. Rates up to 95% have been reported in women whose pregnancy is complicated by other substance use. In this group, the potential for poor pregnancy outcomes and adverse physical and neurobiological fetal development are elevated by tobacco smoking. Unfortunately, few targeted and effective tobacco dependence treatments exist to assist cessation in this population. The study will trial an evidence-based, multicomponent tobacco smoking treatment tailored to pregnant women who use other substances. The intervention comprises financial incentives for biochemically verified abstinence, psychotherapy delivered by drug and alcohol counsellors, and nicotine replacement therapy. It will be piloted at three government-based, primary healthcare facilities in New South Wales (NSW) and Victoria, Australia. The study will assess the feasibility and acceptability of the treatment when integrated into routine antenatal care offered by substance use in pregnancy antenatal services. Methods and analysis The study will use a single-arm design with pre–post comparisons. One hundred clients will be recruited from antenatal clinics with a substance use in pregnancy service. Women must be <33 weeks’ gestation, ≥16 years old and a current tobacco smoker. The primary outcomes are feasibility, assessed by recruitment and retention and the acceptability of addressing smoking among this population. Secondary outcomes include changes in smoking behaviours, the comparison of adverse maternal outcomes and neonatal characteristics to those of a historical control group, and a cost-consequence analysis of the intervention implementation. Ethics and dissemination Protocol approval was granted by Hunter New England Human Research Ethics Committee (Reference 17/04/12/4.05), with additional ethical approval sought from the Aboriginal Health and Medical Research Council of NSW (Reference 1249/17). Findings will be disseminated via academic conferences, peer-reviewed publications and social media. Trial registration number Australia New Zealand Clinical Trial Registry (Ref: ACTRN12618000576224).
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To inform smoking interventions by clinicians, particularly doctors, in primary healthcare settings in remote Aboriginal communities, we describe the results of tobacco surveys in remote Northern Territory communities. During 2008-09 in three remote communities in the Northern Territory, 400 people (aged ≥16 years) were asked about their tobacco use. Extremely high rates of smoking persist: 71%, 78% and 82% of those interviewed in the three communities. More than half the smokers were either thinking about or actively trying to quit, despite limited access to appropriate support. Among former smokers, the most common motivator for quitting was 'health concerns'. Of those citing 'health concerns', 22% specifically mentioned receiving advice from a clinician, usually a 'doctor'. General practitioners, and their colleagues in similar primary healthcare settings, are well placed and are strongly encouraged to take every opportunity to make what could be a significant impact on reducing harms related to smoking and environmental smoke.
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