SThe SANE Smokefree KitThird, revised edition

IntroductionI cant believe how good I feel. I even kicked the footy with my nephew for the first time in years.

Peter, aged 65, who smoked 80 cigarettes a day, after 13 weeks of being smokefree. He has cancer, diabetes and heart disease (all illnesses caused or exacerbated by smoking).

The benefits of not being a smoker of being smokefree should be something that all Australians can enjoy.

While smoking rates have been falling among the general population over the past four

decades, this is not true of people seriously affected by mental illnesses such as schizophrenia,

the majority of whom smoke regularly. Almost half of all cigarettes purchased are smoked by

people with a mental illness (Lasser et al, 2000). Research has also revealed that Australians

with a mental illness have a life expectancy 20 years lower than average, and that smoking is

significantly implicated in this (Coghlan et al, 2001).

While the reasons for people with a mental illness continuing to smoke so heavily are

complex, they do not want the serious damage to their health that smoking involves. Some

smokers with a mental illness also need higher doses of antipsychotic medication than non-

smokers to gain a therapeutic effect, increasing the likelihood of unwanted side-effects. Many

people are also concerned about the very high cost of smoking, especially when the Disability

pension is their principal income.

Many people with a mental illness desperately want to quit smoking, and are capable of

quitting or reducing smoking with the right assistance. They are asking for help, but often find

that they cant quit alone, or cant make successful use of the available community resources

to do so. All too frequently they have difficulty finding a health professional who feels

confident to help them in this task.

The SANE Smokefree Kit provides the information and guidance you need to give this help.

Many health professionals have contacted SANE Australia seeking information about how

to help their clients who have a mental illness to quit smoking, and to reduce the damage

smoking causes to their lives. In response to this need, the SANE Smokefree Kit was initially

developed in 1999. The need for such a resource was proved and the Kit was revised in 2004

and now again in 2009. It includes a Quit Smoking Program specifically designed to help

address the needs of people with a mental illness. Blending traditional smoking cessation

theories and principles with expertise and knowledge from the mental health field, this

Program gives people with a mental illness a realistic opportunity to quit or reduce smoking.

The Program also provides an opportunity to examine a broad range of issues related to

lifestyle as well as to the symptoms of mental illness. Strategies for dealing with psychiatric

symptoms, managing stress, exercise and good diet all contribute to successful reduction and

cessation of smoking as well as improved quality of life.

Using this Kit

This Kit, the first of its kind, is based on an extensive literature review, consultation with

people living with a mental illness and mental health workers, drug and alcohol counsellors,

and the trialing of the Program in a number of psychosocial rehabilitation programs.

The eight-session Program it contains is designed to be used by professionals working in the

mental health, drug and alcohol or smoking cessation fields. The Kit is intended to cover all

the different aspects of smoking cessation for people with a mental illness. It also gives some

guidance on smokefree policy.

It is essential to study the first section Smoking and Mental Illness before you run the

Program. Become familiar, too, with the SANE Guide to a Smokefree Life, which has been

specially written to complement the Kit and is a useful resource for your group members.

The Program can be modified for different settings and groups, as well as used as a basis for

working with individuals, as long as the underlying principles and guidelines are followed.

SANE Australia welcomes feedback on the Program, so that lessons learned can be

incorporated into future editions.

The SANE SmokeFree Kit is in three sections.

ff Smoking and Mental Illness

Essential information on the relationship between smoking and mental illness.

ff The SANE Quit Smoking Program

A session-by-session manual.

ff Appendixes: Program Materials

Handouts and other materials needed for the Program.

Contents

Smoking and mental illness: an overview 1

The benefits of reducing and quitting smoking 1

A specially targeted program 2

Why have a special program for people who experience mental illness? 4

Who can run quit smoking groups? 5

Is quitting the only measure of success? 5

Theoretical approaches behind this program 5

Pharmacotherapy 10

Smokefree environments 12

The evidence regarding cessation 15

The SANE Quit Smoking Program 17

The role of the facilitator 17

The size of the group 17

The length of the program 18

Encouraging group members 18

Promoting the program 19

Goals of the program 19

Introduction and informal assessment 20

Specific issues in facilitating groups for people affected by mental illness 21

Setting goals with participants and measuring outcomes 23

Individual versus group cessation support 24

Follow-up 24

References 25

The SANE Quit Smoking Program Continued

Program guidelines 29

Session 1 Introduction to the program reasons to smoke and reasons to quit 33

Session 2 Working with the positives 41

Session 3 How smoking affects your body 47

Session 4 Being empowered 53

Session 5 Dealing with stress and strong negative feelings 61

Session 6 Fit and well 69

Session 7 Planning for high-risk situations 75

Session 8 Celebrating the journey 81

Supplementary sessions - Optional expansion of Session 5 86

Session 5a Dealing with stress and Helping relationships 86

Session 5b Healthy ways of dealing with feeling down 93

Session 5c Dealing with strong negative feelings 99

Appendixes: Program Materials 105

1Group promotion flyer* 105

2Letter to treating doctor* 106

3Resources and contact details 107

4Healthy food and drink 108

5Strengths cards* 109

6Contract* 110

7Dealing with stress 111

8Dealing with feelings 113

9Faulty beliefs and positive thoughts 114

10Strategy sheet for dealing with feelings 116

11A healthy weight 117

12Things to do 118

13Certificate* 119

14Evaluation form 121

* Also available from www.sane.org

1Smoking and mental illness: an overview

I have tried to quit so many times. I know that I wont go back to it now.

My kids are happy and my doctor says that it made his day to hear that I have quit.

Joan, smokefree for eight weeks

The benefits of being smokefree should be available and accessible to all Australians. However,

when it comes to smokers who have a mental illness, its often said Why bother trying to

change their smoking, its their only pleasure? The simple answer to this is that, for many

people with a mental illness, there are additional physical, psychological and social risks and

disadvantages involved in continuing to smoke. Quite simply, people with a mental illness

have a lot to gain from quitting smoking and a right to better opportunities for pleasure than

smoking.

The benefits of reducing and quitting smoking

A healthier and longer life

The health of people with mental illness is being damaged by smoking. Compared to the

general community, people with a mental illness are more likely to smoke and have other

risk factors leading to cardiovascular disease (Davidson et al, 2001). Subsequently they are

more likely to die from cardiovascular disease (Coghlan et al, 2001). Smoking is related to

increased complications of diabetes, rates of which are higher among people with a mental

illness. Smoking is widely known to cause many cancers and respiratory illnesses and slows

down the recovery from wounds and surgery. It is related to back pain, stomach ulcers and

osteoporosis. Unfortunately people with a mental illness are less likely to be treated for their

physical health conditions leading to a poorer quality of life and early death (Coghlan et al,

2001). Quitting gives people with a mental illness the possibility of a healthier and longer life.

Improved income

Smokers with mental illness spend large amounts of their income on cigarettes which leaves

little for things like rent, travel and food (Lawn, 2001 and Access Economics, 2007). In an

attempt to cut costs, they are more likely to smoke illegal tobacco, known as chop-chop

(Moeller-Saxone, 2008). This can lead to additional health problems. Quitting smoking can

mean that there is money spare for the ordinary pleasures of life, such as eating out or going

to the movies.

Breaking down barriers to socialising or getting work

People with a mental illness, and in particular men, smoke on average far more than the

general population. This affects hygiene and appearance, for example stained fingers and

teeth, lined skin as well as smoking odour. Most public buildings, work places and recreation

centres are now smoke free and smokers can feel uncomfortable in these places. These factors

can increase barriers to socialising or getting work.

Smoking and M

ental Illness

2Less stress, better coping. Smokers have more stress because they are constantly dealing with

the anxiety that cravings cause. Research has shown that three to six months after quitting,

ex-smokers feel better. They have less stress and anxiety than before they quit smoking (Ragg

& Ahmed, 2008). Smoking also prevents people from learning new and effective ways to deal

with stress as they are dependent on smoking to cope. Quitting can provide an opportunity to

develop new and effective coping strategies.

Reducing fire hazards in the home. The majority of people with a mental illness live in the

community in their own home, in boarding houses, group homes, with parents, other family,

friends or alone, and there is a real risk of accidental fire caused by cigarettes. Smoking less

and quitting reduces fire dangers for people with a mental illness.

Review of medication. Smoking can change the way the body processes some medications

commonly prescribed for certain mental illnesses. It is important to involve the treating doctor

in any quit attempt so they can monitor any side effects and lower the dose if required (Olivier,

Lubman & Fraser, 2007 and Campion, Checinski & Nurse, 2008).

A sense of achievement. Even small steps towards quitting raise self-esteem and self-

confidence soars as people realise they can take control of their lives. Group facilitators have

found that even if no-one in their group is ready to quit they still see the positive effects of

participants learning about and being able to discuss their smoking.

Enjoying ordinary smokefree activities. Many heavy smokers cannot take part in community

activities because of smoking bans at many public venues. Going to the movies is one activity

many people cannot enjoy because of their heavy smoking habit. Cutting down or quitting

promotes access to ordinary community activities increasing social inclusion.

A specially targeted program

The benefits of helping people with a mental illness to quit smoking with a specially targeted

program are significant and clear. Some people find it difficult to access community quit

smoking groups and counselling services because of their illness. Difficulty concentrating,

the fear of revealing their illness in a group setting, and the lack of adequately trained quit

smoking health professionals mean that a special program is needed.

High prevalence

On average, smoking is more prevalent among people with a mental illness such as

schizophrenia, than the general population. Smoking rates among Australians with a mental

illness range from 56.3% of women and 73.2% of men with psychotic disorders (Jablensky

et al, 1999) to 61.9% of Area Mental Health Services outpatients (Davidson et al, 2001)

compared to 15% of the general community. High smoking rates have also been reported for

people with mood disorders, anxiety and personality disorders. Research also suggests that a

history of depression increases the likelihood of smoking, difficulties in quitting and relapse of

depression on smoking cessation.

3Why are smoking rates so high?

There are many theories to explain these high smoking rates and they can be grouped into two

categories:

Psychological and social factors

ff Boredom is one of the most commonly reported reasons for smoking. Many people

struggle to find a reason to get up in the morning and smoking fills in the long hours before

going to bed. So often, the problem is the perception or reality that there is nothing else

to do.

ffCigarettes have been used to reinforce behaviours. Also in in-patient settings, cigarettes

have often been used to persuade people to take their medication.

ff Studies show that people with schizophrenia are more likely to smoke for its perceived

effect on mood (Gurpegui et al, 2007). Smoking is associated with a desire for

cheerfulness, alertness and calming particularly for people who also experience more

depressive symptoms. Despite being addicted to nicotine, smokers with mental illness may

believe that smoking gives them a sense of freedom and control over their lives. The daily

experiences of stigma, powerlessness and hopelessness associated with mental illness

is counteracted by smoking as a symbol of taking charge (Lawn, Pols & Barber, 2002).

However, poor or inadequate strategies for coping creates a vicious cycle of smoking.

ff For many people with a mental illness, being hospitalised can be a traumatic and stressful

experience. Smoking has been used as a way of relieving such stress and to help people

to socialise while in hospital. Consequently, people tend to smoke more when they are

admitted to a psychiatric hospital. In fact, many people report starting smoking when

hospitalised for the first time. However, smokefree environments are now becoming the

norm rather than the exception.

ff In the past, staff have used smoking as a means of engaging clients, and as a bonding tool

Lets go for a smoke together and talk about it.

ff Many myths and beliefs exist around smoking and mental health so often health

professionals miss opportunities to assist people with a mental illness to quit smoking.

While a smoking culture exists among people with a mental illness, it can be more difficult

to quit smoking when a large percentage of their friends continue to smoke. However,

with the help of resources such as this Kit, we can continue to change this culture and

allow people the freedom to choose how they wish to live, and not just bow to the social

pressures to smoke.

Smoking and M

ental Illness

4Biological factors

Researchers interested in biological explanations for the high rates of smoking among people

with mental illness have found various links between the two phenomena. For example,

shared genetic susceptibility to tobacco addiction with alcohol abuse and major depression;

the impact of nicotine on neurotransmitters suggests that nicotine might be perceived as

alleviating some symptoms of depression and improve attention; and the stimulating effects

of nicotine might offset the sedating effects of psychiatric medications and alcohol

(Benowitz, 2009).

However, in a recent review it was noted that much of the evidence is based on experiments

with addicted smokers. This means that improvement in functioning is related to the loss of

functioning associated with withdrawal (Ragg & Ahmed, 2008). By contrast, when studies

of stress and mood disorder are conducted with young people who take up smoking, smokers

experience more stress and depression (Ibid). Furthermore, people who quit smoking report

that their stress and depression levels decrease (Kassel et al, 2003).

Why have a special program for people with mental illness?

People with a mental illness face specific issues when they try to quit smoking. Some have

difficulty accessing community smoking cessation programs and need extra support and

benefit from a program tailored to meet their particular needs.

The interactions between smoking and medication mean that people need to be informed

about the possible consequences of quitting on their mental health.

It is also important that information about quitting includes the role of nicotine replacement

therapy (nrt) and quitting medications. Sometimes withdrawal symptoms can be mistaken

for symptoms of mental illness. Program facilitators need to consider participants possible

history of depression, their ability to deal with stress, and the local availability of supports

for people who choose to quit smoking. An exacerbation of depressive symptoms may be

brought on by quitting, and appropriate coping strategies and supports must be provided if

this happens. Some people may experience a relapse in their mental health but others will not.

Largely the evidence shows that quitting smoking will not lead to a relapse in a mental health

problem.

Group programs in community settings are sometimes conducted by facilitators with little

experience of mental illness, who may become worried that quitting is too stressful for

participants. In addition, people with a mental illness often join a generic community-based

group and find it hard to reveal to the group the dilemmas their illness can create due to the

stigma attached to mental illness. The fear of discussing their illness openly can make it hard

to participate fully in such groups. Group programs can also be expensive for those who

already spend much of their income on cigarettes. Mental illness often affects the persons

ability to pay attention and maintain concentration for a sustained period. Traditional smoking

cessation programs which require extended concentration and clear thinking may therefore

be inappropriate. Finally, teaching positive coping strategies for dealing with negative feelings

may be particularly warranted in this group, and community smoking cessation groups rarely

contain this information.

5Who can run quit smoking groups?

Drug and alcohol workers, community health centre workers, smoking cessation counsellors

and mental health workers including consumer consultants are all ideal to conduct quit

smoking programs. While each of these groups may need extra resourcing to build up their

knowledge and skill base, one recommended solution lies in health professionals working

together. For example, a mental health worker could call in a drug and alcohol worker to

co-facilitate a quit smoking group. Ideally there will be a consumer facilitator or co-facilitator

who has successfully quit.

While training programs for working on smoking cessation with people with mental illness are

not easy to access in most states and territories, they are recommended. Contact your state

Quit smoking agency or peak mental health body who can assist you with finding a training

course and getting your knowledge up-to-date.

This Kit is intended to provide the resources and guidance needed to drug and alcohol

agencies, mental health agencies and quit smoking services who want to provide a course

specifically for people affected by mental illness.

For further information on mental illness see the SANE website at www.sane.org.

Is quitting completely the only measure of success?

In traditional Quit programs, reduction is not regarded as a successful outcome. For people

with a mental illness, however, while there may not be as many benefits to physical health

in reduction, there are clear social, economic and safety benefits, as well as other potential

benefits related to medication use. For this population, reduction can be a valid measure of

success, and an important step in gaining the confidence to quit completely (Fagerstrom,

2009). There is evidence that this can be achieved in conjunction with use of nicotine

replacement therapy. This must, however, be supervised by the treating doctor to address

medication and dosage issues.

Some people who reduce their smoking will do what is called compensatory smoking where

they will still be able to get the same amount of nicotine from fewer cigarettes by inhaling

deeper, therefore drawing in hotter smoke that damages the lungs, smoking down to the butt

and puffing more frequently on the cigarette. So quitting should remain as the ultimate goal.

Theoretical approaches behind this program

The SANE Quit Smoking Program is structured around eight sessions (with an optional extra

two sessions) and makes use of the 5As and theoretical components from motivational

counselling, cognitive-behavioural approaches, and art therapy. It is recommended that

facilitators do background reading about these approaches before running the course. We have

provided some basic information here.

Smoking and M

ental Illness

6Helping smokers to quit using the 5As framework

This simple framework has been developed for general practitioners but is useful as a quick

reference for anyone working regularly with a client. (To order the Smoking Cessation Guideline

For Australian General Practice, call 1800 020 103).

ff Ask patients about their smoking at every visit or contact. Some will not be ready to

change. Quitting smoking can take time and many attempts.

ff Assess clients nicotine dependence as well as their willingness and confidence to quit.

The three questions to assess nicotine dependence are: do you smoke within 30 minutes

of waking; do you smoke more that 10 cigarettes per day; what is your history of cravings

and withdrawal symptoms? The three questions to assess readiness to change are: where

are you at with your quitting/smoking; are you thinking about quitting in the near future;

how confident/motivated do you feel about quitting?

ff Advise clients to quit (or to stay smokefree after quitting) based on the health effects of

smoking and the benefits of quitting. Mental illness is not a reason to avoid quitting.

ff Assist clients with quitting dependent on where they are at with their smoking. This may

be giving information, providing a smoking cessation course, or a referral to Quitline.

Discuss any concerns around becoming unwell, withdrawal, weight gain and coping in

stressful situations.

ff Arrange for follow-up, and ask again at the next visit or contact. People trying to quit need

ongoing support and encouragement.

Motivational counselling

One of the most inuential and widely used behavioural-change approaches to stopping

smoking is the transtheoretical model (Prochaska, DiClemente & Norcross, 1992). The

Program is based on this model which sees behavioural change as a process involving five

stages that can be cyclical:

The stages of change

Precontemplation Not thinking about quitting in the next six months

Contemplation Thinking of quitting in the next six months

Preparation Planning to quit in the next thirty days

Action The time of quitting and the following period

Maintenance More than six months after quitting

The information and activities provided during the Program help the participants move through

these stages. The facilitator needs to be aware of each participants current stage of change

and to offer information and counselling that matches that stage.

7The precontemplation stage is the time before the person recognises the need to consider

quitting. The next stage in the change process is the contemplation stage where the person

recognises the problem and considers doing something about it. It is possible for the individual

to remain at this stage for long periods of time if a decision to move to the next stage is not

made. People in this situation are sometimes referred to as chronic contemplators. At the

precontemplation or contemplation stage, the strategies used to help the person move to the

next stage are: to raise awareness of the effects of smoking on health; to foster a sense of

hope for those who feel demoralised by previous failed attempts; and to encourage openness

to the possibility of change.

The preparation stage is where people intend to take action in the very near future, usually

within a month. At this stage, the person may have worked out a plan of action for example,

by consulting their doctor or reading Quit resources.

The action stage is where the person makes a quit attempt.

In the maintenance stage, the person works toward staying a non-smoker and avoiding

relapse.

Note that Lawn et al (2002) challenge Prochaska & DiClementes assertions about the

movement from precontemplation to contemplation stages, arguing that the model does not

take into account the search for autonomy and their experience of stigma and powerlessness

by people with a mental illness. According to Lawn et al, smokers with a mental illness require

special emphasis on the development of an empathic therapeutic relationship to address

these issues. For this reason, the Program emphasises the use of group processes that build

self-efficacy, encourage autonomy and the development of social skills and interpersonal

relationships. There is also extra information to group facilitators to improve their empathy

skills within the group context.

Smoking and M

ental Illness

8Brief guidelines for motivational interviewing

Motivational interviewing is a method that assumes potential for change and is client-centred.

The client is the expert and gives their own reasons for changing. The helpers role is to work

with the client:

ff rolling with resistance and avoiding arguments

ff asking open-ended questions

ff working to develop or highlight discrepancies in thoughts, feelings and actions

ff supporting self-efficacy (Miller & Rollnick, 2002).

These guidelines can be used as you deliver the program.

Preparing to quit

ff Assess the persons unique situation, smoking and quitting history, current smoking

behaviour, and environmental and social factors.

ff Educate the person about addiction and withdrawal symptoms (refer to the Quit resources

www.quitnow.info.au phone 13 78 48).

ff Enhance the persons motivation to change by looking at pros and cons of smoking,

exploring the benefits of quitting and examining barriers to quitting.

ff Make sure the person has checked in with their GP or treating doctor about the interaction

of smoking and medication, the role of NRT and other medication that assists with quitting.

ff Increase self-confidence by reframing any past experiences of quitting as positive learning

experiences and emphasising any past success. Encourage the use of positive self-talk such

as I can handle this craving.

ff Identify difficult situations and develop coping strategies.

ff Suggest the client has a reward system for example, put the money saved by not smoking

into a jar or plan an outing.

ff Explore the persons social and professional support network.

ff Work together to set a quit date or plan a structured cutting down sheet.

ff Examine particular issues for each individual for example, stress, anxiety, boredom,

dealing with a non-supportive environment.

Action

ff Assess the persons progress, motivation and self-confidence and offer encouragement.

ff Normalise withdrawal symptoms for example, many people feel cranky for the first

couple of weeks; its quite normal to feel like this and it will pass.

ff Evaluate how effective the persons coping strategies are and work though other options.

ff Talk through any emerging potential slip-up or relapse situations (high risk situations).

9ff Assist with revising the quitting plan as needed.

ff Suggest the person spends time with non-smokers and tells others that they have quit. This

helps the person develop a self-image as a non-smoker.

ff How is the social support and reward system going? Revise if necessary.

Dealing with Relapse

ff Distinguish between a slip-up and relapse. A slip-up does not need to lead to a total relapse

- I have had one cigarette, I might as well be smoking again.

ff Reframe slip-ups as a learning opportunity for better understanding the triggers associated

with smoking.

ff Assess the stage the participant is at after the relapse. Because of the cyclical nature of

the change model, the person may find themselves at any of the stages (Miller & Rollnick,

2002).

Cognitive-behavioural approach

Based on feedback from facilitators, the interventions in this Kit have been adapted to allow

for facilitator inexperience with the cognitive-behavioural method and the varying levels of

cognitive ability found in groups.

The cognitive-behavioural approach focuses on restructuring the persons beliefs about their

smoking and ability to quit, while emphasising the development and implementation of

appropriate coping strategies. For example, a participant whose self-esteem is low would be

encouraged to challenge self-defeating thoughts about quitting smoking.

As noted earlier, people with mental illness may come to depend on smoking as a way of

improving their mood and mental state. However, this coping strategy, when accompanied

by addiction, leaves them acutely vulnerable if cigarettes are not available. Many people find

themselves desperately searching for cigarettes when finances are low, just to avert the anxiety

and low mood associated with withdrawal.

This Program offers the participants alternative coping strategies to deal with feelings such

as anxiety, depression and anger. It does this by employing cognitive-behavioural techniques.

Behavioural techniques that help deal with anxiety and anger include relaxation, meditation

and other stress-management strategies. Low or depressed moods can be alleviated by

identifying and changing unhelpful thinking styles, and by behavioural approaches that

emphasise a balanced lifestyle. For example, instead of thinking, I am hopeless. Every time I

try to quit smoking I fail, participants can be encouraged to react more positively When I

quit for two hours, I learn something more about quitting.

Smoking and M

ental Illness

10

Pharmacotherapy

Biological factors need to be addressed in any intervention program. It is important that

people with a mental illness are fully informed about the possible consequences of quitting, so

that they can plan for any negative effects on their mental health. This is discussed in session

one of the Program.

Nicotine Replacement Therapy (NRT)

NRT is medication that contains nicotine for the purpose of quitting smoking. NRT replaces

some of the nicotine usually obtained from cigarettes but without the thousands of other

chemicals produced when tobacco is smoked. There are five types of NRT available in varying

strengths in Australia: patches, inhaler, chewing gum, lozenges and microtabs (tablets that

dissolve under the tongue).

There are different advantages and disadvantages with each form of NRT. Nicotine patches are

the most popular choice however they deliver nicotine more slowly so are not so responsive

to strong cravings. Users of the oral products (acute dosing forms of NRT) can more easily

control the amount and timing of the dose. However, some users only use acute NRT when

experiencing cravings, and under-dosing is a common problem. Under-dosing can lead to

people confusing withdrawal symptoms with symptoms of mental illness.

Peak nicotine levels in the blood are reached within seconds when smoking a cigarette. Oral

forms of NRT take more than 30 minutes to reach peak blood levels. Patches take at least 4

hours but then the nicotine levels in the blood stay constant while wearing the patch.

It is now possible to use NRT assistance as smokers reduce their intake. It is also possible

to combine different forms of NRT with guidance from your pharmacist. NRT can be bought

from a pharmacy without a prescription, and from other outlets. It is very worthwhile for

people affected by mental illness to talk to their treating doctor before reducing or quitting

smoking and using NRT, to talk through any issues. Like any medication, NRT needs to be used

according to instructions and only for the length of time recommended.

No serious side effects from NRT have been reported. Using NRT is always safer than

continuing to smoke. The most common side effects are skin rashes (where the patch is

applied) and sleep disturbances from the patches. Some people using oral products experience

irritation in the mouth or throat, headaches, hiccups, indigestion, nausea and coughing.

NRT can be used effectively by people affected by mental illness, including schizophrenia. Each

person needs to make their own decision about NRT using their doctor, pharmacist and other

health professionals as a resource to get the best possible information and advice. If problems

such as early signs of depression or changes in the uptake of medication occur, then early

intervention can take place.

11

The cost of all forms of NRT can be a problem for people on a limited income. NRT costs about

the same as three packets of cigarettes a week. However, the cost of NRT should only be short-

term (two to four months), while the cost of continuing to smoke is ongoing. It is worth asking

if there is any chance of your service covering the cost of NRT for group members during the

program delivery.

Studies of the effectiveness of NRT have shown that NRT enhances quitting success, especially

used in conjunction with support. Any tools or techniques which make quitting easier are

useful for people with a mental illness, who often face considerable obstacles when quitting.

During the cessation process, three tasks must be undertaken dealing with physical

withdrawal; breaking the habit of smoking; and learning to deal with feelings. NRT simplifies

the quit attempt by relieving physical withdrawal and some of the stress associated with

quitting, which allows the person to focus on the habit and psychological aspects of their

smoking.

It is important to avoid acidic drinks (such as coffee and coke) while chewing the nicotine

gum.

Many people will be given free NRT while in hospital, however unless your organisation can

assist, they will need to fund their own supplies if they wish to continue for the recommended

period once they leave hospital.

Other pharmacological support

The other main pharmacological smoking cessation aids at the time of printing are Buproprion

(Zyban SR, Clorpax, Prexaton and Buproprion - RL) and Varenicline (Champix). While efficacy

has been established they both carry specific risks for people with a mental illness. They are

available on prescription so should be used only with an informed discussion and monitoring

from the treating doctor.

To obtain full information on NRT and other medications look at the regularly updated Tobacco

in Australia www.tobaccoinaustralia.org.au. You can also search the websites for each brand

available where you will find Consumer Medicine Information.

Smoking and M

ental Illness

12

Smokefree environments

What works with creating smokefree environments in mental health services

All workplaces have a duty to provide a safe environment for their staff and users of the

service, yet because of high smoking rates in mental health settings this can be difficult

For example, in a Dutch study of exposure to environmental tobacco smoke in mental health

settings, 87% of respondents were exposed to tobacco smoke and 29% said that on an

average day they were exposed to a lot of smoke (Willemson et al, 2004). Workplaces that

ignore this risk litigation if workers or service users develop smoking related illnesses, and can

link it back to their exposure in that setting.

Not only is smoking an occupational health and safety risk but it creates huge costs to the

healthcare system. A report for SANE by Access Economics found that the total financial

cost to Australia from smoking by people with a mental illness was estimated as $3.53 billion

dollars in 2005. This includes the healthcare, carer and productivity costs to the community

as well as the loss of wellbeing associated with smoking.

The impact of smoking bans

It is within this context that smoking bans have become progressively more common in mental

health services. The United States was the first country to implement smoking bans in mental

health services in 1992. Canada, the UK,New Zealand and Australia have all been moving

towards smoking bans in mental health services in recent years.

While the purpose of these policies is to protect the health of service users and workers they

have encountered problems because they do not address the special circumstances for service

users such as those who are involuntary patients and those experiencing high levels of distress.

Also psychiatric services are both a workplace and a place of residence. An attempt to address

this by the UK Health Development Agency focuses on ensuring that staff assess smoking and

offer cessation interventions (NHS, 2001).

Concerns have been raised that smoking bans are a violation of human rights, particularly for

involuntary or residential patients (Marcus, 2008). However, employers responsibilities and

occupational health and safety concerns also need to be considered.

Adapting to local circumstances

There is a growing consensus that while smokefree policies are highly appropriate for

psychiatric inpatient settings, they must be adapted to meet local circumstances rather than

a one size fits all approach (Campion et al, Lawn, 2005). For example, in a Queensland

psychiatric ward a smokefree policy failed after six weeks because of a combination of staff

and patient factors. Staff factors included pessimism and fear about the impact of smokefree

policies and a tentative management style in adhering to the policy. Patient factors included

the difficulty of implementing policies when patients are long term residents or have high levels

of distress.

13

What we have learned

A major review of smokefree policy in psychiatric services found that in most cases the

concerns expressed by staff did not eventuate. For example, there was no increase in

aggression, discharge against medical advice or increased use of as-needed medication

following the bans (Lawn, 2005). A survey of 99 inpatient psychiatric units found that clear

leadership and cohesive teamwork were decisive factors in successful policy implementation.

Alongside this, provision of NRT to staff and consumers, staff education and lower staff

smoking rates were also important (Lawn & Campion, 2009). A review by Ragg & Ahmed

(2008) found that patients initial concerns abate more quickly than staffs and that patients

frequently approve of the bans. However, they also remarked that much of the research is

focussed on how the policies affect the institution and staff and very little is focussed on

patient needs.

Wye et al (2009) surveyed all inpatient units in NSW and found that smokefree policy

adoption was lower in psychiatric wards than for the general hospital. Despite nicotine

addiction being a category of mental illness, most services had no requirement to assess

or record smoking status or provide smoking-related care. The type of smoking care most

frequently offered was controlling access to cigarettes. The authors suggested that those

units most able to implement smokefree policies were ones that had documented unit policies

on smoking restriction, fewer staff smokers, staff who were more likely to provide smoking

cessation advice and staff who complied with the policy.

A study by Schmueli et al (2008) found that during an admission to a smokefree ward,

inpatients experienced an increase in expectancy of success with quitting.

Community-based support services

Little is known about smokefree policies in community-based support services. However, the

policies and practice of these services are crucial for the implementation of smokefree policies

within hospitals. Furthermore, because smoking cessation typically includes relapse, ongoing

community support can be vital to the success of individual quit attempts.

One major provider of psychiatric disability rehabilitation and support (Neami) did implement

a smoking ban that extended beyond government requirements in Victoria at the time. The

process evolved from staff and consumer concerns about the impact of smoking on service

amenity and staff workloads. Once management were aware of the benefits of a smoking

ban, a firm and consistent management process combined with extensive consultation ensured

that the policy was smoothly implemented. When problems were encountered, reiteration

of the reasons for the ban and consistent reinforcement ensured smooth resolution. Despite

some initial negative reactions, there was no change in the number of people using the service

(Personal communication, G. Tobias, 2006). Further to that experience, Neami has gone on to

implement smokefree policies throughout the whole organisation.

Smoking and M

ental Illness

14

Key Points

ff Decide to develop a smokefree policy and be clear about its benefits.

ff Ideally tobacco is viewed as an addiction like any other substance and treated accordingly

(Green & Hawranik, 2008). Plan your policy evaluation with consumer consultation from

the start.

ff Allow time for the policy process. Successful smokefree policies take at least six months to

implement (Lawn & Campion, 2009).

ff Consult consumers and staff on the issues that concern them. Look at other policy

statements, such as the South Australian Quit and Department of Healths Addressing

Tobacco in Mental Health, Cancer Council NSWs Addressing Smoking in Community Service

Organisations: Policy Toolkit or the UK report, Where Do We Go From Here. Check if related

mental health services have smokefree policies in place.

ff Ensure that staff are offered smoking cessation interventions or support. Upgrade training

for all staff in smoking cessation interventions.

ff Ensure that smoking status, motivation stage and intervention offered by staff is recorded

for all clients.

ff When writing smokefree policy, senior management need to budget so that NRT can be

provided free of charge to clients. Ideally this is supported by individual or group smoking

cessation counselling.

ff Implement bans appropriate to your service decisively both at management level and on the

ground. Be prepared for people to express concerns.

ff Evaluate the policy process and, if possible, write it up for publication to build the

evidence-base.

15

The evidence regarding cessation

Smoking cessation interventions increase the rate of smoking cessation among people with

mental illness (Baker, Richmond, Haile et al, 2006; Campion, Checinski, & Nurse, 2008;

Baker et al 2009). A review of smoking cessation interventions for people with a mental

illness found that quit rates were similar to those found in the general population (el-Guebaly,

2002). A simple model is the 5As for health professionals (see earlier in this section) that

tailors brief interventions to the persons stage of change (Quit Victoria).

A more comprehensive manual for cognitive-behavioural interventions has been developed

(Baker et al, 2004). From a medical perspective, nicotine replacement therapy is the first line

of treatment preferred for people with mental illness and a combination of nicotine patch and

faster-acting oral NRT appears most effective (Campion & Hewitt, 2008).

Other smoking-reduction medications, such as buproprion and varenicline, have also been

approved by the PBS for subsidy and thereby provide the most cost effective smoking cessation

support for consumers (SANE Australia; Access Economics 2007). However, they both carry

risks for people with mental illness and require individual assessment in conjunction with the

treating doctor.

The SANE report (SANE Australia; Access Economics 2007) reviewed smoking cessation

intervention studies and found that similar success rates were reported for interventions

involving smokers with a mental illness as for the general population. In addition, most studies

did not report adverse effects of quitting as a result of interventions. There is no reason not to

offer smoking cessation interventions, therefore, and every good reason to offer them, as they

will improve the health and wellbeing of clients, their families and staff at your service.

Smoking and M

ental Illness

16

17

The SANE Quit Smoking Program

The role of the facilitator

The role of the facilitator is fundamental to a quit smoking program. This is especially true

when running a program for people with a mental illness, where lack of motivation amongst

participants can be a significant barrier. It is crucial that the facilitator has the ability to assist

group members to stay positive, take small steps, and remember their goals. Creating an

environment that maintains participants motivation over the series of sessions requires careful

planning. Facilitators must be able to commit to running the entire program because of their

significance as a role model and support person.

Communication with case managers, key workers and doctors is important as they can all

play a key role in the motivating process. Even simple interventions, such as a doctor checking

on the quitting process with a participant, can reinforce the Program. It is important for all

people with mental illness to monitor their mental health and to look after themselves and

seek help if they are concerned. In addition the facilitator needs to: keep key workers and/or

other health professionals informed about any concerns; tell them if their client has stopped

attending; check that they are monitoring their client as usual during the course; and ask that

they follow-up regularly once the course is finished.

The facilitator needs to be knowledgeable and sensitive around smoking and mental illness,

non-judgemental, self aware and experienced in running groups.

The size of the group

The size of the group needs to be kept small (between five and ten is ideal), in order to allow

the facilitator time for all participants. This small size is particularly important if the group

includes participants who have difficulties with concentration. People with a mental illness

are often restless in group programs, due to anxiety, lack of concentration and other factors.

Limited group size allows better control and management of these obstacles by the facilitator.

If you have two facilitators you can have a larger group.

The SANE Q

uit Smoking Program

18

However, true attendance numbers will probably only start to become apparent in the days

immediately before the Program starts. People can change their minds, become physically

or mentally ill, have family commitments or many other reasons for not being able to attend.

So allow for many more than the recommended five to ten participants, as some are likely to

come along for the initial sessions and then drop out. (One of the pilot groups started out with

twenty-five participants, of whom fourteen showed up to the first session and eight completed

the Program.)

Length of the program

The Program is designed to run for two hours twice a week for four weeks, or once a week for

eight weeks with some follow-up after the sessions recommended. Each session takes about

two to two and a half hours including the break.

Encouraging group members

Some members may be reluctant to talk at all, so the facilitator should invite them to

contribute once or twice during each session. For these members just being part of the group

and being exposed to alternative ways of thinking about smoking can be helpful. This is true

even if their psychotic symptoms, or poor social and verbal skills, have limited their ability to

participate more actively.

Group members should be encouraged to come along, even if they have missed a session.

You could offer to catch up on material one on one or buddy them up with another member.

The Program teaches skills which can be applied to a wide range of behaviours, and often

fits in with other wellness or recovery goals. It can, for example, be an excellent focus for a

healthy lifestyle program because of the emphasis on developing good coping strategies and

healthy eating and exercise habits (see also the SANE Guide to Healthy Living).

The Program works best for inexperienced facilitators when they have a co-facilitator. This

will ensure that each participant receives individual attention as well as allowing for smaller

group discussions. Ideally both facilitators would be trained in the field of drug addiction as

well as mental health and one with lived experience as a consumer. If this arrangement is not

possible, it is highly desirable that, between them, the facilitators have experience of working

in mental health services as well as smoking cessation programs.

Facilitator notes accompany each session description to assist in dealing with challenges that

may arise.

19

Promoting the Program

As well as attracting participants, good promotion can help people to make a commitment

to quitting. There is a draft promotion yer in the appendixes. You may choose to develop

your own from scratch. The Quit campaign in your State or Territory will have a variety of

posters, stickers and booklets that can be used if you are promoting the course in an in-patient

or community setting. Finally, pharmaceutical companies that produce nicotine replacement

therapies will have promotional material that you may choose to use as prizes or incentives.

The Program can be promoted in a mailout to clients from participating services. A simple

letter from the centre informing people of the course, the times and location is an effective

way of making sure everyone gets the opportunity to participate.

It is best to start promotion at least four weeks before the Program begins. When people

register interest, make sure you get full contact details, and, as mentioned, be prepared for

interest to uctuate.

Lastly, make it clear that anyone who joins the group does not have to quit. The pressure

people feel can be enough to put them off participating.

Goals of the Program

The ultimate goal of the Program is to provide an environment where participants are

supported to reduce or quit smoking as part of their wellness or recovery goals.

The course provides the information and space needed for participants to consider their own

smoking and make realistic incremental goals that take them closer to quitting for good. It is

unrealistic to have a specific goal for the course of how many participants will actually quit

or reduce their smoking. Setting small goals initially, that are more easily achievable, will

enhance the smokers confidence. Having said that, it is possible for people to successfully quit

on their first attempt.

A successful group is one where participants:

ff regularly attend

ff form an accurate picture of their smoking

ff have made achievable goals

ff are closer to the healthier lifestyle they want for themselves.

Running a smoking cessation course also provides a good opportunity for the organisation to

review its smoking policy and provide a training update for staff.

The SANE Q

uit Smoking Program

20

Introduction and informal assessment

During the introductory information session it is important to present some basic information

about smoking, quitting and mental illness so that people can start to get an idea about

their readiness to quit. You may choose to open the session up to supporters. Be clear about

the group process so that potential participants can decide, perhaps with the assistance of

their key worker, whether a group course will work for them. You will also be able to get an

idea of whether someone is ready for a group. It is really important to set the ground rules

of participating in the group at this stage so people understand the environment you are

providing.

Some facilitators have found that they needed to run this information session twice just to

encourage people to attend. If facilitators have the time they can meet with every interested

person individually instead of as a group.

It is important that potential participants realise they will make their own achievable goals in

the group, and not be forced into something they are not ready for.

If a potential participant has a key worker it makes sense for them to continue to work with

and support the client over the course. However, if someone has less contact with the service

they may need more support from you and the initial assessment is the time to sort this out.

The connection you make will help reduce drop-out rates.

Things to consider

ff How does the person feel about their smoking? How ready are they to quit or reduce their

smoking? Have they tried to quit before?

ff Do you want to gather baseline data on participants smoking? This helps with the

evaluation of the course and is also useful for people to monitor their own progress, and

for you to provide feedback to them during the course.

ff Would the person benefit from referral to another service? They might have drug or alcohol

issues or benefit from a recreation program referral.

ff Does the person need assistance with reading and writing?

ff What sort of social support does the person have and do friends or family smoke?

ff Who is the persons treating doctor and or GP? You will need permission if you want to

contact them about the course so that they can support the participant. Because of the

interplay between nicotine and particular medications they will need to consider how to

best manage medication levels. As appointments with a psychiatrist can be months apart,

the participant should be encouraged to make an appointment as soon as possible if this

seems necessary.

21

Possible activity

To give the group an idea of the sort of activities the group will do you may like to do a simple

exercise. Give out paper and pens and ask participants to calculate how much they spend on

cigarettes in a year. Give an example on the white board. Then brainstorm what else you could

buy with that amount of money.

You may also be able to offer an assessment of their smoking using the Fagerstrom test

(available at http://www.tobaccoinaustralia.org.au/chapter-6-addiction/6-5measures-

of-dependence). If you have access to a Smokelyser (contact your State Quit group for

information about this) you could also measure carbon monoxide levels. Please note that these

machines are sometimes unreliable. This helps establish people starting point and can be

repeated at the end of the program.

Options for someone who is not ready or suitable for a group course but is ready to quit:

ff Consider seeing them one on one to go through some of the course material

ff Give them the contact numbers for Quit (see appendixes). You can refer more formally or

they can ring themselves. They could also go through the quit coach online.

ff You will need to emphasise the importance of talking about quitting to the treating doctor

at the beginning of the process.

ff Ring the SANE Helpline on 1800 18 sane(7263) for assistance with finding other services

(including alcohol and drug services) in your State or Territory.

Specific issues in facilitating groups for people affected by mental illness

Literacy and concentration

The Program will have its greatest impact if information is communicated in an effective

manner and participants are able to process the information for themselves in a way that

suits their learning style (visual, auditory and kinaesthetic learning by doing or moving).

Participants may have a short attention span, poor concentration or difficulty in organising

their thoughts. These are common features of psychiatric disability. Suggested ways of

compensating for this are for participants to:

ff keep a pocket diary

ff make lists

ff break tasks into small steps and focus on one at a time. This decreases the load on the

persons attention and makes it easier to keep track of what needs to be done.

To maintain the interest of participants, each session incorporates a variety of modes of

presentation, including group discussions, activities, role-play and presentations by the

facilitators. Group activities are used occasionally to stimulate group discussion, and lengthy

presentations by the facilitator are avoided.

The SANE Q

uit Smoking Program

22

To enhance concentration, there are breaks half-way through each 2 hour session. During

breaks, participants should be encouraged to practice delaying techniques in order to develop

a sense of control over their nicotine cravings. This is encouraged initially by providing

participants with a healthy afternoon snack and asking them to refrain from smoking during

the fifteen minute break in the sessions. This can be a small but significant achievement for

all the group members and can be employed as a means of increasing participants levels of

confidence and motivation to quit.

Difficulty with reading and writing among some people requires exibility when running such

groups. Homework assignments are an integral part of the course, and every effort has been

made to keep the assignments easy to read and stimulating. Some participants with literacy

problems may require extra support, and should be linked to a support person such as their

case manager or key worker. If appropriate they could buddy-up with another participant.

Cannabis use

Some people who smoke tobacco also use cannabis, particularly young people with a mental

illness. If cannabis is used infrequently, then the Program may be appropriate. If you have any

doubts it is best to refer the person to a drug and alcohol worker trained in dual diagnosis.

Resources such as the SANE Factsheet on Cannabis and Psychotic illness (available at www.sane.

org) should be read so that you understand the particular issues for this group. However, this

is a quit smoking program with a focus on tobacco, and discussion of cannabis during the

sessions should be limited to its impact on quitting tobacco.

NRT use

Some participants will have access to Nicotine Replacement Therapy (either provided for free

for a limited period while in acute care, or prioritised and bought with their own money)

and others wont. Some participants may have no interest in using NRT. This needs to be

considered when working with the group.

It is important that you have a basic knowledge of the different forms of NRT. Check in

regularly with group members to see if they are using their NRT as recommended (eg. not

cutting patches in half). See the Pharmacotherapy section and Quit website www.quit.org.nz

for more information.

Smokefree hospital environments

Some participants will have experienced smokefree mental health services and may have

strong feelings about the change. Many of these services provide nicotine replacement for

the time the person is in hospital and perhaps for a further week or two following discharge.

Some patients try to maintain the change and others do not or are unable to for a variety of

reasons. (See earlier in this section).

23

Setting goals with participants and measuring outcomes

While emphasis is always given to stopping smoking as the goal, particular attention needs

to be given to the role of learning about smoking cessation as a process. Some participants

have cautious goals because of lack of success in the past. The symptoms of psychotic

illnesses (such as hearing voices and difficulty with motivation) and the negative thinking that

comes with depression and anxiety make teaching realistic goal-setting an important part of

maintaining motivation to quit. Teaching participants skills when they are well gives them time

to practice for when they may become unwell again.

The outcome of addiction treatment programs is traditionally measured by quit rates at

various time intervals, and of course many people entering a Smoke Free program will hope

to quit their tobacco use. It is important to measure the quit rates achieved, however it is also

important to measure reduction in the number of cigarettes smoked, and increased knowledge

and self-efficacy as well. A successful outcome involves the participants moving through the

stages of change for example, from precontemplation to contemplation or action.

Reduction or quitting can lead to other benefits too. For example, in one course, through

reduction in smoking, participants were able to take part in leisure activities such as going

to the movies, not previously possible due to restriction on smoking at such venues. Another

participant became aware of her negative style of thinking and was able to challenge the

negative thoughts in relation to her ability to quit. This recognition was crucial in precipitating

change and gaining a sense of control over other parts of her life. These indirect changes will

often lead to improved wellness and quality of life in general for the participants.

As well as basic information collected during the assessment interview, questionnaires may be

used at the beginning and completion of the Program for evaluation purposes. Data collected

will vary with the needs and resources of the organisation undertaking the Program, but may

include the Fagerstrom test to measure the nicotine addiction and information on diet, physical

exercise, quality of life and social activities as well as smoking behaviour and progress through

the stages of change cycle.

If you have access to a Smokelyser machine you can measure carbon monoxide levels. When

repeated at the end of the program this can give participants immediate feedback on how far

they have come. Please note these machines are sometimes not very reliable.

A very simple evaluation form is included in the appendixes.

Im now not smoking. It was really important to me that the facilitator talked about quitting smoking but

didnt try to force people to change. To smoke or not to smoke should be your personal choice, you dont

want to be dictated to.

The SANE Q

uit Smoking Program

24

Individual versus group cessation support

Some participants clearly need individual attention as well as, or instead of, attending the

Program. Although it has been developed for group settings, the entire Program can also

be adapted into individual sessions. Group programs will, of course, be more cost-effective.

Peer support, modelling of appropriate behaviour, feedback, normalisation of experiences

(especially withdrawals, past slip-ups and relapses), are some of the processes in the Program

which are particularly suited to individual use, especially in combination with using the SANE

Guide to a Smokefree Life.

Follow-up

Request that follow-up be provided regularly by the participants key worker or doctor.

You may choose to arrange to contact participants by phone and/or provide a follow-up

refresher group session two weeks or a month after the course finishes. This follow-up

recognises that reducing and quitting is an ongoing process rather than a discrete event.

Reminder calls may be necessary to ensure attendance at the follow-up session, particularly

if it is scheduled for more than one week after the final Program session. If possible, find

common themes in the issues brought up by participants and deal with those. Encourage all

the participants to be involved in supporting each other and problem solving.

Dont forget to be on the lookout for progress. If participants have relapsed they can be very

negative in their assessment of their efforts. Encouraging a positive attitude to everything

participants learn about smoking reduction and quitting is vital to them becoming smokefree.

25

References

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Nicotine Dependence. AmericanJournalofPsychiatry 153 (10), Supplement, pp. 131

Baker, A., et al, 2004. Interventionfortobaccodependenceamongpeoplewithamentalillness.

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http://ndarc.med.unsw.edu.au/NDARCWeb.nsf/page/NDARC%20Technical%20Reports

Baker, A., et al, 2006. A randomized controlled trial of a smoking cessation intervention

among people with a psychotic disorder. AmericanJournalofPsychiatry 163: 1934-1942

Baker A., et al, 2009. Coronary heart disease risk reduction intervention among overweight

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129-135

Baxter, D.N., 1996. The mortality experience of individuals on the Salford psychiatric case

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Benowitz, N.L., 2009. Pharmacology of nicotine: addiction, smoking-induced disease, and

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Campion J, Checinski K, Nurse J., 2008. Review of smoking cessation treatments for people

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Davidson, S., et al, 2001. Cardiovascular risk factors for people with mental illness. Australian

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el-Guebaly N., et al, 2002. Smoking Cessation approaches for persons with mental illness or

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Fagerstrom K., Aubin H-J., 2009. Management of smoking cessation in patients with

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Green, M.A. & Hawranik, P.G., 2008. Smokefree policies in the psychiatric population on the

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Gurpegui, M. et al, 2007. Subjective effects and the main reason for smoking in outpatients

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uit Smoking Program

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Jablensky, A. et al, 2007. PeopleLivingwithPsychoticIllness:anAustralianStudy,1997-98.

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Lawn, S., Pols, R. & Barber, J., 2002. Smoking and quitting: a qualitative study with

community-living psychiatric patients. SocialScienceandMedicine 54 (1): 93

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research. AustralianandNewZealandJournalofPsychiatry 39: 866-885.

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27

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The SANE Q

uit Smoking Program

28

29

Program guidelines

The eight sessions in this manual include all the information and activities needed to run

the SANE Quit Smoking Program. Before running the Program, you may wish to go through

the sessions and adapt them to your own facilitation style. Handout sheets, overheads and

background information are found as appendixes in the third section of this Kit, Program

Materials.

The manual contains:

ff Facilitators checklist

ff Program philosophy

ff Brief guidelines on the 5As, motivational interviewing and the

cognitive-behavioural approach

ff Session Guidelines.

Facilitators checklist

Before running the program, each facilitator should be able to answer Yes to all the following

questions:

ff Are you informed about issues related to smoking, mental illness and medication?

(See section 1 of this kit, Smoking and Mental Illness).

ff Do you fully understand the stages of change model?

ff Do you have a good understanding of the 5As, motivational interviewing and the cognitive-

behavioural approaches? (See section 1).

ff Have you contacted Quit in your State or Territory for any training, information and

resources? (See Appendix 3 for contact details.)

ff Have you explored what ongoing support is available locally? For example, GPs, case

managers and pharmacists?

ff Have you thought about guest presenters? For example, a fitness or Tai Chi instructor or a

financial advisor. (One group had a bank manager come to talk about what to do with the

money saved from not smoking.)

ff Are you fully informed about nicotine replacement therapy and other medication?

ff Have you promoted your group program among staff and prospective participants?

ff Have you organised a pre-group information session for prospective participants or met

them individually?

The SANE Q

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30

Other issues to consider

ff Do you have a co-facilitator? (Its great to work with someone with personal experience of

mental illness and quitting smoking, if that does not describe you.)

ff Do you have support from your manager and other staff?

ff Do you have a budget for costs such as catering? Are you able to provide nrt?

ff Have you booked a venue? You need large room with a whiteboard and preferably a

separate kitchen/eating space.

Allow 2 hours for each session.

If you have any doubts regarding these questions, refer to Section 1 of the Kit.

Program philosophy

This program aims to engage participants in an active and interesting process that

acknowledges that the responsibility for change lies with them. The process for facilitators

over the eight sessions is to be more directive and informative in the initial stages. As the

sessions progress, facilitators hand over the power to participants through such methods as

encouraging other participants to offer information and support to a participant, and even

encouraging the group to set the agenda for the session. Obviously, this latter suggestion

requires experience and confidence on the part of the facilitator and may be used only after a

number of groups have been run.

Smoking cessation programs for the general population encourage smokers to arrange a quit

date at which point they are encouraged to quit completely. This is appropriate for those

participants who feel ready and able to do this however others may choose to focus on short-

term goals of mini-quits or smoking reduction. This harm-reduction approach has proved to

be successful with this group and may help increase the success rates of later quit attempts and

reduce withdrawal symptoms (Fagerstrom and Aubin, 2009).

The exercises and activities in the program draw on art therapy, stress management,

psychodrama and health and fitness principles. Again, as facilitators grow in confidence with

this program, other activities can be incorporated depending on the make-up of the group.

For example, any ice-breakers and warm-up exercises found in other group training manuals

or courses can help to vary the program (particularly if you have participants who have

already completed one or more courses). Make sure you cater to different learning styles with

a mix of visual, auditory and kinaesthetic process and content. Some groups might include

very confident participants who can handle group and couple discussion activities while others

might benefit from more active, concrete exercises such as playing games to help them feel

comfortable.

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Some facilitators choose to transform the program into a shorter-length session weekly

support group style rather than a discrete course. This works best after working with the set

program for a while. A weekly support and information group can be very effective in acute

units where new patients may be struggling or wanting to make the most of the smokefree

environment they find themselves in. A more exible approach has been shown to be more

effective with people affected by mental illness.

If you are new to facilitating smoking cessation programs for people with a mental illness, it

can be useful to establish your own support network by contacting other facilitators. (Quit

may be able to assist and also run training programs.) There is much to learn and you will

get better at the program the more you run it. Facilitator notes have been included with each

session outline to assist with some of the challenges and pitfalls you may encounter

If your agency requires quantitative evaluation of the program, you could go to the Tobacco in

Australia: Facts and Issues website to obtain copies of the Fagerstrom questionnaire, a measure

of addiction (http://www.tobaccoinaustralia.org.au/chapter-6-addiction/6-5measures-of-

dependence). You could also write up a discussion with participants about their progress

through the Stages of Change. Remember, however, that these measures are only one aspect

of the impact of the group program and reect this in your evaluation report. There is a simple

evaluation form in Appendix 14 that you can use or adapt.

The SANE Q

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33

Session 1 Introduction to the program: reasons to smoke and reasons to quit

Aims

ff To familiarise participants with the Program format.

ff To build a cohesive group.

ff To gain agreement on ground rules for the group.

ff To discuss the positive and negative effects of smoking.

Session content: Summary

Welcome participants

Explain group meeting times, location and format.

Introduce yourself. Talk about your experience of working in the smoking cessation and mental

health areas. Discuss your role.

Icebreaker

Ask the group members to introduce themselves and say something about how/when/why

they started smoking. Summarise the themes that emerge and how they fit into the overall

program. Brainstorm group guidelines and gain agreement to keep within them.

Break

Prior to the break, discuss the role of the breaks in this Program. Encourage participants to

use the breaks as a time to practise their strategies.

Why I smoke exercise

Use art materials to assist participants gain a clearer picture about their individual reasons

to smoke.

Conclusion

Hand out Quitting Diaries and encourage participants to record their thoughts and experiences

about smoking and quitting.

Session 1

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Facilitator notes

The process of gaining understanding about smoking and quitting through the exercises in

todays session help participants get a picture of their smoking. As participants discuss why

they started smoking and why they continue to smoke, feelings of anxiety and negativity about

their smoking can arise. Offer tips in the Why I smoke exercise to help people move towards

healthy behaviour change. The homework exercise continues this process outside the group.

At the end of the session you should have a sense of each group member and whether

there may be any new issues around particular participants. For example, common issues

include: difficulty containing a talkative person, members who walk in and out of the group,

and members who fall asleep or struggle to maintain engagement (possibly because of

medication).

Methods for dealing with these issues include: keeping a watch on time taken up with any one

person, discussing it if it happens in the group, tailoring group activities to help the person

manage better, and re-evaluating whether the person should stay in the group (individual work

is better for people without sufficient group skills).

Sedation is often an issue linked to smoking, as people use the smoking to wake themselves

up. Talking about this in the group more is useful because many people experience the

problem. Make sure you do not run the group first thing in the morning.

If participants require further information about mental illness, see www.sane.org for

Factsheets and other useful resources. Quit Australia also has a good range of resources about

quitting that participants may find useful.

Let people know that if they want to quit a good time is around Session 5.

Preparation

ff Call and remind all prospective participants about the group and check out any

transport issues.

ff Prepare a timetable, with dates and times for all sessions to give out.

ff Photocopy the SANE Smoking and Mental Illness factsheet and information on the SANE Guide

to a Smokefree Life for each participant.

ff Buy a range of healthy snacks and drinks for the break.

(See Appendix 4 for suggestions.)

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f

On the day

ff Make sure the room is large enough (the first few sessions may see some extra participants

who come and go). Arrange chairs in a semi-circle.

ff Set up the food table ready for the break and away from the area where participants would

normally smoke. Make it bright and appealing.

ff Set up whiteboard. Write up the session activities on the board (this gives participants a

sense of what to expect and alleviates some of the anxiety of the first session).

Bring

ff Big sheets of paper, textas/pencils/crayons/paints, whiteboard markers

ff Quitting Diaries and timetable for the Program

ff SANE Smoking and Mental Illness factsheets and copies of, or information about,

the SANE Guide to a Smokefree Life

ff If you have the resources you may also like to hand out folders to participants to keep the

factsheets and any other information distributed during the group program.

Session content

It is important that you start the group in a clear, strong and warm way so participants feel

welcomed. Your role here is to get the group started on the process of behaviour change, and

generally the most important issue for a new group is to help people feel comfortable.

Welcome

Start by welcoming group members to the course in a way appropriate to the mix of people

who are there.

Group times and format

Let group members know that the location and starting time will be the same each session

and that their attendance at as many sessions as possible is desired. Explain that each session

builds on previous work and make arrangements for missed sessions (for example, ask the

person to catch up with another group member). Give a general overview of what the course

contains and its purpose. For example, Each week youll have an opportunity to talk about

how quitting is going for you and well help you to deal with whatever obstacles that might

arise. As the group facilitator I will not be making you quit smoking, but rather helping you to

get the most out of this group to achieve your goals.

Introduce yourself

Introduce yourself and talk about your experiences in working with similar groups and about

your personal experience with smoking. If you are unknown to participants, talk about any

previous experience in working with people with a mental illness and in helping people to

quit smoking.

Session 1

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If you are an ex-smoker, tell them how you feel now that youve stopped. Talk about your

personal struggle with quitting. If you have never smoked, talk about how you succeeded in

getting over another significant hurdle or addiction in your life for example, getting your

weight down to a healthy level.

Give as much information about yourself as you would like group members to give about

themselves.