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Visions Journal

A reminder that this article from our magazine Visions was published more than 1 year ago. It is here for reference only. Some information in it may no longer be current. It also represents the point of the view of the author only. See the author box at the bottom of the article for more about the contributor.

Tobacco - NOT the 'Least of their Worries'

Interior Health’s Nicotine Intervention Counselling

MaryAnne Waters

Reprinted from Visions Journal, 2007, 3 (4), pp. 31-32

“I have kicked alcohol and crack (cocaine), but I can tell you from the bottom of my heart that stopping smoking is the hardest thing I have ever done!”

“Thanks for not giving up on me when I was trying to stop smoking. Stopping smoking is so hard.”

These quotes are from individuals who struggle with mental illness, as well as tobacco dependence. They highlight the importance of support on the difficult journey to become tobacco-free.

Tobacco use remains the leading preventable cause illness and death in our society. The facts show that smoking kills more people in this country than HIV/AIDS, motor vehicle collisions, murder, suicide and illicit drug use combined.1

Tobacco smoking prevalence among people with mental illness, however, is twice that of the general population.2

People struggling with mental illness as well as tobacco dependence often find it very difficult to stop smoking on their own or with little support. Many have additional challenges. They may have lower incomes and, because of this powerful addiction, may spend their limited resources on tobacco rather than on basics of life such as food. Many have fewer social supports and less education than members of the general population do. They may also have other physical illnesses, such as lung disease, heart disease and diabetes. The health effects of tobacco use are, needless to say, huge.

Tobacco use by people who have a mental illness is sometimes viewed—by the clients, their family and friends, and even health care professionals—as “the least of their worries” or “normal.” This has meant that many mental health consumers have not been supported to stop their tobacco use. Worse still, tobacco use has sometimes been encouraged in ways such as sanctioned “smoke breaks” or tobacco offered as a “reward.”

Most health care providers have received little (if any) training in effective ways to help people stop smoking. Other than saying, “don’t smoke,” many have few other tools, so find it difficult to be helpful.

The NIC pilot

In Interior Health, we piloted the Nicotine Intervention Counselling (NIC) program from April 2003 to December 2006. This program was designed to help tobacco users who may need more intensive support to be successful in stopping their use. It addressed those unlikely to succeed with interventions such as self-help books, websites, ordinary physician appointments or talking to their pharmacist.

NIC was based on the world-renowned Nicotine Dependence Centre (NDC) program at the Mayo Clinic in the United States3 and on the Nicotine Intervention Counselling Centre (NICC) program offered in BC’s Northern Health Authority.4

Interior Health adapted these programs to best fit the needs of our region. This included adapting for a variety of health professionals—respiratory therapists, nurses, pharmacists, care aids, social workers and doctors—who work in a variety of settings, from hospital wards to community outreach. These professionals serve communities that range from small, remote locations to larger urban centres. Fifteen communities were involved in the pilot project.

Over the three years of the pilot, 173 health care providers were trained to provide NIC services. The initial training was two days, followed by a yearly, two-hour recertification. These health care providers learned a comprehensive approach to providing support for their clients, as an integrated part of the regular care given. Client-centred care was a key focus.

Our NIC pilot had three major components:

  • Planning session—Clients and health care providers met to develop a plan that was best for the individual client. These sessions addressed tobacco use habits such as how much they smoke, how long they’ve smoked and when they smoke. They explored whether the client has tried to quit before and, if so, what has worked for them and what hasn’t worked. Carbon monoxide levels and nicotine dependence were tested. How important quitting is to the client, their confidence in their ability to quit, their triggers and fears, what support systems they have, and other health issues were also discussed.

  • Medication support—A seven-day supply of nicotine patches and gum was offered to the client in most cases. Clients were also encouraged to see their doctor about other possible medications that may be helpful.

  • Ongoing support—Clients were offered brief support by health care providers in the weeks and months after the initial visit. This tended to vary, depending on health care providers’ abilities to do follow-up. Initially, phone contact was routinely offered at one, three, six and 12 months, but this changed to a three-month limit for follow-up. An office visit was encouraged at the one-week mark, where tobacco use was reassessed, including carbon monoxide testing. If clients were tobacco-free, they were offered a second ‘starter kit’ of nicotine replacement therapy.

Some communities had a one-hour, weekly support group. People were encouraged to use other support, such as QuitNow internet or phone support, or other health care providers.

The NIC pilot also had a very small but significant staff component. Support was offered to staff who wanted to stop using tobacco. Staff comprised about 5% of the quit-smoking clients.

NIC results

Over the three-year pilot, a total of 2,125 clients, including staff, were seen. “Tobacco-free” rates for NIC participants were:

  • 59% at one week

  • 47% at one month

  • 40% at three months

These rates compare well with other effective stop smoking programs.5

There were some challenges in following up with clients, including clients moving or not having phones, as well as limited staffing time. Also, phone follow-up was sometimes done locally and sometimes centrally; in the latter case, the client was called by someone they didn’t know. However, even in cases where clients had started to smoke again, most of them welcomed the phone support and encouragement offered.

It is important to note that as smokers quit, the risk of exposure to second-hand smoke may also decrease. Second-hand smoke exposure is a clear health hazard.6 By becoming tobacco-free, clients were no longer exposing others to their tobacco smoke.

The experience with our NIC pilot has increased the skills and abilities of both clients and health care providers in dealing with tobacco dependence. Future steps for this service are being evaluated.

For more information: contact MaryAnne at 250-851-7954 or [email protected]

About the author
MaryAnne is a Senior Tobacco Reduction Coordinator with Interior Health. For the past three years, she has coordinated the successful Nicotine Intervention Counselling (NIC) pilot project across BC’s interior region. She is passionate about supporting health care providers to help their clients become tobacco-free
  1. BC Ministry of Health Services. (2004). BC’s tobacco control strategy: Targeting our efforts.

  2. Lasser, K., Boyd, J.W., Woolhandler, S. et al. (2000). Smoking and mental illness: A population-based prevalence study. JAMA: The Journal of the American Medical Association, 284(20), 2606-2610.

  3. Nicotine Dependence Centre (NDC), Mayo Clinic, Rochester, Minnesota:

  4. Nicotine Intervention Counselling Centre (NICC), Northern Health Authority: Visit, or for information on the program contact Wanda Dean at 250-649-7271.

  5. Nicotine Intervention Counselling Centre, Northern Health Authority. (2007, January 29). NICC participants smoking status by follow-up type: January 1, 2006, to December 31, 2006. General Smoking Status Report. Prince George: Author.

  6. Health Canada. (2006). It’s your health: Second-hand smoke (Fact sheet).

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