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S

The SANE

Smokefree Kit
Third, revised edition

Introduction

I 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 nonsmokers 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 nd
that they cant quit alone, or cant make successful use of the available community resources
to do so. All too frequently they have difculty nding a health professional who feels
condent 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 specically 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 eld, 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.
Theeight-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 rst 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

The benefits of reducing and quitting smoking

A specially targeted program

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

Who can run quit smoking groups?

Is quitting the only measure of success?

Theoretical approaches behind this program

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

1 Group promotion flyer*

105

2 Letter to treating doctor*

106

3 Resources and contact details

107

4 Healthy food and drink

108

5 Strengths cards*

109

6 Contract*

110

7 Dealing with stress

111

8 Dealing with feelings

113

9 Faulty beliefs and positive thoughts

114

10 Strategy sheet for dealing with feelings

116

11 A healthy weight

117

12 Things to do

118

13 Certificate*

119

14 Evaluation form

121

* Also available from www.sane.org

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 benets 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 benets 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.

Smoking and Mental Illness

Smoking and mental illness:


an overview

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 ngers 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.

Less 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 re 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 re caused by cigarettes. Smoking less
and quitting reduces re 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 selfcondence 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 benets of helping people with a mental illness to quit smoking with a specially targeted
program are signicant and clear. Some people nd it difcult to access community quit
smoking groups and counselling services because of their illness. Difculty 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.

Psychological and social factors

ff Boredom is one of the most commonly reported reasons for smoking. Many people
struggle to nd a reason to get up in the morning and smoking lls in the long hours before
going to bed. So often, the problem is the perception or reality that there is nothing else
to do.

f Cigarettes 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 rst 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

Smoking and Mental Illness

Why are smoking rates so high?


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

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.

Biological 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 specic 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 nd 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.

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.

Smoking and Mental Illness

Who can run quit smoking groups?

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.

Helping 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 ve
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.

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.

Smoking and Mental Illness

The 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.

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.

Brief 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 benets 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-condence 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 difcult 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 rst
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).

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.

Smoking and Mental Illness

ff Assist with revising the quitting plan as needed.

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.

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.

10

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 simplies
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 Mental Illness

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 shortterm (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.

11

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.

12

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.

Smoking and Mental Illness

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.

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.

13

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.

14

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 Mental Illness

The evidence regarding cessation

15

16

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 signicant 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 ve 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 difculties 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 Quit Smoking Program

The SANE
Quit Smoking Program

17

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-ve participants, of whom fourteen showed up to the rst 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
ts 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.

18

As well as attracting participants, good promotion can help people to make a commitment
to quitting. There is a draft promotion flyer 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

The SANE Quit Smoking Program

Promoting the Program

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.

19

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.

20

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/6-5measuresof-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.

Specic 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 difculty 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

The SANE Quit Smoking Program

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.

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.

21

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 fteen minute break in the sessions. This can be a small but signicant achievement for
all the group members and can be employed as a means of increasing participants levels of
condence and motivation to quit.
Difculty with reading and writing among some people requires flexibility 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. Ifcannabis 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).

22

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 difculty 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 benets 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.

The SANE Quit Smoking Program

Setting goals with participants and measuring outcomes

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.

23

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 nal Program session. If possible, nd
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.

24

American Psychiatric Association, 1996. Practice Guideline for the Treatment of Patients With
Nicotine Dependence. American Journal of Psychiatry 153 (10), Supplement, pp. 131
Baker, A., et al, 2004. Intervention for tobacco dependence among people with a mental illness.
National Drug and Alcohol Research Centre. Accessed at:
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. American Journal of Psychiatry 163: 1934-1942
Baker A., et al, 2009. Coronary heart disease risk reduction intervention among overweight
smokers with a psychotic disorder: pilot trial. Australian and New Zealand Journal of Psychiatry 43:
129-135
Baxter, D.N., 1996. The mortality experience of individuals on the Salford psychiatric case
register. British Journal of Psychiatry 168: 772779
Benowitz, N.L., 2009. Pharmacology of nicotine: addiction, smoking-induced disease, and
therapeutics. Annual Review of Pharmacology and Toxicology 49:57-71
Buchanan, C.R., Huffman, C. & Barbour, V.M., 1994. Smoking health risk: counselling of
psychiatric patients. Journal of Psychosocial Nursing 32 (1): 2732
Buckley, et al, 2009. Psychiatric Comorbidities and Schizophrenia. Schizophrenia Bulletin
35(2): 383-402.
Campion J, Checinski K, Nurse J., 2008. Review of smoking cessation treatments for people
with mental illness. Advances in Psychiatric Treatment 14:2 08-216.
Campion J. Hewitt J, 2008, Guidance on Smoking Cessation in Mental Health Settings, Sussex
Partnership, NHS Foundation, UK.
Coghlan, R. et al, 2001. Duty to Care: Preventable physical illness in people with mental illness.
University of Western Australia
Davidson, S., et al, 2001. Cardiovascular risk factors for people with mental illness. Australian
and New Zealand Journal of Psychiatry 35: 196-202
el-Guebaly N., et al, 2002. Smoking Cessation approaches for persons with mental illness or
addictive disorders. Psychiatric Services 53: 1166-1170

The SANE Quit Smoking Program

References

Fagerstrom K., Aubin H-J., 2009. Management of smoking cessation in patients with
psychiatric disorders. Current Medical Research and Opinion 25 (2): 511-518
Green, M.A. & Hawranik, P.G., 2008. Smokefree policies in the psychiatric population on the
ward and beyond: A discussion paper. International Journal of Nursing Studies 45(10): 1543-9
Gurpegui, M. et al, 2007. Subjective effects and the main reason for smoking in outpatients
with schizophrenia: a case-control study. Comprehensive Psychiatry 48: 186-191

25

Jablensky, A. et al, 2007. People Living with Psychotic Illness: an Australian Study, 1997-98.
Commonwealth Dept of Health and Aged Care
Kassel, J.D., Stroud, L.R. & Paronis, C.A., 2003. Smoking, stress, and negative affect:
correlation, causation, and context across stages of smoking. Psychological Bulletin 129(2):
270-304
Lawn S., 2001. Australians with mental illness who smoke. British Journal of Psychiatry
178(1): 85
Lawn, S. & Campion, J., 2009 (In Press). Smoke-free initiatives in psychiatric inpatient units:
a national consultation with Australian sites. Psychiatric Services Flinders University
Lawn, S., Pols, R. & Barber, J., 2002. Smoking and quitting: a qualitative study with
community-living psychiatric patients. Social Science and Medicine 54 (1): 93
Lawn, S. & Pols, R., 2005 Smoking bans in psychiatric inpatient settings? A review of the
research. Australian and New Zealand Journal of Psychiatry 39: 866-885.
Marcus, K., 2008. Smoking bans in long-term inpatient settings: A dilemma. Psychiatric
Services 59: 30.
Miller, WR and Rollnick S, 2002. Motivational Interviewing: Preparing People for Change,
Second edition. Guilford Press
Moeller-Saxone K., 2008. Cigarette smoking and interest in quitting among consumers at a
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NSW Cancer Council, 2008. Addressing Smoking In Community Service Organisation: Tackling
Tobacco: Action on smoking and disadvantage. Accessed at:
www.cancercouncil.com.au/tacklingtobacco
Olivier D., Lubman D., Fraser R., 2007. Tobacco smoking within psychiatric inpatient
settings: a biopsychosocial perspective. Australian and New Zealand Journal of Psychiatry
41: 572-580
Prochaska J.O., DiClemente C.C. & Norcross J.C., 1992. In search of how people change:
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Quit S.A. & South Australian Department of Health, 2005. Smoking and Mental Health:
Addressing tobacco in mental health: Improving the environment, services and health outcomes for staff,
clients and visitors.Accessed at:
www.quitsa.org.au/cms_resources/documents/resource_addressing_tobacco.pdf
Quit Victoria, 2004. 5As for health professionals. Accessed at:
http://www.quit.org.au/article.asp?ContentID=45540
Ragg M & Ahmed, T., 2008. Smoke and mirrors: a review of the literature on smoking and mental
illness. Cancer Council NSW

26

SANE Australia; Access Economics 2007. Smoking and Mental Illness: Costs. SANE Australia
SANE Australia, 2009. The SANE Guide to a Smokefree Life. SANE Australia
SANE Australia, 2008. The SANE Guide to Healthy Living. SANE Australia
SANE Australia, 2009 (forthcoming). Primary Care Guidance on Smoking and Mental Health.
SANE Australia
Schmueli, Dikla et al., 2008. Changes in psychiatric patients thoughts about quitting smoking
during a smokefree hospitalization. Nicotine and Tobacco Research 10 (May): 875-881
Scollo, M.M. & Winstanley, M.H., eds, 2008. Tobacco in Australia: Facts and Issues, Third
edition. Cancer Council Victoria
Seymour, L., 2001. Where Do We Go From Here? Tobacco control policies within psychiatric and longstay units. UK Health Development Agency. Accessed at:
https://www.nice.org.uk/nicemedia/documents/wheredowego.pdf
Wanigaratne, S. et al, 1990. Relapse Prevention for Addictive Behaviours. Blackwell Scientific
Willemsen, M.C., et al, 2004. Exposure to environmental tobacco smoke (ETS) and
determinants of support for complete smoking bans in psychiatric settings. Tobacco Control
(13)180-185
Wye, P.M., et al, 2009. Smoking restrictions and treatment for smoking: Policies and
procedures in psychiatric inpatient units in Australia. Psychiatric Services 60: 100-107

The SANE Quit Smoking Program

SANE Australia, 1996. Mental Illness and Smoking Cessation: An Urgent Public Health Issue: Forum
Proceedings, 19 November, 1996. SANE Australia

27

28

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 cognitivebehavioural 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.)

The SANE Quit Smoking Program

Program guidelines

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?

29

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 shortterm 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.

30

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-ofdependence). 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 reflect this in your evaluation report. There is a simple
evaluation form in Appendix 14 that you can use or adapt.

The SANE Quit Smoking Program

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 flexible approach has been shown to be more
effective with people affected by mental illness.

31

32

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.

Session 1

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

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.

33

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.)

34

ff Make sure the room is large enough (the rst 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 rst session).
Bring

Session 1

On the day

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.

35

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.
Keep an eye on group members to assess concentration levels. If you detect boredom or
restlessness, pause. You can use these moments to notice group members and ask if they need
a break or change of activity.
Icebreaker
Ask each group member in turn to introduce themselves briefly and say something about how,
when and why they started smoking.
Conclude with reflections on the themes that emerge such as:

ff realisations that there was a life before smoking


ff the effect of other people on their smoking
ff smoking and quitting as a journey
ff tie these in with how the group can help each other to achieve their goals.
For example:

ff that the group can help them to develop their identity as a non-smoker (even if the last
time they did this was when they were twelve years old)

ff acknowledge that just as other people influenced their decision to start smoking, the
group will help influence them to become smokefree

ff this program will assist them to realise that changing their smoking habits is a process
rather than an event and that we are interested in all changes leading to a healthier
life, not just quitting.
Group guidelines

ff Brainstorm
Use the whiteboard to brainstorm group guidelines. This may include: confidentiality,
regular breaks, not talking over each other, arriving on time etc. Talk these through with
the group and get some agreement. This is an opportunity to ask for agreement for you to
contact participants key workers and doctor if you think this is necessary and you have
not already done so. (See letter in Appendixes.)

36

Explain
Introduce the break as an important part of the group process.
Firstly there will be snacks and food available that are useful for quitting for example, lowfat to avoid weight gain; that are good for dealing with cravings; useful if chewing nicotine
gum; or to get rid of a bad taste in the mouth.
Secondly it is a chance to practise taking a break without smoking. Encourage people to
stay in the kitchen (or wherever you hold the break) and socialise. This also gives people an
opportunity to get to know each other and form support networks for outside the group.
Allow about ten minutes for the break and help people to start conversations if required.

Session 1

Break

Make sure that the food and drink you offer is appealing to the eye and includes interesting
tastes and textures. Talk about your choices among the group and encourage them to
experiment with new foods and drinks at home. You could even compare the cost of the items
to the cost of smoking. For example, what did you buy for the cost of one packet of cigarettes?

Why I smoke exercise


Explain
Before participants can move on to quitting, they must first of all develop a clear idea about
why they smoke. Often smoking is so ingrained and unconscious that people just answer with
something like Im addicted or Its a habit. This exercise will bring out each individuals
particular reasons for smoking and is designed to get them thinking, rather than just sitting
and listening.
Activity
Introduce the exercise with a brief talk about the importance of knowing what you are trying
to change. The analogy of shadow-boxing can be useful it is hard to hit your target if you
dont know what it is.
Each individual is asked to draw a picture of themselves surrounded by words and pictures
describing why I smoke. They are encouraged to talk about their picture but can keep it
private if they prefer.
Begin by drawing a stick figure. Ask the group for some reasons to smoke. Write these on
the board then make up a picture or a shape that represents each reason. Show that they do
not need drawing skills and that they can represent reasons to smoke using shape, colour and
size and position. (You can use humour if your own drawing skills are basic, and this will help
lighten up the exercise.)

37

Explain that everyone is different, for example while the addiction might be why Joanne
smokes, Tom keeps smoking because the thought of quitting is too hard. If boredom is an
important reason to smoke it could be closest to the self, depicted as a large, grey blob.
Similarly if someone just loves that cigarette after dinner, it could be depicted as a warm, pink
glow. Fear of quitting could be a black hole or an angry shark! The idea is to engage peoples
imagination and creativity. At the same time, accept that some people prefer to use words or
are lacking in confidence.
Encourage participants to use the floor to work if that would be more comfortable and have
the materials arranged so that people need to move to access them. The more creative you are
with materials (using paints instead of pens for example) the more expansive the exercise will
be. While people are working, encourage them to give as many reasons to smoke as they can
think of and assist them to move from the general (Im addicted) to the specific (I need to
smoke every 20 minutes).
Discuss
When participants are finished, ask for comments on the exercise (and if they want to,
to show their work to the group). What new realisations did the person have about their
smoking? Has this exercise helped them learn more about their smoking, or did they know it
all already? Have other peoples ideas inspired them to think differently about smoking? Are
they dominated by one or two really important reasons to smoke, or surrounded by lots of
little reasons that add up? How can this help them to quit smoking? Do they now realise why
quitting may not have succeeded in the past?
Encourage some response from each person. Conclude the exercise by explaining that to really
quit for good, each person must bring their habit to consciousness, getting to know their own
triggers to smoke.
Explain
Explain that there are three main factors that underpin smoking: chemical addiction, habit and
dealing with feelings. During the course we will attend to each of these factors as they relate
to each individual. You may like to offer brief suggestions on how they can be overcome, as
participants are usually focused on the ultimate goal of quitting. For some, chemical addiction
is the easiest to deal with, using nicotine replacement therapy. For others, habits are relatively
easily broken (for example by sitting in a different chair when watching TV). For many, dealing
with feelings in a different way is not easy and we will be focusing on this in the group. Each
person will experience these factors slightly differently, of course.

38

Check if anyone has any questions.


Encourage participants to view the tasks they will be given to do between sessions as an
important part of the Program that will help them to quit. It helps them to keep focused on
quitting between sessions and provides important information to help them achieve their
goals. They may want to buddy-up if they need help with their reading and writing. Of course,
there is no punishment if they do not complete their task.
Reasons to quit
Hand out the Quitting Diaries for people to write in as they quit. A pocket size spiral bound
notepad is all that is required. Encourage them to use the diary to record anything to do with
smoking and quitting. This week, ask participants to list the reasons why they want to quit
smoking. Again encourage specific rather than general reasons. You may even like to turn this
into a small competition and offer a token prize next week for the most reasons listed.

Session 1

Conclusion

Let people know that if they choose to quit a good time is around Session 5.
You can also give out a copy of the SANE Factsheet, Smoking and Mental Illness, and information
about the SANE Guide to a Smokefree Life. This will help to consolidate the discussions had in
this session, and group members may choose to pass it on to supporters.

39

40

Aims

ff Review previous session


ff Continue to build group connections
ff Increase awareness of participants strengths
ff Build confidence

Session 2

Session 2
Working with the positives

ff Build positive associations with quitting


Session content: Summary
Review
Introduce any new group members and review the group guidelines. Ask for responses to the
Reasons to Quit exercise (and give out prizes if a competition was incorporated). Encourage
connections between group members. Bring out themes and incorporate information if
required (have information ready if needed). Tie in themes with todays topic.
Break
Remind the group about the purpose of the break and encourage participants to enjoy the food
and drink provided.
Strengths exercise
Place the Strengths cards in various spots around the room. Ask participants to walk around
and look at the strengths and take those that apply to them (encourage them to take as many
as possible). Leave some blank cards and pens and ask people to write any new strengths, or
copies of ones that someone else has taken if necessary. Discuss.
Conclusion
Ask group members to think of as many things as possible, which they like to do that do not
relate to smoking. Ask each person to name one strength now and write it in their Quitting
Diary as a start.
Homework
To develop a long list of things I like to do that dont involve smoking.

41

Facilitator notes
In this session, the group should be making further connections with each other and with
you, the facilitator. You may have new group members to introduce in the second session, so
incorporating them and helping them feel part of the group is important. Notice any people
who have not come back to the group and follow them up with a phone call after the group.
While some people dont return because of outside constraints or a decision not to take action
at this time, non-attendance can be caused by poor planning ability, transport issues or other
mental health related matters. Maintain a proactive approach to group attendance, assisting
people to overcome the obstacles as they arise. Remind them that the more sessions they
attend, the greater their chances of achieving their goals.
Mental illness and quitting can be associated with feelings of failure and poor self-image.
Focusing on peoples strengths and what they enjoy will build them up for the work ahead. The
Stages of Change Model acknowledges that self-efficacy is fundamental to successful behaviour
change. Building self-esteem also fits neatly into the work of recovery and wellness planning.
Remember that many smokers with a mental illness lead isolated lives. The review and
strengths exercises repeat the emphasis on encouraging participants to listen, respond and
reach out to others in the group. Being open in the group can put participants in a vulnerable
position. So remind people of the group guidelines including confidentiality. Discuss with their
case manager or support worker if you have any concerns.
In the strengths exercise participants are encouraged to move around by placing cards around
the room for them to look at and choose from. This helps combat fidgeting, boredom and
sedation in the group.
In this session questions regularly arise about issues like nicotine replacement therapy and
other information about smoking and quitting. As facilitator you need to decide whether
to address the issues in depth or give a brief answer and ask the person to wait until the
appropriate session for a full discussion. You could also choose to give an information
hand-out. If you choose to give a full answer, it will limit your time to do the allotted group
work. However, if it is a common concern and fits in with the session theme then it may
meet the groups needs. Dont forget that too much information can be counterproductive if
concentration is overloaded.
Preparation

ff Call all participants and remind them about the group if necessary.
ff Photocopy Strengths cards (Appendix 5) and cut them up, then place them around
the room.

ff Buy a range of healthy snacks and drinks and some smokefree prizes for any small fun
competitions you run over the program such as sugar-free lollies or chewing gum, an
inexpensive stress ball or a pack of herbal tea.

42

(See session 1)

ff Place strength cards around the room


Bring

ff Paper, cards and pens.


ff A prize if a competition was set for the Reasons to Quit exercise.
ff Always have information sheets ready in case of questions, including NRT information (see
Appendix 1) and parts of the Introduction section (such as Why is Smoking a Problem?)

Session 2

On the day

Session content
Review

ff Introduce any new people and review the group guidelines


Begin the session with discussion by the group. Start it off by asking people to make
any comments about the last session or to talk about any changes they have made. Ask
for responses to the Reasons to Quit exercise (and give out prizes if a competition was
incorporated). Note any themes that emerge which can be incorporated into the session.
Encourage people to talk to each other as well as to the facilitator. For example, ask if
what the speaker describes is experienced by other group members. If someone is nodding
in response to a comment, ask that person to say more.

ff Explain and discuss


Taking this approach will create an environment where the group begins to connect and
become a source of mutual strength and support for each other. It also helps build social
skills. Rather than the focus being solely on you as an expert it is also on participants
developing their own ability to change, which you are facilitating. This is particularly
important as mental illness is often felt as disempowering and isolating, which are reasons
why many people smoke.
The emphasis will be on supporting each individuals style. Whenever someone begins
to notice particular patterns in their smoking behaviour, remind them about triggers.
Encourage awareness of their own particular triggers and development of ways to
overcome them. For example, if drinking coffee is a trigger, then something simple like
switching to tea can diffuse it. Praise any examples of overcoming triggers that you notice.

ff Give information
The review is a good time to incorporate information into the session. For example,
questions may arise about using nicotine patches or gum and you can discuss their relative
benefits and give other information about nrt (refer to Section 1).

43

For people keen to try quitting sooner rather than later (see Program philosophy) it is worth
talking about possible withdrawal symptoms that lead to the high number of relapses.
For people affected by mental illness the most common symptoms are: anger/irritability,
impatience, restlessness, anxiety, craving, poor concentration and hunger. While many of
these symptoms return to pre-cessation levels within a month of quitting, hunger and craving
can continue for up to 6 months.
When is a good time to quit?
After the previous session, you may find that someone has gone away and tried to start
quitting straight away. Others may respond by smoking more. Acknowledge that everyone is
different and the Program is not about being prescriptive. Remind participants that quitting is
best approached in a planned way and that the optimal time to quit is around session 5.
Respond to difficulties
A participants comments may alert you to the effect of smoking reduction or cessation on
their mental health. For example, someone may reveal that they are experiencing real difficulty
with quitting and that they feel overwhelmed. Drawing from information in the Introduction
(see Why is Smoking a Problem?), you could:

ff alert them to the possibility of relapse of depression or psychosis and strongly suggest
that they only make changes with support from their doctor and other mental health
professionals

ff provide information on the role of medication in preventing relapse


ff reassure them that should they choose to keep attending the group, their goals may need
to become more modest for example, delaying quitting until immediate stressors pass, or
going outside to smoke when at home.
Be sensitive to how much you should say in front of the group and what would be better said
in private.
Summarise
Wind up the review with a summary of themes which have emerged. Tie these in with the
topic for Session 2, which is about drawing on strengths to help quit smoking.
Break
Remind everyone that there are some enticing food and drinks ready, and that they can use
this opportunity to practise being a non-smoker.
Strengths exercise
Place the Strengths cards (Appendix 5) in various spots around the room if you havent already
done so. Make sure you have enough of each so that people dont miss out on a card that
describes one of their strengths.

44

In pairs
When everyone has chosen their cards, ask them to form pairs to discuss their strengths and
how these could help them to quit smoking. Allow at least five minutes for discussion and help
any pairs that struggle to start or maintain a conversation.
Discuss
Ask people to share the results of these discussions with the whole group, preferably talking
about their partner, and vice versa. Assist anyone who may not be aware of their strengths
or how they relate to quitting with the help of other group members. For example, someone
who is a caring person may not realise that they can use this strength to be a caring friend to
themselves as they quit, or that they can ask their friends for support at this time. Another
person may not realise that being good with their hands is an excellent skill for keeping
themselves busy and distracted as they quit smoking.

Session 2

Explain
Ask participants to walk around and look at the strengths and take those that apply to them
(encourage them to take as many as apply). Leave some blank cards and pens so people can
write some new ones.

If someone cant think of many strengths, this can be worked with in a number of ways.
Some coaching from the facilitator and group may bring out strengths of which the person
is unaware. For example, the person may be a good listener, or a good example to others
by being committed to the Program. These are strengths the person is demonstrating with
their presence and style in the group so far. Another issue you may highlight is the need for
someone to build their self-esteem. Be careful that you do not put too much pressure on one
person in the group. They may choose to do more work with their support worker or in a day
program to address this issue in more detail. While one of the great benefits of quitting is the
boost to self-esteem, the effects of mental illness may be such that an individual needs extra
help in this area.
Close the exercise up with a review of how different strengths can help with quitting smoking,
often in unexpected ways. Encourage people to also think about whether there are any gaps in
their strengths that they need to develop or get help with from others.

45

Conclusion
Ask group members to think of as many things as possible which they like to do, that do not
relate to smoking. Ask each person to think of one thing immediately and write it in their
Quitting Diary as a start.
Suggest examples such as writing poetry, meeting with friends, going to church, soaking in a
bath, eating strawberries, the feeling of clean teeth. Guide people towards simple pleasures
rather than expensive ones such as shopping. Encourage them to ask other people for ideas to
build up their possible activities. You may choose to offer a reward for the longest list at the
next session.
Explain that quitting is about increasing opportunities for enjoyment and pleasure, without the
price of poor health and low income that comes with smoking.

46

Aims

ff To review progress
ff To develop a greater sense of the impact of smoking on the body
ff To build motivation by encouraging participants to think about the costs of smoking and

Session 3

Session 3
How smoking affects your body
Last session to incorporate new members

realise that change is important to their view of themselves and their future
Session content: Summary
Review
Discuss homework and give a reward for the longest list.
Discuss progress or setbacks experienced since the last session, plans to quit and realisations
about smoking patterns tie discussion in with topic of current session.
Break
Smoking and your body
Discuss negative impact of smoking on body.
Ask each group member to talk about how smoking will be affecting their own body.
Whats in cigarettes?
Set out a number of common products that include the chemicals found in cigarettes.
Pick each item up and pass it around the group, discussing the role of the chemical.
Discuss the contrast between participants desire to lead a happier, healthier life and the
negative impact of smoking.
Conclusion
Deep breathing exercise. Remind about Quitting Diary.

47

Facilitator notes
This is the first session to be heavily discussion-based while also emphasising the negative
consequences of smoking. This may be difficult for those who struggle to concentrate and you
could introduce the deep breathing exercise earlier in the session if concentration is waning.
Discussion of the negative effects of smoking may make some people feel stressed and
defensive, leading to coping strategies including smoking. Some may go blank in the Smoking
and your body discussion, dismiss the risks of smoking or feel hopeless about themselves and
quitting. Others may become frightened about their health status, so talk about the value of
involving the gp in their quit attempt. If anyone seems particularly concerned, follow up with
them after the group. If appropriate, express your concerns to their support worker.
The Whats in cigarettes? exercise uses concrete, everyday examples of chemicals to make
more real the poisons that smokers take into their bodies. Rather than an abstract discussion
with complicated chemical names, participants see and touch the chemicals they would
otherwise view as dangerous to ingest. There are also photos showing damage to different
parts of the body from smoking that you can get from Quit if you think this would be helpful.
Bringing out the negative aspects of smoking is a crucial part of the change process. Many
people struggle to move beyond the precontemplation stage because the emotional impact
of their destructive habits is continually denied or avoided, and yet this process is vital to
effective smoking reduction and cessation. Everyone who quits successfully will go through
this in some way. Your role as facilitator is to manage the process of facing the distress, fear
and anxiety that some may feel.
Preparation

ff Buy a range of healthy snacks and drinks.


ff Gather items for the Whats in a cigarette activity
ff If necessary, contact participants and remind them about the group.
On the day

ff Set up food table ready for the break.


ff Set up whiteboard, with markers and cleaner.
Bring

ff Food and drinks for break


ff SANE Factsheets in case needed to answer questions
ff Prize for homework competition
ff Items for Whats in cigarettes? activity:
m Rat poison (available from supermarkets)
m Paintstripper
m Toilet cleaner
m Nail polish remover
m Information and poster from Quit (or download information from websites).

48

Review
Introductions
This is the last session in which new members can be incorporated. If there are new people
present, start the review by asking participants to let the new person know what they have got
out of attending the group so far. Encourage any new people to speak about why they smoke
and their reasons to quit. Make sure that you give them a chance to feel involved in the group.
Feedback on strengths exercise
Ask participants to respond to the Strengths exercise from the previous session. You may
choose to give a prize to the person with the biggest list of things they like to do.

Session 3

Session content

Discussion
Move the discussion on to progress or setbacks experienced since the last group, plans to quit
and realisations about their smoking patterns.
Remember to use this part of the session to focus on group interaction and building a working
group, rather than a group that is dependent on the facilitator for change. Acknowledge
themes as they emerge and weave them into the exercises for the session. For example, John
may have experienced illnesses caused by smoking and Rachel is finding it hard to commit to
quitting because she feels the consequences are too far away. Ask John You went through a
stage when you didnt worry about the effects of smoking too, didnt you John? What do you
think of what Rachel is saying? John will usually be happy to let Rachel know that smoking did
hurt him and he regrets it.
Break
See session 1

Smoking and your body


Introduction
Start by making the connection between the program so far and this sessions topic.
The program has focused on a better understanding of how to change (by working out each
individuals pattern of addiction) and has been building motivation to change by focusing on
the strengths and supports participants have and how they can increase their opportunities
for enjoyment.
Session 3 will shift the focus onto the negative impact of smoking on participants
and on others.

49

Explain
You may wish to start this exercise with a presentation on the effects of smoking on the body.
Refer to the Quit website or Quitline for information. The main message here is that smoking is
one of the most damaging things that you can do to your body. Participants are often shocked
to know that smokers have a one in two chance of dying from a disease caused by their habit.
Even if it doesnt kill them, the ill-health and physical disability caused by smoking by far
outweighs any satisfaction.
Discussion
Ask each group member to talk about where in their body smoking affects them.

ff Many people feel that their lungs are profoundly affected. They notice that they cant walk
far without feeling breathless, or that inhaling deeply causes pain.

ff Some notice that smoking affects their digestion making them feel nauseous or affecting
bowel movements.

ff Others notice how it affects their thinking, sometimes sharpening it, at other times making
it difficult to focus.

ff Encourage telling of stories about friends and family members whose health has been
damaged by smoking (which may also include stories about the person who lived to a ripe
old age and smoked fifty cigarettes per day). Respond to this, with the idea of the genetic
lottery or Russian roulette. Remind them that a one in two chance of dying from smoking
is a far higher risk than playing the pokies or Tattslotto.
Activity: Whats in cigarettes?
This exercise explains how cigarettes cause damage to the body and brain.
Show and discuss the chemicals
What goes into a cigarette? As well as tobacco and cigarette paper, there are herbicides,
pesticides and other agricultural chemicals from growing tobacco, as well as chemicals added
when the cigarettes are made. When the cigarette is lit, these elements burn and produce
chemicals (around 4,000) that make up the smoke. Most of these chemicals come from
burning the tobacco itself. So whether you smoke ready-made cigarettes, roll your own, or
illegal tobacco (chop chop), the smoke still contains the same deadly chemicals from burning
tobacco.
Set out a number of common products that contain the chemicals found in cigarette smoke.
Include some toilet cleaner (ammonia), rat poison (Hydrogen cyanide), nail polish remover
(acetone), and paint stripper (benzene).
Pick each item up and hand it to participants to pass around, discussing the role of the
chemical. For example, open the bottle of floor cleaner and ask participants to carefully smell
the pungent odour, explaining that ammonia is added to cigarettes so your body can absorb
more nicotine making smoking more addictive. (Refer to the comprehensive list of chemicals
from your local Quit office and a Whats in cigarettes? poster if available).

50

Wrap up the session by highlighting comments made by participants that reflect their desire to
have a healthier happier life. Contrast these comments with the information from the session
that continuing smoking will only destroy their bodies.
Conclusion
Deep breathing exercise

Session 3

Discussion
Generate discussion about these chemicals, impressing upon participants the reality that they
ingest them frequently every day as smokers.

Lead a brief deep breathing exercise, explaining that participation is voluntary.

ff Ask all participants to stand and place their hands on their bellies.
ff Instruct them to breathe in through their noses to the count of three, feeling their bellies
swell with the air (rather than their chests).

ff Hold this breath for three seconds and then expel for another three through the nose. Make
sure that no one is too dizzy or breathless to stand and encourage people to do this at their
own pace.

ff Repeat the exercise twice.


ff Ask participants to feel the effect of the oxygen and to describe how they feel.
Explain that one of the benefits of quitting is becoming more conscious of how their bodies
feel. Another benefit of deep breathing is that it is a free, healthy way to get a brief high,
stimulate the body and mind, as well as relaxing it.
Encourage participants to reflect during the week on the impact of smoking on their bodies,
practice deep breathing and write or draw in their Quitting Diaries.

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52

Aims
ff To build confidence and encourage group connection

ff To assist with planning for change in smoking


ff To encourage participants to make a firm commitment to change
ff To learn and practise ways of refusing cigarettes
ff To provide hands-on experience with healthy food preparation

Session 4

Session 4
Being empowered: making a firm commitment to change

Session content: Summary


Review
Ask participants if they have noticed the effects of smoking on their bodies. Ensure that you
have had an opportunity to discuss nrt and mental health issues in detail by now.
Break
Make popcorn and fresh orange juice.
Saying No exercise
Ask for examples of situations in which participants find it difficult to resist smoking. Use the
whiteboard to list strategies to help resist having a cigarette. Ask someone to be a scribe,
writing down the list on a piece of paper to be photocopied and distributed at the end of the
session. Discuss body language.
Role play
Participants to pair up, one to practise offering cigarettes and the other to refuse. Warm the
Offerers up to being persistent in their efforts, not giving up easily. Warm the Refusers
up to effective communication, using body language and other strategies such as leaving if
necessary.
Conclusion
Contracts. Ask each person to complete a contract (Appendix 6).
Take them through the contract step by step.

53

Facilitator notes
Remember that your purpose in this session is to build people up to action, whether it is
quitting for good, a quit day or cutting down. A firm commitment to change is the next step
in the change process. Participants need to have some self-confidence to embark on any
course of action so this session aims to build confidence through practice (making healthy
snacks, saying no role plays) and preparation (contracts).
These new skills and self-confidence may be balanced by the emergence of negatives that the
change process brings out. For example people doing the Saying No exercise can experience
hopelessness, with some participants finding it hard to see their successes. Some participants
may already experience depression, whether as their primary diagnosis or in addition to other
symptoms.
As a facilitator, it can be difficult to resist the all or nothing thinking that comes from
working with people with depression. Persist with your emphasis on rewarding every success,
no matter how small.
Acknowledge that the presence of positives and negatives with participants is a normal part of
life. With every step forward there is something lost and something gained. Your role is to help
participants stay positive so that they can reach their goal.
Preparation

ff Check that the venue has somewhere to make popcorn and orange juice
ff Photocopy the contracts
ff If necessary, contact participants to remind them about session
On the day

ff Prepare kitchen ready for cooking (cutting boards and other equipment set up)
ff Set up whiteboard, markers etc
Bring

ff Contracts (Appendix 6)
ff Popping corn, oil, salt and large saucepan or microwave popcorn (if microwave available)
and a suitable serving bowl

ff A bag of oranges, knife, glasses and one or two hand-juicers


ff Whiteboard and markers
ff Pen and paper

54

Review
You may choose to let participants know about anyone who cant make it to the session.
Encourage them to phone or talk to the absent person (if they have agreed to be contacted),
to keep them involved in the group and to support their decision to cut down or quit. Doing
this values the presence of each group member, and sends a message to everyone that their
absence would be missed.
Discussion

Session 4

Session content

Ask participants for any comments following the last session. Did anyone notice how smoking
affects their body? For those who have quit or cut down, can they feel their body recovering a
little already? Did anyone try the deep breathing at home?
Remember that the Review part of the session is an excellent opportunity to check out and
address the information needs of group members. Make sure that you have had an opportunity
to discuss nrt and mental health issues in detail by now.
Break making snacks
Prepare the snacks together
Involve participants in preparing the snacks. Ask if anyone knows how to make popcorn and
encourage them to take charge of the process. Encourage others to watch and learn how to
make it. Meanwhile, ask for some volunteers to cut the oranges and squeeze them to make the
juice. Involve everyone in some way.
Discussion
When the preparation is finished, talk about why popcorn is a good snack for quitters (its
cheap, quick and easy to prepare, tasty and keeps hands busy). If prepared with minimal oil
it is has fewer calories. Similarly, emphasise the benefits of making orange juice (keeps you
busy, is a good source of vitamins, satisfies sugar cravings and tastes fantastic when freshly
made). Encourage participants to make some up and have it ready in the fridge for when they
wake in the morning. Rather than reaching for a cigarette, they can reach for a juice and start
the day in a healthy way.

55

Saying No exercise
Background
Everyone whos tried to quit knows about how hard it is to refuse cigarettes. They report an
inability to resist even the sight of cigarettes and some will have found a Smokefree Area sign
a prompt to smoke!
The experience of mental illness can make this susceptibility even greater. People with a
mental illness have experienced loss of control over their lives in many ways. The impact of
chronic illness along with involuntary hospitalisation, Community Treatment Orders and the
stigma still present in the community are some examples. For some participants, therefore,
developing the belief that they can choose to smoke or not may be quite a journey. Your role
as facilitator of this exercise may involve recognising even very small steps forward.
Introduction
Introduce this exercise with examples that will have inevitably arisen during discussions
thus far. For example, Scott may have left during sessions to smoke because the discussion
generated cravings or Mandy may have told the group that living with a smoking flatmate made
it impossible for her to quit.
Explain that strengthening your ability to say No is vital to becoming a non-smoker. Whether
a person is challenged by the very presence of a cigarette or teased by friends who would like
to see them fall from grace, each person will encounter temptation often on their smokefree
journey. Reassure them that it will become easier as time goes by, but initially much effort may
be required to resist temptation. This exercise will give them some tools to help them improve.
Brainstorm and discussion
Ask each participant for examples of situations in which they find it difficult to resist smoking.
From the examples identify whether the temptation is to do with people or situations. Generate
discussion and use the whiteboard to list the many different strategies a person could use to
resist the cigarette. Be particularly vigilant for any examples of good resistance displayed by
participants to use later in the exercise (see following examples).

ff Situation Flatmate smoking


m Talk to flatmate about smoking outside.
m Watch TV in own room.
m Say no to offers (use body language too).
m Leave the room when temptation gets too much.

ff Situation Out with friends


m Dont drink alcohol.
m Have some low fat nibbles ready to snack on.
m Play with keys, a straw, anything to keep hands busy.
m Dont socialise with smoking friends for a while.
m Leave early and have a good nights sleep.

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m Ring a friend/Smokefree group member/Smoking helpline/Support worker.


m Write a list of things to do.
m Go to a smokefree venue (for example, movies, library, inside a caf).
m Get some exercise: swim, run, go to a low cost gym.
Ask someone to be a scribe, neatly writing down the list on a piece of paper to be photocopied
and distributed at the end of the group.
Bring the discussion around to the issue of saying no and develop the components of body
language that help to getting the message across.

Session 4

ff Situation At home and bored

How to say No using Body language


Demonstrate how to convey assertive behaviour through eye contact, body contact, gesture
and tone of voice. A person can say one thing but communicate the opposite by incongruent
body language for example, by saying I am listening while facing away from the person
who is talking. To communicate effectively and assertively, the spoken message and the body
language need to match each other.
Body language includes a number of elements, including posture, personal space, facial
expression, eye contact and gesture. An assertive posture is relaxed, upright, open and
balanced. Being tense and erect will give the impression of being aggressive, while being
slumped and closed-in will give the impression of submission. Again demonstrate, using
exaggerated examples of poor posture and no eye contact while saying, No thanks, I dont
want a cigarette.
How to say No using Speech
Describe how speech may be divided into what is being said and how it is communicated.
Assertive statements are clear and concise. While what is being said is important, how it
is said is even more important. Being overly loud, threatening and interruptive suggests
aggression, whereas talking too softly, quietly or with too much hesitation suggests
submission. If the point is made with the right amount of feeling, the person is seen as being
assertive and is more likely to be regarded positively by the listener. Demonstrate this point by
emphasising the hesitant voice tone from the previous example.
Pull these points together by clearly stating the importance of body language, choice of words
and voice tone in helping both the refuser and the offerer to communicate the right message.
(Dont forget that assertiveness works even if the person is sitting alone in their room!
Practising saying No out loud or moving away from cigarettes helps to resist the temptation
to smoke.)

57

Role Play exercise


This is a fun exercise that will generate a lot of laughter and discussion.
Practice in pairs
Ask participants to pair up again, choosing one person to offer cigarettes and another
to refuse. Encourage the Offerers to be persistent, not giving up easily. Encourage the
Refusers to communicate effectively, using body language and other strategies, including
leaving if necessary. Ask them to play this out for a couple of minutes. Offer coaching to any
participants struggling with their role.
Whole group discussion
Ask participants to share their experiences with the whole group. Reinforce the assertiveness
message and be vigilant for any ways people find to refuse, such as using humour and
distraction.
Swap roles
Now ask participants to repeat the exercise with roles reversed. Dont forget to ask the
Offerers what their experience was like, as they will experience new insights as the Refuser
tries different strategies. This will also give the Refuser further insight into the effect of their
behaviour.
Wrap up
Wrap this exercise up with a general discussion about the value of practising the Refuser role.
Remind people that everything, even resisting cigarettes, gets easier with practise. Participants
may like to say No into the mirror each morning or wrap a no smoking symbol around their
cigarettes to remind them. They may also need to modify their refusals as they go along. For
example, while saying, No thanks, Im a non-smoker may work for offers in some situations,
offers from teasing friends may require a white lie to distract them, such as No, thanks. Im
still getting over the flu.

58

Contracts
Ask each person to complete a contract (Appendix 6). Emphasise that this is a personal
contract to help them form their own goals. Take them through the wording, step by step.
First, ask them to identify one or two manageable goals to be completed before the next
session. Examples include: cut down by five cigarettes a day, handle a trigger situation
without smoking or have a quit day. Once this is complete, ask them to rate the likelihood of
completing the goal on the scale, explaining that 0% is completely unlikely and that 100% is
completely achievable. Ensure that each persons goal is at least 65% achievable. This rating
means that the goal involves sufficient challenge without being unrealistic. Amend any goals
that are much higher or lower than this.

Session 4

Conclusion

Witness and photocopy each contract. Participants may wish to engage a support person to
fulfil the contract, in which case, a copy can be given to them as well.
You may need to work closely with some people in this exercise as planning abilities are often
affected by the symptoms of mental illness.

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60

Aims

ff To follow up contracts
ff To explore participants perceptions of stress and develop new ways of dealing with it
ff To encourage alternative, healthy ways of dealing with negative feelings.

Session 5

Session 5
Dealing with stress and strong negative feelings

Session content: Summary


Review
Follow up contracts.
Note successes and opportunities for learning.
Stress and smoking
Discuss the role of stress as a cause of relapse. Define stress and discuss stress management
techniques used by participants. Hand out Appendix 7 and ask participants to add to the list
those ideas that appeal to them. Encourage participants to develop their stress management
abilities outside the group.
Break
Introduce the idea of eating seasonal foods, such as soup in winter or seasonal fruits
in summer.
Smoking and strong negative feelings
Ask participants for examples of smoking when feeling bored, angry or anxious (for example).
Write on the whiteboard under the following headings: Physical sensations, Thoughts,
Feelings, Actions.
Encourage discussion among participants about how quitting may exacerbate these feelings as
well as ways to handle them. Hand out strategy sheet (Appendix 10).
A Strategy: Identifying faulty beliefs and promoting positive thinking
Explore faulty thinking and positive thinking and other ways of dealing with feelings
using handouts.
Conclusion
Ask the group to practise becoming aware of negative thoughts and replacing with positive
thoughts before the next session. Write ideas in quitting diary.

61

Facilitator notes
The material in this session was originally spread over three sessions. If you find the activities
too much to get through you can complete the content at the next session. These original three
sessions (Session 5a, 5b and 5c) are available later in the kit if you are able to run the group
over 10 weeks instead of 8.
Encouraging support from within the group
Successful behaviour changers seek out and use various forms of support to help them to
change. Improving social networks and using the group for support is a fundamental principle
that underpins this group program so encourage helpful interaction.
The stress management exercise is designed to prompt further work outside the group.
Be clear in your role as information giver and motivator, rather than solver of problems.
Sometimes participants raise significant life stressors and emotions in this session, such as a
relationship breakdown and housing problems, which can challenge your role as a facilitator
of a quit smoking group. Resist the urge to become involved in solving these stressors as this
goes beyond the boundaries of the group program. However, this doesnt mean abandoning
the person. You are offering the proven tool of positive thinking and handouts that people
can work through. Also you can engage other group members in a supportive role. With
agreement you can engage the persons support worker or discuss the issues impact on the
persons quitting in private, outside the group.
Dealing with strong feelings
Research indicates that people whose smoking is most heavily associated with dealing with
negative feelings, need the most support to quit smoking. Therefore this session dealing with
negative feelings is an important and challenging one.
Grief is a feeling that often comes to the fore as people quit smoking. This can relate to their
feeling that they are losing an unconditionally supportive friend (smoking has always been
there in hard times) as well as bringing up some of the loss associated with developing a
chronic illness. Despite the fact that smoking is a very conditionally supportive friend, only
challenge this gently and if required. The most important work of the facilitator here is to let
people express the connection with their feelings and to feel accepted by the facilitator and the
group. Empathic listening skills help. It also helps to assist people to make the link to smoking
themselves. For example It sounds like you find it hard to let go of the support of smoking, as
you feel you have lost so much since you became unwell.
That said, this does not have to be a heavy session. It can vary from a light, cathartic exercise
to the introduction of profound new ideas for participants.

62

For any participants struggling to make changes, introduce some strategies for reducing the
pleasure of smoking. For example, only buying a brand of cigarettes that they dont like such
as menthol or low tar; holding the cigarette awkwardly such as between the second and third
fingers; or keeping a jar with wet cigarette butts handy and smelling it before smoking. Remind
the person to carry around a list of reasons why they want to quit smoking and assist them to
focus on the benefits of changing.
Rewards for progress

Session 5

Reducing the pleasure from smoking

For those participants who are making tangible progress, ask them how they are rewarding
themselves. Encourage those who have long-term rewards planned to also insert some small,
immediate rewards to help them on their way.
Changing to a looser group process
If you have the confidence, then you could allow the discussion to produce the work for the
session. Doing this hands over the work of change to the participants and they will help each
other if you step back. Even if you choose to continue with the set program, do so in a less
directive manner than in the earlier sessions if possible.
Review
Keep the review to between 20-30 minutes in this session so that there is plenty of time to
get through all the material. Let participants know at the start that this session is different as
there is a bit more information to get through.
Prepare for this session by having information and support on stress management and dealing
with strong emotions available in the local area so that people can follow up opportunities for
themselves.
The food preparation activities for the break offer practical and enjoyable ways to alleviate
boredom and promote healthy eating.
Preparation

ff Find out about stress management activities in the area through community health centres
and local newspapers.

ff Get referral options ready for dealing with feelings (for example, information on courses in
the local area and phone number for Lifeline, 13 11 14).

ff If necessary contact participants to remind them about session.


ff Decide on the seasonal food for session break and purchase.

63

On the day

ff Prepare equipment for food preparation (for example, soup-pot, platter for summer fruits).
ff Set up room and food table ready for break.
Bring

ff Handouts: Appendixes 7-10 and 14


ff Pens and small paper for those who have forgotten their Quitting Diaries.
ff Referral information.

Session content
Review
Follow-up on contracts and progress
Ask each person to comment on their experience with the contracts so far. Allow about 2025 minutes. Note any successes as well as opportunities for learning. For example, Tim may
have planned to cut down by ten cigarettes a day but had a couple of days when he felt very
depressed and actually smoked more. This led to him giving up on the contract. Respond by
acknowledging the days in which he did meet his goal and asking Tim to acknowledge that
success. Then move on to raising awareness about unexpected challenges and encouraging
group support and ideas.
Explain
Repeat the idea that each person attends the group program because, to some degree, they
find that the presence of other people is helpful when they are trying to learn something new.
Knowing this about themselves may come in handy when they face challenges to their quitting
efforts. For example, in the future should some stressful event arise and they are tempted
to smoke, then having the phone number of a helpful person available may avert a return to
smoking.
Stress and smoking
Explain
Explain that one of the major causes of relapse is stress. Relate this to examples given by
participants so far. Normalise their experience and explain that this is one of the great
challenges to successful long-term quitting. This session will briefly introduce some ideas
about handling stress, but the aim is for participants to devote some time outside the group
to improving their ability to handle it without smoking. This may include doing a stress
management course at a day program or community centre, reading books on the topic or
talking to their support worker.

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Explain that stress occurs when the body responds to changes in the external or internal
environment that are perceived as demands. It consists of:

ff the stressor, the change or demand. For example, a atmate asks for money.
ff how this stressor is perceived. For example, you feel this is yet another pressure that you
dont need.

Session 4

Dening stress
Hand out Appendix 7, ask participants to list what stresses them, and discuss what stress
actually means.

ff The stress response in the body and mind. For example, thinking about all the stress in
your life, heart beats faster and mouth goes dry leading to having a cigarette to calm
down.
Brainstorm examples from group members
Fit stress examples given by participants into these three categories.
Explain that stress arises when there is an imbalance between the persons coping capacity
and the stressors encountered. Stress can be reduced by:

ff decreasing the sources of stress


ff learning coping strategies to deal with the stress.
Ask group members to brainstorm ways of managing stress that they already know of or have
tried. Write these on the whiteboard. Include some of your own if necessary to ensure that
there are plenty of stress management ideas on the board. (Appendix 7 has examples).
Have handouts and information on local stress management opportunities on a table for
participants to look at and follow-up on.
Discussion
Encourage discussion about what has worked and why, as well as what doesnt work and why.
Many people try a new idea once and call it hopeless if it doesnt work. The idea of practise
can be raised here. Remind them that they didnt become a 30-cigarettes-a-day smoker
overnight, they built up to it. Equally, using meditation or ringing a helpline may require a
number of tries before it really feels comfortable.
Break
Use seasonal foods that the group can share, as a way of giving the Break variety for
example, bring homemade fruit juice icy poles to the group on a hot day. Many people find that
ice is a good craving killer, so this idea also has practical application.
In winter, a quick easy snack can be a home-made soup. This is a good substitute drink to
minimise caffeine intake.

65

Strong negative thoughts and feelings


Explain
Most people start smoking in early adolescence and this can affect how they learn to cope
with feelings. Smoking is such an addictive habit that it quickly becomes associated with most
daily experiences. As adolescence is an emotionally charged time when people are learning
adult responses, the power of the habit of dealing with feelings through smoking is substantial.
Brainstorm
Ask participants if they have ever smoked because they are bored, angry or anxious.
(Normalise this by informing participants that these are very common experiences for
smokers.) Allow discussion to emerge about their experience of boredom, anger and anxiety.
Ask participants to define the feelings that they raise. Fit the definitions into the following
categories on the whiteboard. For example:
Sensation/Emotion

Thoughts

Anger
Churning stomach I hate the way . .

Feelings

Actions

Enraged

Withdraw and smoke

Boredom
Agitated

Nothing to do again Frustrated

Smoke

Anxious
Palpitations

Racing thoughts

Smoke to keep hands occupied

Nervous

Discussion
Ask participants if they are experiencing these feelings and thoughts more or differently as
they go through the quitting process.
Again, normalise those recovery symptoms that result from nicotine leaving the body. Remind
participants that the amount of nicotine in the body drops by half after only two hours, and
that some irritability is the result of the body trying to restore the chemical balance it has
been used to. As time goes on however, those feelings of irritability are more the result of the
psychological experience of quitting, such as awkwardness at learning new habits and grief
and anger as you let go of old habits. Encourage discussion among the group about peoples
experience of feelings, just allowing issues to emerge.

66

Explain
Using Appendix 9 go through the examples of faulty beliefs
(for example, Black and White thinking).
Discuss
Can anyone identify with these and give examples?
Explain
Move fairly quickly onto the second part of Appendix 9 Positive thoughts. Explain that
although positive thinking seems like an overly simplistic approach to a complex issue like
quitting smoking, it has been shown to work.

Session 5

A Strategy: Identifying faulty beliefs and promoting positive thinking

Discuss
Can anyone give other examples of how to turn around Faulty thinking?
Explain
Hand out the Strategy sheet (Appendix 10). The strategies are only suggestions and more
substantial supports may be needed. Remind participants about Lifeline and other telephone
counselling agencies, along with their existing support network.

Conclusion
Ask participants to spend the time before the next session becoming aware of negative
thoughts they have about themselves and quitting smoking. Ask them to practise their positive
thoughts whenever possible. They can write ideas in their quitting diaries or place a reminder
beside their beds for when they wake up.

67

68

Aims
ff To motivate participants to engage in more exercise

ff To encourage healthy eating habits


ff To explore obstacles to a healthy lifestyle
ff To encourage group connection.

Session 6

Session 6
Fit and well

Session content: Summary


Review
Draw a chart on the whiteboard to show the groups progress.
Break
Try walking during the break and instead have the snacks during second half of the session.
Healthy living physical activity
Discuss the value of exercising and list benefits on whiteboard. Place brochures promoting
activity programs around the room, ask participants to choose those that interest them and
discuss why. Talk about obstacles to participation.
A Healthy Weight
Brainstorm what people know already and talk about the challenges around maintaining
a healthy weight for people affected by mental illness. Hand out information and address
concerns about weight gain.
Conclusion
Preparatory discussion about the end of the program.

69

Facilitator notes
We now have greatly increased knowledge about the strong links between mental illness and
physical health. Some medication greatly increases the risk of obesity and associated type 2
diabetes and cardiovascular disease. Add this to smoking and many people are struggling with
major physical illness as well as on-going mental illness. (For more information see the SANE
Guide to Healthy Living and SANE Factsheet 35 Mind and Body: Looking after your physical health when
you have a mental illness.)
This session focuses on healthier alternatives to smoking physical activity and healthy
eating. The role of physical activity in quitting and improving mental health cannot be overemphasised. Having a healthier lifestyle also provides distraction and an alternative activity to
smoking as well as building a healthier body. Less time is spent on healthy eating as this has
been covered in a small way each week through healthy snacking at breaks.
Bring your ingenuity and enthusiasm to planning and delivering this session. This doesnt mean
that you have to be a model of fitness yourself as you have helpful resources around you.
Someone from the group or the wider service may have emerged as a role model and be happy
to talk about their experiences. There are also local experts who may be able to come and
talk to the group a physiotherapist or personal trainer who works with people with mental
illness.

ff The SANE Guide to Healthy Living contains useful information and tips on ways to change to a
healthier lifestyle. There are also simple language resources on the healthy eating pyramid
available from public health centres.
Preparation

ff Choose some new snack foods and buy.


ff Photocopy Appendix 11.
ff Collect brochures from local exercise programs and pamphlets on the healthy eating
pyramid and Australian Guide to Healthy Eating from www.healthyeatingclub.com.

ff If necessary, contact participants to remind them about session.


On the day

ff Set up the food table so that people can help themselves during the second half of
the session.

ff Set up whiteboard, markers and cleaner. etc.


Bring

ff New foods
ff Whiteboard and markers
ff Brochures and pamphlets
ff Appendix 11 A Healthy Weight

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Review
Discuss
Encourage discussion among participants about their progress and any obstacles that they are
encountering. Reiterate what has been learned from previous sessions as obstacles to quitting
are discussed.
Use the whiteboard
For those who are still smoking, it is important that you focus on assisting them to view their
progress positively. Draw a graph on the whiteboard to show them how much they have cut
down for example. Or draw a road on the whiteboard and asking them to describe the major
signposts and turning points on their journey. For example, they may have joined the group
when smoking 40 cigarettes per day. Along the way they have realised that dealing with
boredom is their major obstacle, so this realisation is a turning point. They may have made
some enquiries about an activity group at the centre that interests them, so this is another
signpost. At one group they mentioned that they stopped smoking inside the house, and at
another they talked about making popcorn at home one day. In addition, they have cut down

Session 6

Session content

to 20 cigarettes a day and they notice that they can breathe easier and have a little money left
over at the end of the week.
By teasing this out and presenting it visually, success is more obvious. Involving the whole
group in this exercise helps other group members to reframe their experience and helps the
group member to feel the support of the group in their struggles. The road analogy shifts the
emphasis from quitting as an event to quitting as a process which takes time and learning.
Break
Go for a short walk with the group during the break today, and then have the snacks to share
during the second half of the session.
Have some new healthy snacks available and write down or explain exactly how they can help
with quitting. For example, if mandarins are in season, they are excellent for sugar cravings
and keep hands busy. Offer decaffeinated coffee and tea, and hot chocolate (with low-fat
milk) as an alternative to coffee. For people who drink a lot of soft drinks have some no-sugar
varieties for people to try. Chilled water with some slices of lemon or strawberries is delicious
and cheap.

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Healthy living physical activity


Discussion
Following the exercise break ask the participants to notice any changes in how their body
feels. Some may also notice that the exercise changed their mental or emotional state as well.
Draw out group members who are more active. This person may be happy to be an advisor to
the rest of the group about simple exercise ideas or groups that are available in the area.
Explain
Research indicates that those people who increase their exercise levels may be more successful
at staying a non-smoker, than those who are less active when quitting. Exercise may also help
reduce withdrawal symptoms and cravings. It is important, therefore, to emphasise the value
of physical activity.
Brainstorm
Ask the group to brainstorm the benefits of exercise. Make sure you include the following
benefits:

ff Distraction from cravings


ff Weight management
ff Improves general mood
ff Provides social contact
ff It is very rewarding when you set goals and reach them
ff Provides structure in the day
ff Improves how you view yourself
ff Improves sleep
ff Provides a period of time out from other life pressures
ff Reduces anxiety
ff Promotes relaxation
ff Relieves boredom.
Activity
Display some brochures promoting exercise programs and groups offered locally. Spread them
out so that participants must move around the room to see what is on offer. Ask them to
choose any activity that appeals to them.
Then ask them to come back to their seats and discuss with the person next to them, what
they like about the activity. What is the likelihood of them actually taking it up in the near
future? What are obstacles that might prevent them?

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Speaker
You may choose to have a speaker about healthy activity with time for questions and
answers instead of or as well as the discussion and activities above. Still have the local group
information available.

Session 6

Discussion
Bring this discussion back to the whole group and encourage the group members to share
what they have been talking about. This is a chance for group members to hear who in
the group is interested in the same activities as they are. Encourage the group to address
obstacles. For example, Sam may feel shy about attending community activities because of
his mental illness. Another group member may offer to go along with Sam, or suggest that he
ask his support worker for help. Others may know that the activity is offered by a specialist
recreation program.

A Healthy Weight
Explain
Give some information about the challenge of maintaining a healthy weight when you are on
some medications. Emphasise the importance of regular visits to the doctor for physical health
testing. But also emphasise that there is a lot people can do themselves to be physically well
including physical activity and healthy eating. It sounds easy but can be extremely challenging
for anyone, and especially for people who are giving up smoking and living with a mental
illness.
Brainstorm
Brainstorm what group members know about healthy eating. Then give out a basic information
pamphlet about the healthy food pyramid.
Then ask:

ff what are the barriers things that make it hard for us to eat healthily?
ff what helps with healthy eating?
Address any concerns about weight gain with information and referral. Hand out and go
through Appendix 11 A Healthy Weight and answer any questions.

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Conclusion
Encourage group members to identify one or two achievable goals around healthy eating or
physical activity and write them in their quitting diary. Remind them that physical activity in
particular is a great distraction from cravings.
Also remind participants that the program is coming to an end soon. You could ask
participants to reflect on issues that remain unresolved about reducing or quitting, so that
they can be covered in the final sessions. Discussing the conclusion of the program prepares
participants for the end of this form of group support and gives them an opportunity to talk
about it. Sometimes participants want further support, and ideas for this can be generated,
such as a follow-up session some weeks later, an informal support group, the opportunity to
participate in smoking cessation programs later in the year or support from friends or health
professionals.

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Aims
ff To address unresolved issues for participants

ff To encourage group connection


ff To prevent relapse by identifying high-risk situations
ff To review coping strategies for dealing with these situations
ff To move towards ending the program.

Session 7

Session 7
Planning for high-risk situations

Session content: Summary


Review
Prepare for the end of the program by discussing progress so far, and issues still to be
resolved. Adapt the session to meet unresolved issues if necessary.
Break
High Risk Situations
List the main reasons for relapse, including downers, having arguments and social pressure.
Ask participants to describe their most tempting situation. Ask the group to brainstorm coping
strategies. Write these on the whiteboard.
Dealing with slip-ups
Divide the group into pairs one person to role-play someone who has quit for a couple of
days and then just had a cigarette; the other to offer suggestions and support. Reverse roles.
Discuss the exercise by linking it with peoples past experiences of slip-ups.
Conclusion
Talk about the final session.

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Facilitator notes
This session focuses on relapse prevention, encouraging participants to think ahead about
situations that may challenge them and to plan for them. This can be challenging for people
with a mental illness where psychiatric disability can affect the ability to plan and followthrough. A slip-up is defined as a cigarette or two or a few puffs. A relapse is where a slip-up
becomes a return to full-time smoking.
You may encounter what seems to be resistance. This can be in the form of not being
interested in the topic, having no ideas about what will undermine their quitting, or even
unrealistic confidence about their abilities to cut down or stay quit. This can be addressed by
working with those participants who can generate ideas and, using your memory of situations
raised by participants in past sessions, to remind them of potential high risk situations. Dont
let any resistance undermine your confidence in the material. Equally, dont become a prophet
of doom in an attempt to get people thinking about possible challenges ahead if they are
generally very positive.
If obstacles are presented as being insurmountable and quitting or cutting down seems
impossible for some participants, it is appropriate to build self-efficacy and continue to work
on tipping the balance towards making the change. As noted in earlier sessions, developing
personal confidence can be a lifetimes work, however you can assist by encouraging the group
to reflect on their progress so far and encourage them to reward the steps they take towards
success. Reinforce the benefits of change by asking again how much money has been saved,
how long they have maintained change, what physical benefits have they noticed, whether
family or friends been pleased about the change and many other indicators.
Some participants may also fear the loss of support from the program, so problems become
more pronounced as it is about to end. Hopefully your work in building group connection will
enable ongoing supports and friendship to create a transition. The next session will focus
on life after the group. If you have particular concerns about the wellbeing of a participant,
discuss this with them and their support worker as appropriate.

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ff Buy a range of healthy snacks and drinks


ff Photocopy Appendix 12 (Things to do when you really want to smoke)
ff If necessary contact participants to remind them about session
On the day

ff Set up food table ready for break


ff Set up whiteboard, markers and cleaner

Session 7

Preparation

Bring

ff Appendix 12
ff Whiteboard, markers, cleaner
ff Paper and pens for those who have forgotten their Quitting Diaries

Session Content
Review
Introduce the review session by acknowledging that the program is almost over. Ask
participants to discuss their progress and any areas that they would still like to cover, or
problems or doubts that have arisen. Remember to involve participants as much as possible
in the offering of support and solutions. Ask if they have removed reminders to smoke in
their homes and cars, for example. While some participants feel safer if they keep cigarettes
in the house, most people benefit from removing all ashtrays and any last cigarettes from
temptation. Encourage participants to spring clean the house, wash clothes to remove the
smell of smoke, and even have their teeth cleaned at the dentist helping to build their new
identity as a non-smoker.
Adapt the session
The material used so far may be helpful to address any on-going issues raised and if required
adapt the session to review and extend previous material. For example, if the group decides
that it would like to address the topic of stress again, then revisit the stress session, rather
than covering high risk situations. Work to build confidence and emphasise the benefits of
changing. This can be done by generating group discussion about the advances made so far
and participants responses to those advances. Participants may need some coaching in feeling
good about their progress. You could ask them to turn to the person seated next to them and
acknowledge the other persons advances, shaking their hand or patting them on the back.
The purpose of this is to help the person build on their resources to reduce the impact of any
incoming stressors.
Break

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High-risk situations
Explain
Dene high-risk situations broadly, that is, any situations which pose a threat to the
participants sense of control and which increases the risk of relapse into smoking. Emphasise
the importance of identication and planning for the high-risk situations, as without the
appropriate coping skills, the most common response is a slip-up or, more probably, a relapse
into smoking.
Brainstorm
Use participants past experiences with slip-ups and relapse to create a list of situations and
strategies for coping on the whiteboard under the following categories:

ff Negative feelings and thoughts


ff Conict with others
ff Social pressure
Hand out the Things to do sheet (Appendix 12) and ask for suggestions of strategies such as
those below, writing these up on the whiteboard.
Negative feelings and thoughts

ff Identify reasons for feeling low


ff Positive thinking or statements
ff See friends or other supporters
ff Treat yourself
Conict with others

ff Get away from the situation


ff Change from how you usually deal with conflict
ff Be assertive
Social pressure

ff Avoid situations where other people smoke


ff Plan ahead so you know what you are gong to do when you feel pressure
ff Just say No
ff Enlist help from friends
ff Practise ways of coping

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Explain
The aim of this section is to explore participants coping responses if a slip-up occurs. The
pattern of thinking following a slip-up is an important inuence on whether or not the person
will proceed to a full-blown relapse. For example, a person who has quit may consider the
whole attempt to be ruined by having just one cigarette, and simply give up and relapse
altogether. To decrease the probability of relapse, slip-ups should be presented as part of the
normal process of quitting and as opportunities for learning about high-risk situations.

Session 7

Dealing with slip-ups

Activity
Divide the group into pairs and ask one person to play someone who has quit for a couple of
days and has just had a cigarette. The other person is to offer support and helpful suggestions.
It is important to encourage participants to talk learn how to talk this way to themselves, to
use in the event of a slip-up. After a few minutes, roles should be reversed.
Discussion
Based on information exchanged between participants in this exercise, write on the
whiteboard steps to take if a slip-up occurs, such as:

ff Stop and take a deep breath


ff Keep calm
ff Review your reasons for quitting
ff Review the situation leading up to the slip-up
ff Make an immediate plan of action for recovery
ff Ask for support.
Each participant should use their Quitting Diaries or be given paper so that they can record
their preferred strategies from the whiteboard.
Conclusion
Tell participants that the next session will be a celebration of the Smokefree program and that
we usually share some celebratory food and drinks. Ask if any participants would like to bring
something to share, preferably with an emphasis on healthy snacks, although all offers are
welcome.

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Aims

ff To review progress
ff To confirm participants decision to cut down or quit smoking
ff To plan for the future
ff To celebrate!

Session 8

Session 8
Celebrating the journey

Session content: Summary


Review
Hand out a piece of paper to each participant and have some drawing materials available, such
as textas, pencils or paints. Draw a winding road on the whiteboard and set signposts along
the way. Ask participants to fill in the signposts (as per exercise in Session 6). Finally, set a
signpost six months ahead and ask participants to imagine themselves in the future.
Remind group about referrals from past sessions and ongoing support options.
Celebration
Bring out food and drinks to share. During the general chat this could be a good time to
talk more about when smoking first became common in Australia and how things are now,
reflecting on the changes in society.
Presentation
Give certificates (Appendix 13) and possibly a small gift.
Evaluation
Ask everyone to fill in an evaluation form or to give you verbal feedback.
This will be useful information for your next group.

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Facilitator notes
This session focuses on the awareness that society is changing to being more smokefree
and that this supports each person as they become smokefree and lead a healthier, more
independent life. The session also encourages participants to recognise the journey involved
in this program and the changes in their lives. This diffuses the self-criticism that can follow
not achieving ones initial goals, and also helps build up a sense of the progress made
regardless of what has so far been achieved. The emphasis on celebration is vital to reinforce
the development of self-efficacy and allows participants to further develop persistence,
appreciation of themselves and a love of life.
Deciding on whether you use the certificates or a card and gift will reflect your own personal
style, time constraints and how many groups you have run. The certificates are less time
intensive, while the card and gift requires more personal effort. It takes time and insight to
think about what is unique about each person and reflect that symbolically, but this will be
worthwhile. If you have people who have attended more than one course, you may also like to
vary your options.
Congratulations on having facilitated seven sessions . . . You have been an important catalyst,
motivator and facilitator through one of the hardest changes that people make. Think about
how you have been successful in this task. Did you:

ff assist participants to move forward in the Stages of Change?


ff facilitate friendships between participants outside the group?
ff encourage awareness about feelings and how people can deal with them?
ff assist participants to eat well and/or be more physically active?
ff assist participants to connect with their bodies?
ff help to build confidence?
ff increase knowledge about smoking?
ff use the group process to help someone quit or cut down?
ff help someone to realise that now is not the right time to take action?
There is an evaluation form in the appendixes that you may choose to modify and use with
participants. If you would like to do more thorough evaluation of the program, you could
obtain copies of the Fagerstrom questionnaire, a measure of addiction, from http://www.
tobaccoinaustralia.org.au/chapter-6-addiction/6-5measures-of-dependence, or you can
develop your own way of measuring movement through the Stages of Change. If participants
agree you may wish to compare carbon monoxide levels from the beginning of the program
using a Smokelyser machine. (Please note that these machines can be unreliable.)

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Remember that this is important work that you are doing. It fits in well with recovery and
wellness planning and offers people greater quality of life. People who experience mental
illness are entitled to lead happier and healthier lives. Keep up the good work and dont forget
to spread the smokefree word in your workplace and among your peers.

Session 8

There are many other markers of success that you may also notice. Being vigilant to each and
every one of them can help you to put your work in perspective. While quitting rates for a
group program are between twenty and twenty-five per cent, it can at times feel like there is
little success for a lot of hard work. Offering a number of courses each year can assist people
to move towards their goal more quickly and will create a climate of change in your work
environment. As you promote the smokefree course and message, then smoking becomes less
a part of the psychiatric culture.

Preparation

ff Buy party food (mostly low fat and low sugar).


ff Obtain butchers paper and art materials.
ff Prepare a certificate (and possibly card or small gift) for each participant.
ff Contact participants to remind them to bring food for the celebration.
On the day

ff Set up the food table ready for break.


Bring

ff Butchers paper and art materials


ff Whiteboard and markers
ff Certificates and/or card and gift
ff Party food

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Session content
Review
Explain
Hand out a piece of paper to each participant and have some drawing materials available, such
as textas, pencils or paints.
Explain that in todays review, each person is going to look at their journey since the beginning
of the group. (Remember to reassure participants that drawing skill is not necessary for this
activity). Draw a winding road on the whiteboard and set a signpost at the beginning. Ask
participants to think back to the first session (or even when enquiring about the program)
and how they felt. Talk about your own hopes for everyone on the program. Participants may
relate to the feeling of high hopes and expectations. Place some words to that effect in the
signpost.
Activity
Ask participants to draw their own picture and to fill in some signposts and turning points
along the way. If necessary coach them with examples, remembering comments and
realisations from the sessions, along with significant events, like cutting down smoking by half
or having a quit day. Ask them to complete the signpost for the end of the group. Finally, ask
participants to imagine themselves in six months time. Place this imagined signpost out in the
distance. Allow enough time for all participants to complete their drawing and assist anyone
who is struggling to remember. Generate a group discussion on the drawings and what they
mean.
Remind about potential supports and referrals covered in previous sessions for those who want
ongoing support. These include:

ff your doctor
ff other participants in the program
ff yourself (if appropriate and available)
ff Quitline (Check out what specific support is offered to people with a mental illness in your
State or Territory on 13 quit (13 7848)

ff support worker or case manager


ff Lifeline and other telephone counselling services
ff community health centres
ff your pharmacist.
Encourage participants to keep the relevant contact details handy, and remind them that if
they dont get the help they need the first time they ask they need to keep asking.

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Rather than having a break, bring the snacks and drinks into the group. Make them festive,
while maintaining the low fat, low-cost options. Healthy cakes and low fat biscuits or a well
decorated fruit platter could be served.
Discuss
Start a remember when discussion about the changes in society since participants started
smoking. For example, people will remember being able to smoke on trains, how cheap
cigarettes were, advertisements for smoking and feeling one of the crowd as a smoker.
The discussion will naturally swing forward to the environment now - the increasing cost of
cigarettes, the lack of smoking facilities and growing social taboo of smoking. Discuss the
benefits of quitting to participants in terms of their social lives, their health and their wealth.

Session 8

Celebrate with food

Evaluation forms
Ask everyone to fill in the evaluation form (in the appendixes) or write down peoples verbal
feedback if they would prefer. Explain that any feedback, positive or negative, will help with
planning the next group.
Conclude with recognition of group members
Complete the program with some recognition of each participants contribution and progress.
This can be done in a couple of ways. Use the certificate to acknowledge goals achieved and
progress made (Appendix 13). When handing out the certificates, tell each participant what
you have enjoyed about their presence in the group.
Alternatively, write out a Bon Voyage card for each participant. Acknowledge what you
liked about the persons presence in the group. You may choose to include a small symbolic
gift that indicates the work they have done, or still need to do on their smokefree journey.
For example, a person who struggles to quit may also have talked about their struggles
with mental illness. This type of person may have a strong free spirit that is challenged by
constraints . A suitable gift for this person could be a butterfly as a symbol of that spirit.
Another person may have difficulties nurturing themselves, so a gift of a seedling or small
plant could be symbolic of their emerging identity as a non-smoker, something that requires
care and attention to grow.

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Optional expansion of Session 5 into three sessions


Session 5a
Dealing with stress and helping relationships
Aims
ff To follow up contracts

ff To explore and consolidate helping relationships


ff To explore participants perceptions of stress
ff To develop new ways of dealing with stress
Session content: Summary
Review
Follow up contracts
Note successes and opportunities for learning.
Break
Trust Exercise
Ask the group to form pairs and for one person to be the blind person, with the use of a
blindfold, and the other to be their guide. The blind person is to close their eyes and allow
themselves to be led around by the guide. The guide should take them by the arm (or however
is comfortable) and gently lead them around the room. Discuss, then ask participants to
reverse roles. Emphasise the value of helping relationships built on trust in quitting smoking.
Stress and smoking
Discuss the role of stress as a cause of relapse. Define stress and discuss stress management
techniques used by participants. Hand out Appendix 7 and ask participants to add to the list
those ideas that appeal to them. Encourage participants to develop their stress management
abilities outside the group.
Conclusion
Deep breathing exercise.

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The trust exercise can be tricky for those participants who struggle with boundaries or who
lack maturity. Your role is to be supportive, containing and vigilant to all participants. Nip in
the bud any inappropriate behaviour, such as guides leaving their partners stranded or moving
too quickly. This exercise can be a real challenge and impart some good learning, even if it is
uncomfortable at times. Remember that the exercise is not compulsory and some people may
benefit most by watching others.
The stress management exercise is designed to prompt further work outside the group.
Be clear in your role as information giver and motivator, rather than solver of problems.
Encourage other group members to offer support. Sometimes participants raise significant
life stressors in this session, such as a relationship breakdown and housing problems, which
can challenge you beyond your role as a facilitator of a quit smoking group. Resist the urge to
become involved in solving these stressors as this goes beyond the boundaries of the group
program. However, this doesnt mean abandoning the person. You could engage other group
members in a supportive role, engage the persons support worker or discuss the issues
impact on the persons quitting in private, outside the group.

Session 5 options

Facilitator notes
This session draws on the fact that successful behaviour changers seek out and use
various forms of support to help them to change. The exercise and discussion on trust
assists participants to experience and understand effective support as well as be able to
recognise what is not helpful. Improving social networks and using the group for support is
a fundamental principle that underpins this group program. Participants also learn to adopt
healthier smokefree alternatives to stress management than smoking. In the next two sessions
healthier alternatives to smoking are also explored in the context of feelings.

If you do not have any experience with teaching stress management, draw on the support of a
colleague or community health centre worker or read further on the matter before you run the
session. Have current information available on stress management opportunities in the local
area. This is important to provide for participants following up on new ideas generated by this
session. Be aware of the range of ways in which stress can be reduced, including exercise,
spending time with friends and family, religious faith or spirituality, humour, art or music.
Preparation

ff Find out about stress management activities in the area through community health centres
and local newspapers.

ff If necessary contact participants to remind them about session.


ff Bring a range of healthy snacks and drinks.
On the day

ff Set up food table ready for break.


ff Set up whiteboard, markers and cleaner.

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Bring

ff The information on stress management programs in the local area


ff Appendix 7 Dealing with stress
ff Pens for adding to stress management ideas

Session content
Review
Ask each person to comment on their experience with the contracts. Note any successes as
well as opportunities for learning. For example, Tim may have planned to cut down by ten
cigarettes a day but had a couple of days when he felt very depressed and actually smoked
more. This led to him giving up on the contract. Respond by acknowledging the days in which
he did meet his goal and asking Tim to acknowledge that success too.
Unexpected challenges
Then move on to raising awareness about unexpected challenges. This course is designed to
provide the support through those unexpected challenges, so that quitting can ultimately be
more successful. Now that Tim knows that depressed days make his job harder, he can plan for
that challenge.
Mini-Brainstorms
Work through the group, with a series of mini-brainstorms to help each person develop
strategies. Ask for any ideas from the group about ways to handle bad days better. Keep the
brainstorming exercise brief, as each person must get a chance to review their contract.
Break
Trust exercise
Explain
Explain that this session is about the importance of supportive relationships and managing
stress as you quit smoking. These relationships come in many forms with oneself, with
professional helpers, with friends and family and with others with a mental illness who are
quitting smoking. Later we will look at how helping relationships can ease the experience of
stress. (Note that this exercise can be challenging to people who are particularly concrete
thinkers. Always allow participants to opt out if necessary.)
Start the trust exercise with a brief explanation about the need for relationships to be built
on trust. Some people have experienced situations when they have reached out to someone
who was unable to support them adequately. Participants need to be able to assess the
trustworthiness of a possible support, as well as being able to reach out and ask for help.
The exercise is a small example of this.

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Discussion
After one or two minutes ask participants to stop and comment on their experience. Did they
like being led around, or did they find it scary? Was the guide comfortable taking charge, or
did they feel nervous about the responsibility?
Reverse roles
Ask participants to reverse roles and repeat the exercise for a further two minutes. Again
bring discussion back to the group. Bring out the emerging themes and relate them back to
quitting. For example a participant may hate the feeling of being powerless or out of control,
finding it difficult to really trust the guide. This may affect their ability to reach out for help
in times of need. Another may be fearful of taking charge and this could mean that they dont
feel confident helping others who ask for help.

Session 5 options

Activity
Ask the group to form pairs and for one person to be the blind person and the other to be
their guide. The blind person closes their eyes and allow themselves to be led around by
the guide. The guide should take them by the arm (or however is comfortable) and lead them
around the room. You can set up some simple tasks like picking up an object and moving
through safe obstacles. The couples should avoid other group members, standing still or
moving too slowly or too fast.

Explain
Repeat the idea that each person attends the group program because, to some degree, they
find that the presence of other people is helpful when they are trying to learn something new.
Knowing this about themselves may come in handy when they face challenges to their quitting
efforts. For example, in the future should some stressful event arise and they are tempted
to smoke, then having the phone number of a helpful person may stop or delay a return to
smoking.
Stress and smoking
Explain
Explain that one of the major causes of relapse is stress. Relate this to examples given by
participants so far. Normalise their experience and explain that this is one of the great
challenges to successful long-term quitting. This session will briefly introduce some ideas
about handling stress, but the aim is for participants to devote some time outside the group
to improving their ability to handle it without smoking. This may include doing a stress
management course at a day program or community centre, reading books on the topic or
talking to their support worker.

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Dening stress
Hand out Appendix 7, ask participants to list what stresses them, and discuss what stress
actually means.
Using the whiteboard explain that stress occurs when the body responds to changes in the
external or internal environment that are perceived as demands. It consists of:

ff the stressor - the change or demand. For example, a housemate asks for money.
ff how this stressor is perceived. For example, you feel this is yet another pressure that you
dont need.

ff the stress response in the body and mind. For example, thinking about all the stress in
your life, your heart beats faster and mouth goes dry leading to having a cigarette to try
and calm down.
Fit examples given by participants into these three categories. Stress arises when there is an
imbalance between the persons coping capacity and the stressors encountered.
Stress can be reduced by:

ff decreasing the sources of stress.


ff learning coping strategies to deal with the stress.

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Explain
Refer to Appendix 7 and ask participants to add any of these ideas that they want to try to the
list. Encourage them to collect a range of ideas for handling stress as they need to have choice
and variety to suit different situations. (Its not always practical to have a relaxing shower or
bath in the middle of the day, for example.)
Have handouts and information on local stress management opportunities presented on a table
for participants to look at and take away.
Discussion
Encourage discussion about what has worked and why, as well as what doesnt work and
why. Many people try a new idea once and call it hopeless if it doesnt work. Again the idea
of practise can be raised here. Remind them that they didnt become a 30-cigarettes-a-day
smoker overnight, they had to build up to it. Equally, using meditation or ringing a helpline
may require a number of tries before it really feels comfortable.

Session 5 options

Brainstorm
Ask group members to brainstorm ways of managing stress that they already know of or have
tried. Write these on the whiteboard. Include some of your own if necessary to ensure that
there are plenty of stress management ideas on the board.

Conclusion
Finish the session off with a deep breathing exercise. Remind participants that deep breathing
is a wonderfully portable stress manager that is healthy and free. The idea is to take a slow
breath in, hold it, then slowly let it out. Repeat.

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92

Aims
ff To encourage alternative, healthy ways of dealing with negative feelings.

ff To encourage group connection.


Session content: Summary
Review
Ask about any successes so far. Reward for positive changes and avoid discussion of negatives
till later in session.
Break
Introduce idea of eating seasonal foods, such as pumpkin soup in winter or fruits in summer.
Smoking and feelings

Session 5 options

Session 5b
Healthy ways of dealing with feeling down

Hand out Appendix 8 and discuss. Lead into a discussion about the relationship between feeling
down, depression and smoking. Incorporate mental health issues and remind participants with
a history of depression to involve the doctor when quitting.
Negative thoughts
Ask participants to name some of the negative thoughts, feelings and actions associated with
quitting and write them on the whiteboard. Discuss. Hand out Appendix 9. Generate positive
ideas to write in Quitting Diary.
Conclusion
Practise becoming aware of negative thoughts and replacing with positive thoughts.

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Facilitator notes
This session continues to explore the process of change. Strong empathy is required when
teaching strategies for managing negative thoughts. This is because strategies for change
are unlikely to be successful if the individuals current experiences and issues are ignored or
glossed over (Lawn et al, 2002).
Sessions 5a to 5c can be the most challenging for the group and facilitator. As the facilitator
be aware of your own responses after each session did you find it particularly draining or
have doubts about the efficacy of the program? Sometimes group negativity can be contagious
and challenging to your role as motivator. Supervision can be useful at these times.
This session is based on cognitive-behavioural principles and is focused on dealing specifically
with negative thinking. Rather than providing a larger, more global approach to managing
depression (which is not the role of this program), it focuses on one aspect of depression as it
relates to quitting, which is the role of negative thoughts. For those participants who suggest
that this is a trivialising of their experience, or those who respond with yes, but . . . to the
idea of positive thoughts, explain to them that you are not trying to solve all their problems
but rather offer them one tool that has been shown to work in the treatment of addictions.
Encourage them to seek out support groups and health professionals who can offer more
comprehensive assistance.
The food preparation activities for the break offer practical and enjoyable ways to alleviate
boredom and promote healthy eating.
If you would like more information on the nature and treatment of depression, see the SANE
Guide to Depression, which is an easy-to-read introduction to the illness and its management.
Psychological therapies are also explained in the SANE Guide to Medication and other Treatments,
and in a podcast and Factsheet, all avalable from www.sane.org.
Preparation

ff Decide on the seasonal food for the break and purchase


ff Photocopy Appendix 8 and 9
ff If necessary contact participants to remind them about session
On the day

ff Prepare equipment for food preparation (for example, soup-pot, chilly bag or Esky for icy
poles or platter for summer fruits)

ff Set up whiteboard, markers and cleaner


Bring

ff Appendix 8 (Feeling down image)


ff Appendix 9 (Faulty beliefs handout)
ff Food for Break (see information in text)
ff Pens and paper for those who have forgotten their Quitting Diaries.

94

Review
Discussion
Encourage discussion on progress with any healthy changes in participants lives. Most will
focus on their wish to quit completely and this can undermine other progress they are making
towards that goal. You will need to listen carefully for any signs of success and bring these out.
You may even like to point out if a participant is negative about their progress. For example,
Joanne may report having reverted back to 20 cigarettes a day and she doesnt know why.
You could thank Joanne for sharing the difficulties of her week with the group and then ask
her for any good things that happened during the week. If she struggles, then ask other group
members if they have noticed any moves forward that Joanne has made. If necessary prompt
them by reminding them that Joanne has cut down from 30 cigarettes a day since the group
started. Use the analogy of the half-full or half-empty glass to show that a negative focus is not
only a half-truth, but also ultimately damaging to their efforts. Explain that this topic will be
covered more fully in the session today.
Participants who are succeeding in their goals should be rewarded with group attention. Ask
others to notice what has changed about the person and how they have managed their change
process. (Of course you also can contribute comments here.) This provides a healthy mirror
to the individual, reflecting their strengths and positives. It helps to build up the fledgling role
of the non-smoker (or successful changer). Make sure you keep negatives and self-doubt out of

Session 5 options

Session content

this discussion, coaching all participants to stay positive at this time.


Ask for feedback about the stress management exercise from the last session.
Break
Use seasonal foods that the group can share, as a way of giving the Break variety for
example, bringing icy poles to the group on a hot day. You could turn this into an exercise by
making them with fruit and juice and putting them in the freezer (if there is one available and
there is sufficient time) to be eaten later. Many people find that ice is a good craving killer, so
this idea also has practical application.
In winter, a quick easy snack is home made soups. Bring some from home or make a simple
soup with the group.

95

Smoking and feelings


This activity is designed to teach participants skills that will assist them to manage their
negative thoughts in relation to smoking and to use strategies other than smoking when they
feel down. These are an adjunct to, not an alternative, to medication.
Hand out copies of Appendix 8 and ask participants to talk about what they see in the picture.
Make sure that themes of isolation and using cigarettes and alcohol when feeling down are
brought out. Ask participants how they relate to the cartoon. How does it compare to the
picture they drew of themselves in Session 1.
Discussion
Initiate a discussion about the relationship between feeling down, depression and smoking.
Tie this in with the discussion about mental health in the review time of previous sessions and
remind participants with a history of depression to involve the doctor when quitting.
Negative thoughts
Explain
Our thoughts, feelings and actions are all linked together and this exercise will tease out the
way that negative thoughts link to negative feelings, particularly in relation to smoking.
Brainstorm
Ask participants to name some of the negative thoughts that they have about smoking and
quitting. Write the headings on the whiteboard. Write up three or four thoughts.
When you have those, move on to the feelings that these thoughts generate. Ask participants
to name the actions that follow.

96

Thoughts

Feelings

Actions

I cant quit.

Hopeless

Smoke

I should be
able to cut down.

Stupid

Smoke

Other people in
the group can do
it, why cant I?

Inadequate

Dont come to the next session.

Pass around the Faulty Beliefs Handout and briefly go through the various thinking styles and
play up how inaccurate they are. Reinforce the counter-productive nature of this pattern and
introduce the idea that participants need to come up with positive thoughts to make their
quitting easier.
Discussion
As a group come up with positive thoughts that counter each faulty belief. Ask each participant
to identify a positive thought that is particularly appealing to them and to highlight it.
Encourage participants to write their positive thought in their Quitting Diary and keep it handy.
Conclusion
Ask participants to spend the time before the next session becoming aware of negative
thoughts they have about themselves and quitting smoking. Practise their positive thoughts
whenever possible, maybe even placing a reminder somewhere obvious, such as beside their
beds for when they wake up.

Session 5 options

Explain
Clearly connect the way in which negative thoughts make it harder for participants to quit
smoking, making them feel worse, which actually leads to them smoking more.

97

98

Aims
ff To explore strong negative feelings and positive ways of dealing with them.

ff To encourage group connection.


Session content: Summary
Review
The discussion should need less active involvement from you now. The topic for the session
can be generated by the discussion or you can lead the discussion to the session material
(below). Focus on reducing the pleasure of smoking and increasing rewards for change.
Break
Stop and smell the roses with some foods that taste, smell or feel interesting. Encourage
participants to savour and describe the sensation of eating the food.

Session 5 options

Session 5c
Dealing with strong negative feelings

Smoking and strong negative feelings


Ask participants for examples of smoking when feeling bored, angry or anxious. Write on the
whiteboard under the following headings: Physical sensations, Thoughts, Feelings, Actions.
Discussion
Encourage discussion among participants about how quitting may exacerbate these feelings as
well as ways to handle them. Hand out strategy sheet (Appendix 10).

99

Facilitator notes
Rather than teaching separate approaches to the various feelings that people perceive as
negative, such as anger, depression, boredom and anxiety, this session works with these
negative feelings together. If you have some expertise in an aspect of managing feelings, such
as anger management, feel free to include your extra knowledge in the program. However,
many facilitators feel that there is enough to learn and cover in the program as it stands.
Participants may also have rudimentary abilities to deal with their feelings already. This
program offers a taster of what is possible and can be an excellent way to lead them into
more emotion focussed personal development.
Increasing discussion about rewards for reduction and cessation of smoking helps to build up a
new identity of a non-smoker in participants. Many smokers have a strong internal critic but
lack a well-developed internal positive supporter to balance it.
Research indicates that people whose smoking is most heavily associated with dealing with
negative feelings, need the most support to quit smoking. Therefore these sessions highlight
that negative feelings are important and challenging. You may be addressing this issue for the
first time for some people. Your challenge is to do this in a contained and focused way. Resist
the urge to jump in with solutions.
Grief can be associated with any kind of loss and it often comes to the fore as people
quit smoking. This can relate to their feeling that giving up smoking is like losing an
unconditionally supportive friend as well as bringing up some of the loss associated with
developing a chronic illness. Despite the fact that smoking is a very conditionally supportive
friend, only challenge this gently and if required. The most important work of the facilitator
here is to let people express the connection with their feelings and to feel accepted by the
facilitator and the group. Empathic listening is helpful, as is reflecting back the link between
the feelings and smoking. For example It sounds like you find it hard to let go of smoking, as
you feel you have lost so much since you became unwell. Dont forget to include other group
members in this discussion hearing others also share the experience helps to breakdown
isolation and eases some of the negative feelings.
That said, this does not have to be a heavy session. It can vary from a light, cathartic exercise
to the introduction of profound new ideas for participants.
Preparation

ff Think ahead and decide on a suitable food for the Break


(see discussion on next page for ideas).

ff Photocopy Appendix 10.


ff Have referral options ready for dealing with feelings (for example, information on courses
in the local area and phone number for Lifeline and Mensline).

ff If necessary contact participants to remind them about session.

100

ff Set up the food table ready for break


ff Set up whiteboard, markers and cleaner
Bring

ff Appendix 10 (strategy sheet)


ff Whiteboard and markers
ff Suitable food for break
ff Referral information

Session content
Review
Review any comments and insights from the last session. By this stage of the program
discussion usually flows easily as the group has formed and participants know each other well
enough for self-disclosure. Your role is much more facilitative than directive now. If you have
the confidence, then you could allow the discussion to produce the work for the session. Doing
this hands over the work of change to the participants and they will help each other if you step
back. Even if you choose to continue with the set program, do so in a less directive manner
than in the earlier sessions if possible.

Session 5 options

On the day

Reducing the pleasure of smoking


For any participants struggling to make changes, introduce some strategies for reducing the
pleasure of smoking. For example, only buying a brand of cigarettes that they dont like such
as menthol or low tar; holding the cigarette awkwardly such as between the second and third
fingers; or keeping a jar with wet cigarette butts handy and smelling it before smoking. Remind
the person to carry around a list of reasons why they want to quit smoking and assist them to
focus on the benefits of changing.
Rewarding progress
For those participants who are making tangible progress, ask them how they are rewarding
themselves. Encourage those who have long-term rewards planned to also insert some small,
immediate rewards to help them on their way. For example, buying a CD or an item of clothing
with some of the money saved will help to keep them going without jeopardising their larger
goal. Even just focusing on the money saved so far, knowing that it has come from their
quitting efforts is enough, particularly if the group offers praise for their efforts.

101

Break Stop and smell the roses


Smokers often have an underdeveloped ability to literally stop and smell the roses as their
smoking habit has overlaid almost everything that they do.
Try offering fresh fruit that is in season (especially during the warmer months). A bowl of
strawberries or stone fruit bought in season is not expensive in fact it can be useful to point
out that participants could eat three punnets of strawberries a day for the price of a packet
of cigarettes! Alternatively, try something unusual like lychees, pickled ginger or other exotic
food. Encourage participants to really savour the experience of eating. Ask them to describe
the taste and texture of the fruit. Generate discussion about the value of slowing down our
experience, so that we do not rush from one sensation to another, but rather experience it
more fully. Often this idea is very new and may take a while to sink in, however it is not
uncommon to hear participants say some time later, that they enjoyed the fruit so much they
have started buying fruit in season.
Strong negative feelings
Explain
Most people start smoking in early adolescence and this can affect the ways they learn to
cope with feelings. Smoking is such an addictive habit that it quickly becomes associated with
most daily experiences. Many people start smoking in adolescence - an emotionally charged
time when people are learning their adult identity and responses. So the power of the habit of
dealing with feelings through smoking is substantial.
Brainstorm
Ask participants if they have ever smoked because they are bored, angry or anxious.
Normalise this by informing participants that these are very common experiences for smokers.
Allow discussion to emerge about their experiences of boredom, anger and anxiety.
Ask participants to define the feelings that they raise. Fit the definitions into the following
categories on the whiteboard. For example:
Emotion/sensation

Thoughts

Feelings

Anger
Churning stomach
I hate the way . . .
Enraged

Withdraw and
smoke

Boredom
Agitated

Nothing to do again

Frustrated

Smoke

Anxious
Palpitations

Racing thoughts

Nervous

Restless

Ask participants if they are experiencing these feelings more, or differently,


as they go through the quitting process.

102

Actions

Discuss
Encourage discussion among the group about peoples experience of feelings, just allowing
issues to emerge. Also encourage group members to make recommendations to one another
about handling these feelings positively. If possible refer them to relevant local courses. Hand
out the Strategy sheet (Appendix 10) with the caveat that the strategies are only suggestions
and that more substantial supports may be required. Remind participants about Lifeline and
other telephone counselling agencies, along with their own existing support network.

Session 5 options

Explain
Again, normalise those recovery symptoms that result from nicotine leaving the body. Remind
participants that nicotine levels in the body are halved after only two hours of not smoking
and that some irritability is the result of the body trying to restore the chemical balance it
was used to. As time goes on however, those feelings of irritability are more the result of the
psychological experience of quitting, such as awkwardness at learning new habits and grief
and anger when letting go of old habits.

103

Do you want to cut back


or quit smoking?
Join our

Smokefree Program

Appendixes

Appendix 1
Group Promotion flyer

for eight weeks at:

Time

(duration 2 hours)

Commencing
Place

ff Learn about your own smoking.


ff Discover ways to reduce and/or quit smoking when you are ready.
ff Get the support of other people wanting to change their smoking.

Come along to the information session on


Date
Place

For more information contact


Name
Phone
By Date

105

Appendix 2
Letter to treating doctor
Date
Address

Dear Doctor
Your patient,
D.O.B
has decided to attend a Quit Smoking
Program specically designed for people with a mental illness to be held from
to
and has given permission for me to contact you.
The program gives information and support for people who want to reduce or quit smoking.
We tell participants about the possible impact on current medication and available
medications to assist with quitting including nicotine replacement therapy. Participants are
strongly encouraged to discuss their individual situation with their doctor and pharmacist.
Your involvement and support in monitoring these issues is appreciated and will assist your
patient to reduce and quit smoking, and improve their overall health and quality of life.
Please do not hesitate to contact me if you would like any other information. Further
medication information can be obtained from the National Prescribing Service (NPS)
Therapeutic Advice and Information Service on 1300 138 677.
Yours sincerely

Your name

Course Facilitator
Contact details

106

SANE Australia
Contact SANE for information, advice, and referral to services in your local area.
The SANE Guide to a Smokefree Life and other publications can be ordered from the SANE
website or by calling 1800 18 sane (7263). Factsheet and podcasts on smoking reduction
and good physical health for people affected by mental illness are also available on the
SANE website.

ff www.sane.org
ff info@sane.org

Appendixes

Appendix 3
Contact details

ff PO Box 226
South Melbourne vic 3205

ff (03) 9682 5933


ff SANE Helpline 1800 18 sane (7263)

Quitline
Contact the Quitline in your State for confidential information and support.

ff 13 quit (13 7848)


ff www.quitnow.info.au

TAIS
Health professionals CAN call the NPS (National Prescribing Service)
Therapeutic Advice and Information Service (TAIS).

ff 1300 138 677

Medicines Line
Contact Medicines Line to talk to a pharmacist about medications.

ff 1300 888 763


ff www.medicinesline.com.au

107

Appendix 4
Healthy food and drink
This is a brief list of healthy food and drink which is good to eat and provides a distraction
from smoking and keeps hands busy. Add your own ideas to the list and refer to it when
putting together snacks for the course. Presenting the food in a bright and appealing
way during breaks in Program sessions will encourage participants to try these ideas
for themselves. The idea is to keep introducing new foods while also sticking with group
favourites.
Food
ff Fruit that is in season - people eat more fruit when it is peeled and cut up

ff Dried fruit serve small amounts at a time as dried fruit is very high in sugar and can
be expensive

ff Veggie sticks serve with a dip


ff Nuts check that no-one is the group is allergic
ff Wholegrain bread or buns with cold sliced meats or canned fish for sandwiches
ff Low-fat dips
ff Crackers with low-fat cheese or vegemite
ff Boiled eggs
ff Icy poles
ff Yoghurt
Drink

ff Iced water with lemon or some berries


ff Orange juice
ff Herbal teas
ff Decaffeinated tea and coffee for people to try
ff Hot chocolate with low-fat milk

108

Session 2 activity

Enlarge and photocopy this page and cut each of the words out. If you will use this activity
again it is worth laminating the cards to protect them. Add any new ones that relate to the
strengths you see in group members as well as leaving some blank cards for participants to
complete.

Creative

Good planner

Open

Thoughtful

Great cook

Good with hands

A good friend

Practical

Caring

Free Spirit

Dreamer

Intelligent

Green thumb

Action Man/Woman

Poetic

Good sense of
humour

Inspiring

Good at writing

Sensible

Tidy

Friendly

Playful

Private person

Spontaneous

Flexible
Artistic

Appendixes

Appendix 5
Strength cards

Good memory

109

Appendix 6
Contract Session 4 handout
Complete this contract, inserting your name and up to three goals you would like to achieve during this
course. You can add new goals as you achieve them.
I,

would like to take charge of my smoking.

To do this, I have decided to set this goal:

(eg. Identify three of my triggers to smoke. Use the 4Ds for a week. (Delay, Deep breathe,
Do something else, Drink water). Make my home smokefree.)
Signed
Date
Support person (if applicable)
Below is a scale to rate your confidence so that you can achieve these goals. 0% means that
you have no confidence in achieving the goals in the set time and 100% means that you are
extremely confident about achieving the goal in the set time. Place a cross on the line to
indicate your confidence.

0%

50%

100%

If you have rated your confidence at around 65 to 80%, then you have chosen an achievable
goal for yourself. If your confidence is higher or lower than this, then adapt your goal so that
your confidence falls within the 65 to 80% range. (This range indicates that the goal offers
you some challenge, without being outside your capabilities. If you rate lower, then the goal
may be too hard for you right now. If you rate higher then the goal may be too easy and will
not help you quit.)

110

Session 5 handout

Think of some times when you feel stressed or anxious. Think about things discussed in the
program, or any other ideas you can think of, to help you deal with these occasions without
smoking.
For example, I felt stressed when the bus was running late. Instead of smoking I walked to the
next bus stop.

ff I felt stressed when

Appendixes

Appendix 7
Dealing with stress

Instead of smoking I

ff I felt stressed when


Instead of smoking I

ff I felt stressed when


Instead of smoking I

ff I felt stressed when


Instead of smoking I

111

Appendix 7 Continued
Dealing with stress

Session 5 handout

Suggestions for dealing with stress

ff Contact a friend
ff Go for a walk
ff Play some relaxing music
ff Make a healthy sandwich
ff Eat a banana
ff Do some housework or gardening
ff Squeeze a stress ball
ff Have a bath or a shower
ff Dance
ff Meditate
ff Walk barefoot on the beach or on grass
ff Give yourself a massage
ff Burn some aromatherapy oils
ff Add your own ideas . . .

112

Session 5 handout

Describe how the person in the picture might be feeling.

Image: Reproduced with permission from Mary Leunig (Theres No Place Like Home, Penguin, 1983)

Have you ever felt like this?


What role do cigarettes and alcohol play in feeling this way?

Appendixes

Appendix 8
Dealing with feelings

113

Appendix 9
Faulty beliefs

Session 5 handout

Be alert to faulty thinking and beliefs. These are some of the examples of distortions and
faulty beliefs commonly associated with depression and addiction.
Black and white thinking
You look at things in absolute, all-or-nothing terms for example, If I dont quit now, I never
will!
Over-generalisation
You view each negative event as a never-ending pattern of defeat for example, Every time I
try to stop smoking I fail.
Selective thinking
You dwell on the negatives and ignore the positive for example, Quitting is so hard, you get
crabby, eat too much and then fail.
Fortune telling
You predict that things will turn out badly for example, I know I wont be able to quit, no
matter how hard I try.
Magnication or minimisation
You blow things up out of proportion or you shrink their importance inappropriately for
example, Quitting is the hardest thing in the world, or I only quit for three hours, thats
pathetic.
Personalisation
You blame yourself for something you are not responsible for for example, I shouldnt have
gone to that smokers house (when you didnt know that they were a smoker).

114

Now generate a more helpful thought for each faulty belief.


Every time I try, I learn something new about quitting
(instead of If I dont quit now, I never will)
Add your positive thought here

My last quit attempt was the longest ever


(instead of Every time I try to stop smoking I fail)

Appendixes

Appendix 9 Continued
Positive thoughts

Add your positive thought here

Quitting can be hard, but I have met new people at the group and I have saved $10 this week
(instead of Quitting is so hard, you get crabby, eat too much and then fail)
Add your positive thought here

I think that this will be my most successful quit attempt yet!


(Instead of I know I wont be able to quit, no matter how hard I try)
Add your positive thought here

Well done me! Three hours without a cigarette is a real achievement


(Instead of I only quit for three hours, thats pathetic)
Add your positive thought here

I didnt know that John (or whoever) was such a heavy smoker. Next time Ill find out if they smoke before
I visit someone new. (Instead of I shouldnt have gone to that smokers house)
Add your positive thought here

115

Appendix 10
Strategies for dealing with feelings

Session 5 handout

Here are some ideas for helping to deal with strong feelings. Try them and see which ones suit
you best. Add your own ideas, too.
Challenging faulty beliefs
Use your positive thoughts to challenge the faulty beliefs. (See Appendix 10) Notice when your
thinking becomes negative and practise using positive thoughts. Notice how your feelings and
actions change.
Activities
Get moving and just do something. Try walking, gardening, going to the movies, sewing,
knitting or fixing the car. Find out about cheap courses in your area if you do not have a hobby
already. Even better, think of two things you can do at the same time, like listening to music
while doing the ironing, or games which use your mind and your body.
Support
Call a friend, ring a support line like Lifeline (13 11 14) or Mensline (1300 789 978) or talk to
a family member. Reach out to another person (preferably one you know is a good listener).
Management
Use your doctor, mental health professionals and medication to assist you if you feel that the
negative feelings are getting too much.
Spirituality
If you follow a religion or meditate, draw on your this to support you in difficult times.
Try distraction techniques such as:

ff Pay attention to things around you


Choose something from your surroundings such as a window, for example. Describe it to
yourself in as much details as possible. How big is it? What colour is it? What is it made of?

ff Use your senses


Try to feel your surroundings using all your senses sight, hearing, taste, touch and smell.
What can you hear inside the room and outside the room? Can you smell coffee? How does
the chair feel under you? What textures do your clothes have?

ff Using your mind


Try games such as counting backwards from 100 by threes, or thinking of animals
beginning with letters of the alphabet.

ff Remembering good times


Remember something that you have enjoyed in the past, like an enjoyable holiday.

ff Your own ideas


Remember that these ideas work best if you practise them.

116

Different people gain differing amounts of weight due to stopping smoking. Some
antipsychotic medications cause weight gain which can complicate the process of quitting.
While some people even lose weight when they quit smoking, it is useful to approach quitting
as part of a move towards a healthier lifestyle. The benefits of quitting far outweigh the risks
of extra body weight.
The general guidelines of healthy living therefore apply:

ff Get some exercise each day. As little as three ten-minute exercise breaks each day will

Appendixes

Appendix 11
A Healthy Weight Session 6 handout

help your mental health and also help keep your weight under control. Research shows that
people who exercise are more likely to quit smoking than those who do not exercise.

ff Get support. Join a gym, an activities group through your local mental health program
or ask your case manager for ideas. Ask a friend to come with you if you feel unsure
about doing new things. Talk to your doctor about any risks associated with your health
(particularly if you have not done much exercise for a while).

ff Eat well. Eat more fresh food and less fast food. Think of the snacks served in the breaks
of this course if you need ideas about healthy eating. If you lack motivation or experience
with food preparation, ask for help.

ff Get more support. Your doctor can help with weight loss and refer you to a dietitian if
necessary. Join a healthy cooking class at the community centre or maybe even a weight
loss group (check the costs first as some groups are expensive).

ff Get help and information. Try the SANE Guide to Healthy Living or use the Internet to
improve your knowledge and give you ideas.

ff Be nice to yourself. If you have not been exercising much or eating well, then it will take
time to change your habits. Notice each time you make a positive choice and feel good
about it. Over time you will find that it gets easier. And besides, giving yourself a hard time
about your weight or your habits usually makes things worse.

ff Spend time with positive role models. Spend more time with the people you know who
enjoy eating well or exercising. Or make new friends at the gym or cooking class. Their
positive influence will rub off and temptation will lessen.

117

Appendix 12
Things to do when you want to smoke

Session 7 handout

Remember the 4Ds: Delay, Deep breath, Drink water, Do something else. Doing something else
can include read a magazine or good book, listen to some favourite music, go for a 10 minute
walk, have a bath, watch a funny DVD.
About your feelings and thoughts

ff Think about why you feel down. Is there something you can change so you feel better?
ff Think about things that distract or cheer you up and do one of them.
ff Remember some good things about yourself.
About being with other people

ff Spend time with friends or other people you like.


ff Try to avoid smokers or places where there will be lots of smokers.
ff Spend time with non-smokers and watch what they do with their hands
ff On social occasions, avoid drinking a lot of alcohol as it may weaken your resolve
ff Plan ahead so that you dont get tempted to smoke by your usual triggers.
ff Try something different for example, if you have been toughing it out try asking for
support.

ff Stand up for yourself if someone is giving you a hard time.


ff If people ask why you arent smoking and you dont want to talk about quitting, give
yourself some space by thinking of things to say. For example, you could tell people you
are not smoking because you have been sick.

ff Practise coping tips you have learned during the program.

118

Copy the certificate overleaf and insert each persons name and goals that they achieved
during the course, sign and date. Present in a folder, plastic pocket or tie with some ribbon.

Appendixes

Appendix 13
Certificate Session 8 handout

119

SmokeFree Certicate
awarded to

for successfully completing

The SANE SmokeFree Program

Course Coordinator
Date

How knowledgeable are you now about reducing and quitting smoking?
q I know a lot
q I know what to do but find it difficult to make changes
q Not very knowledgeable at all
Comments

Appendixes

Appendix 14
Evaluation form for the SANE Smokefree Program

How are you progressing with reducing/quitting smoking?


q I have quit smoking
q I have reduced my smoking and made a date to quit
q I have not reduced or quit smoking yet
Comments:

How confident do you feel now about talking to your GP and other supporters about
quitting smoking?
q Very confident
q Somewhat confident
q Not confident at all
Comments:

Whats one key healthy change you are going to make after this course?

Thank you

121

The SANE SmokeFree Kit.


Third, revised edition
isbn 978 1875182 56 5
SANE Australia, 2009
No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise, without clearance from the copyright holder. This publication is intended to provide
general information only. It does not provide specic advice, which should be sought from an appropriately qualied professional
person. It is sold or otherwise distributed on the condition that SANE Australia, its ofcers and others involved in its production and
distribution shall not be held responsible for the results of any actions taken as a result of information or opinions contained in it.

This Kit is part of the SANE SmokeFree program,


supported by the Friends of SANE and Perpetual Trustees.
Acknowledgements
SANE Australia gratefully acknowledges the assistance of the following in development of the
Kit: Kristen Moeller-Saxone; Maxie Ashton (Tobacco and Mental Illness Project, SA);
Carla Cowles (Breathe Easy Project Coordinator, Mental Health Coordinating Council, NSW);
Sacha Filia (Alfred Psychiatry Research Centre); Judi Brewster (Mental Health Settings,
Quit Victoria).
Acknowledgements for previous editions
Members and staff at Bromham Place Clubhouse, Catch 23 Day Program (Neami) and Loddon
Campaspe Combined Support Services for help with piloting the program. Staff at Quit
Victoria. Associate Professor Kay Wilhelm (from first edition), Dr Graham Meadows and
Professor Nicholas Keks for their support for this project. The support of staff at Eastern
Access Community Health, MIDAS, Prahran Mission, Northwest Adelaide Health Service,
NEAMI, with particular thanks to Scotty Maxwell, Jeanette James, Maxi Ashton, Glenn Tobias
and Sharon Lawn.
SANE Australia
SANE Australia is a national charity working for a better life for people affected by mental
illness. SANE produces a range of easy-to-read publications and multimedia resources on
mental illness and related topics. For more details, visit www.sane.org, or contact:
SANE Australia
PO Box 226
South Melbourne 3205
Phone (03) 9682 5933
Fax
(03) 9682 5944
email info@sane.org
Helpline 1800 18 sane(7263)