• In both the veteran and general populations, smoking rates appear to be on the decline.
• Smoking is a major contributor to premature death and illness and veterans should be encouraged to quit by their health practitioner.

Prevalence

In 2010, 15 per cent of Australians over the age of 14 were daily smokers, down from 24 per cent in 1991 (AIHW, 2011).

Evidence suggests that smoking is more prevalent among veterans than in the general community. Rates differ across the three branches and deployments (Barton et al., 2010).

Assessment

Assessing mental health provides an opportunity to assess and address smoking and for the person to consider changes in their smoking habits.

The following questions from the Royal Australian College of General Practitioner guidelines (2011) can be used to identify the veteran's level of motivation to cease smoking:

• How do you feel about your smoking at the moment?
• Are you ready to stop smoking now?

The Smoking Cessation Framework can be used as a guide to further assess:

• the veteran's smoking history
• past quit attempts
• readiness for change 

Most smokers will shift across stages of readiness from:

1. not thinking about quitting
2. contemplation
3. planning
4. taking action to stop smoking
5. reconsideration following relapses

If the veteran is considering quitting, it is important to assess his or her level of nicotine dependence. This will predict withdrawal and inform treatment planning. Signs of nicotine dependence include:

• smoking within 30 minutes of waking
• smoking more than 10 cigarettes per day
• a history of withdrawal symptoms in previous quit attempts

A useful tool is the Fagerstrom Test for Nicotine Dependence.

Treatment

As smoking is a major contributor to premature death and illness, veterans should be encouraged to quit by their mental health practitioner even when they may not be principally presenting for that problem. It is also important to incorporate smoking cessation in a veteran’s overall treatment. Continued smoking is likely to contribute to poor mental health through raised: 

• anxiety
• sleep disturbance
• irritability
• labile mood

However, there is evidence to suggest that repeatedly advising smokers to quit can damage the practitioner-client relationship. Therefore, it is important to develop strong rapport and ask permission before discussing the veteran’s smoking.

The interventions used for helping veterans to quit smoking will vary on the veteran's assessed readiness to quit. However, for all veterans who smoke, including those who are not ready to quit, providing advice and support is recommended.

Treatment to assist to quit smoking will include a combination of:

• pharmacotherapy
• provision of self-management resource
• brief counselling

Psychological interventions

Psychological interventions should be adjusted according to the veteran’s motivation to change.

Not ready to quit

Veterans who are not ready to quit do not require formal psychological intervention. They should be provided with education on the benefits of quitting and the effects of passive smoking, and followed up with later.

Unsure about quitting

Motivational interviewing can help to resolve ambivalence about smoking and prepare the veteran for change. Ambivalence should be acknowledged. Discrepancies between smoking behaviour, personal beliefs and goals should be discussed. Questions to ask include:

• “What do you like about smoking? What are the things you don’t like about smoking?”
• After summarising the client’s pros and cons ask, “Where does this leave us now?”

This 'decisional balance' technique can assist the veteran to:

• resolve ambivalence about change
• move towards action and behaviour change

Motivational interviewing can also help resolve ambivalence about alcohol and other unhelpful behaviours such as problem gambling.

Ready to quit

Individual or group counselling that uses cognitive behavioural therapy-based strategies is recommended for veterans who are ready to quit smoking. These strategies  form the basis of the Quitline counselling services. Key components of treatment include:

• assistance to identify high-risk smoking situations, and develop problem-solving strategies to deal with those situations
• strategies and skills to cope with cravings, for example ‘The 4Ds’ (delay, deep breathe, drink water, do something)
• encouragement for the veteran to utilise his or her social supports, e.g. family, friends and/or other veterans

Psychoeducation and self-management strategies

Veterans who are considering quitting or are ready to quit may benefit from the following advice and information before undergoing targeted treatment. Encourage the veteran to:

• discuss the impact of smoking, and provide information about harms related to smoking
• go through reading material on how to quit smoking, and the health consequences of smoking (available from http://www.quitnow.gov.au/ and the relevant state-based ‘Quit’ website)
• select a quit date, ideally within the next two weeks. Arrange follow-up appointments about one week and one month after quit date
• use the Quitline services (13 7848)
• use his or her social supports, e.g. family, friends and/or other veterans

Pharmacological interventions

Slow-release nicotine replacement therapy (NRT) by means of a transdermal patch is the preferred pharmacological intervention. Pharmacological interventions are central to effective smoking cessation treatments, especially for veterans smoking more than 10 cigarettes each day. Treatment usually lasts between 7 and 12 weeks. Quick-release preparations such as gum or lozenges can contribute to nicotine dependence. The sustained mode of release also counters a withdrawal syndrome. Over time, NRT is reduced at a gradual rate that the person finds tolerable without resuming smoking.

Veterans experiencing episodic cravings may benefit from a ‘top-up dose’ of quick-release NRT. This should be monitored to ensure that use does not become habitual. Note that resumption of smoking at the same time as using NRT may lead to nicotine toxicity with harmful effects on physical and mental health.

In cases of severe nicotine dependence or a history of failure of cessation with slow-release NRT, bupropion (e.g. Zyban) or varenicline (e.g. Champix) may be added to slow-release NRT to reduce cravings and increase treatment effectiveness.

See also