You can’t sell people something they don’t want.
Let’s say that you are determined to buy a new pair of pants.
You know you don’t want anything else: not shorts, not shoes, not a sweater. You just want pants. Now imagine walking into a clothing store and being pestered by the salesperson to buy a T-shirt. Do you think that you could be pressured into buying it? Not likely. You would probably walk out and buy a pair of pants elsewhere. Well, the same is true of anti-smoking programs. Communities have to want them for them to work. So assessing the feelings of a community about smoking and smoking programs is very important.

But what is readiness? Readiness is a willingness to discuss issues and the extent to which community leaders are ready to take the necessary actions.

But who are our leaders? Anyone who takes the lead can be a leader. Leaders can be Elders, community workers, or even children. A child who says, “Daddy, I want you to stop smoking because I don’t want you to die” is taking a lead. As well, our regional facilitators can provide more information about what you can do to help your community.

How can you tell how ready your community is? Ask them about the issues. “How important is tobacco abuse to you, on a scale of one to ten?” For someone dealing with family violence or poverty, smoking may not be a priority. Certain communities may be dealing with issues that they think are more important than smoking. Ask a follow-up question: “If it is important, how feasible is it and how confident do you feel that you can make these changes?”
There are many different stages of community readiness. Communities don’t have to fall exactly into the categories on this list. They can be a mixture of both, or moving from one into another.

1. Tolerance: The community tolerates the existing condition. They are not doing anything to change it.
2. Denial: The community denies the problem of chewing or smoking. Some defences might be that “We don’t need a program, we have other more serious issues to deal with.”
3. Vague Awareness: The community knows about the tobacco abuse problem, but they don’t believe that any action is needed.
4. Preplanning: The community is aware of the local problem, and some information has been gathered on the nature and extent of the problem.
5. Preparation: The community is trying to start a program. There are committed people trying to set it up. Maybe they are seeking funding, or have already planned out the program.
6. Initiation: The program is now getting off the ground.
7. Institutionalization: The program is in place, the community supports it, and most community members think that it is a good idea.
8. Confirmation: The program is expanding, and the local authorities support it.
9. Professionalization: The community now collects detailed and sophisticated local information on smoking (through surveys or focus groups, for example). They have designed programs to help different kinds of smokers, such as pregnant women or teenagers. Everyone in the community thinks the programs are a good idea. The staff is highly trained.

Once the community’s attitude about smoking programs is known, decisions can be made on which strategies are best. Here are some examples:

DENIAL STAGE: Teach the community leaders and community groups about tobacco abuse. Maybe a story could be told about how smoking has hurt one of the community members. Did someone’s grandfather die of smoking-induced lung cancer? Local stories are a powerful way to open people’s eyes and really bring the problem home. Denial can be broken down simply by asking questions. But remember, accusing questions like “Don’t you know smoking is bad?” may only push people further into denial. Try not to ask questions that involve the words " why," "should" and "could." Ask neutral questions that get people thinking, like: “How do you feel when you smoke?”

VAGUE AWARENESS: Educate communities on the problem of smoking in other similar communities. How is smoking a problem there? A media campaign could be done in the community to
emphasize the consequences of tobacco abuse and the benefits of changing. Smokers tend to prefer ads that talk about the benefits of quitting, instead of the horrible consequences of not quitting. Again, hearing other people’s stories is a good tool. Positive stories about how a person quit, or how much money somebody saved by not buying cigarettes are good, because they provide hope, instead of blaming the smoker.

INSTITUTIONALIZATION: At this stage the community could do something to recognize the hard work of its leaders or the participants in the anti-smoking programs. A health worker could be honored at a feast, or maybe someone who successfully made their home smoke free for their children could be celebrated.

CONFIRMATION: Here the community could begin to take a closer look at smoking trends. They could look at different groups of smokers, such as the elderly or children. They could try to answer questions like: "What are the conditions that contribute to smoking in this particular group?" The answers to these questions could then be made available to the community.

SMOKING: BEST PRACTICES IN CESSATION

When deciding what action is best for a particular community, it is important to remember to ask, not tell, a community what they need. Community members are themselves the best experts on what will or won’t work. Only the community can say who wants pants and who wants a T-shirt.

We know about the alarming rates of smoking in Aboriginal communities, so now let’s look at some ways of quitting. A good place to begin is with the cigarette itself. What are cigarettes made of? What makes them addictive? Is it true that “light” cigarettes are less harmful than regular cigarettes?

Tobacco: Only a fraction of the tobacco inside a cigarette comes from the leaf of a tobacco plant. What you see inside a cigarette is mostly made up of something called “reconstituted tobacco” or “homogenized sheet tobacco.” These are made mainly from mashed tobacco stems, which are flattened into a sheet. The sheet is sprayed with nicotine and other substances, including as many as 600 chemical additives. Ammonia is used to aid in the delivery of nicotine, and chocolate is used to hide the bitter taste of tobacco. This sheet is chopped up to make it look like shredded leaf tobacco.

Paper Wrap: Cigarette paper is responsible for how fast a cigarette burns and how much smoke it lets out. Like tobacco, cigarette paper contains many chemicals, including titanium oxide, which is also found in jet fuel. It is used to make sure the cigarette doesn’t go out, and that the smoke comes out evenly with each puff. The chemicals in the paper wrap have contributed to many cigarette-caused fires. Cigarette manufacturers are just now beginning to address this problem.

Filter: The filter began to be widely used in 1954, after doctors and researchers began to publicize the harmful effects of smoking. Some cigarette manufacturers today advertise a “charcoal filter” which they claim reduces certain toxins in the smoke. However, there is no evidence that these cigarettes are significantly less dangerous for the smoker. "Light" tobacco is exactly the same as "regular" tobacco. Cigarettes that are called “light” simply have more holes in the filter. This enables more fresh air to be sucked out when a machine tests the cigarette. The holes make the machine think that there is less tar and nicotine in the cigarette. But in reality, smokers block these extra holes with their mouth while they smoke, and can still draw out the higher nicotine and tar levels they crave.

WHY DO PEOPLE KEEP SMOKING?

The vast majority of smokers know about the health risks. So why do they continue to smoke? People smoke cigarettes because it eases tension and stress, it heightens concentration, it controls your appetite, and it makes you feel good. Smoking is a way to deal with things that are hard to deal with. It is a coping mechanism.
Of course, reasons for smoking are different for each smoker. For example, for some women, smoking may provide a sense of control. Women who feel powerless in their lives may get a sense of power from deciding when they smoke their cigarettes.

GETTING ADDICTED

What are the factors involved?

NICOTINE: The addictive agent in cigarettes is nicotine. Nicotine is more addictive than heroin or cocaine (according to the US Surgeon General). It is extremely addictive if inhaled and smoked, but not as addictive if it is taken through the patch. Think of it this way: cigarettes are to the patch what crack-cocaine is to cocaine. Both crack and cigarettes are much more addictive because of the way they enter the body. The patch is the way to go!

GENETICS: How addicted you get to a substance depends on the make-up of your body. You will get more addicted to a substance if the pleasure centres in your brain get a bigger buzz when they are stimulated by it.

ENVIRONMENT: If cigarettes are everywhere, and easy to obtain, the chances of starting to smoke will be higher. The same is true if people often find themselves in situations where others are smoking.

THE MANUFACTURER: The company that makes the drug will have a huge effect on many factors. They affect the smoker by controlling what goes into the cigarette (how much nicotine, how much, tar, etc.). They impact the environment through advertisements and by fighting against smoke-free by-laws.

All of these aspects play a role in addiction. Focusing on just one of them will not give you the big picture. When programs are being developed, all of these factors should be kept in mind. Smoking is not just about the brain, or how easy it is to get cigarettes. It’s a complicated issue with many things to consider.

WHY IS IT SO HARD TO QUIT SMOKING?

Humans are creatures of habit and we learn very quickly.
For example, once you learn to ride a bike, you have that ability for life. That learning is ingrained, or has become a part of you. Much like riding a bike, learning to smoke can become an ingrained behaviour. Let's say a smoker takes 200 puffs of cigarettes each day. That action will become automatic. The smoker will reach for that next cigarette without thinking twice.

THE KEY FACTORS IN QUITTING

Setting a quit date.
Getting help.
Getting social support from family members or friends. (The helper should be someone who will not tempt the smoker to have a cigarette).
Using a drug therapy like the patch, or gum, or Zyban.
Making a plan for avoiding high-risk situations. (High-risk situations are different for everyone. A person who is used to having their morning coffee with a cigarette might go to a smoke-free environment instead. Another person may want to have lunch with a non-smoking friend instead of with their usual friend who is a smoker).
Doing something to remain cigarette-free, like visiting a support group for several months after quitting.

Just raising the issue of smoking in conversation can get a smoker to start thinking about their addiction. A simple procedure that all health care workers can use when they talk to patients is the 4A PROGRAM: Ask all patients if they smoke; Advise all smokers to quit; Assess their willingness to quit; and Assist them according to their readiness to change.

One way to determine how ready a smoker is to quit is to use the STAGES OF CHANGE model. Think of these changes as occurring in a spiral, not a straight line. Different stages can be happening at the same time, in a different order, backwards or forwards.

1) Precontemplation: The smoker is unaware of his or her problem and unwilling to change.
2) Contemplation: The smoker hasn’t decided either way, but is thinking about changing. This may include, for example, thinking about which friends they will have to avoid if they want to try to quit.
3) Preparation: At this point the smoker is ready to quit. He or she has decided to change and is taking steps. One step may be to start counting how many cigarettes are smoked in a day.
4) Action: The smoker has started to do things differently.
5) Maintenance: The person is not smoking. They are on their way to being a non-smoker, but they may still be having cravings or withdrawal symptoms.

Sometimes, smokers are just not ready to quit. If that is the case, don’t argue. Ask them questions about smoking. The best thing to do is get the smokers thinking about their behaviours. Ask them about the positives of smoking. Ask them about the negatives. Help them remove barriers. Brainstorm on ways to quit. Take baby steps with them.

Another important part of the quitting process is to figure out how addicted a person is to cigarettes. Heavy smokers will have less chance of quitting. A simple way to assess how addicted a person is to nicotine is to ask them when they have their first cigarette of the day. If it is within 30 minutes of waking up, the smoker is very addicted. Addiction can also be measured by asking about withdrawal symptoms that have occurred when they have tried to quit in the past.

Withdrawal symptoms include strong urges to smoke, “cravings,” irritability, anxiety, difficulty concentrating, sleeping problems, lightheadedness and headaches. Another overlooked element to withdrawal is that you go through a depression, and this is one of the reasons that many people smoke in the first place. One tip to help a smoker with their withdrawal symptoms is to emphasize their positive effects. For example, the bad cough that some smokers get after quitting doesn’t mean that they are getting sick, but that their lungs are finally renewing themselves.

Nicotine Replacement Therapy is used to help relieve some of the withdrawal symptoms people experience when they quit smoking. The most common forms are the patch and chewing gum, both of which contain nicotine. They are less addictive due to the way they enter the body. NRT is very effective and its use should be encouraged. It is preferable for patients to keep using NRT instead of returning to smoking. However, pregnant women and people who are in risk of having a heart attack should not use it.

Zyban is a nicotine-free pill that helps reduce a smoker’s urge to smoke. There are minimal side effects to Zyban (it also helps as an anti-depressant), but smokers should start taking the medication at least a week prior to their quitting date. One of the ways Zyban works is by making cigarettes taste bad. This helps break down a smoker’s habitual behavior.
Bad-tasting cigarettes also lessen the pleasurable effects of smoking. And as opposed to the patch, patients can smoke while they take Zyban.

SOME FINAL POINTERS ON QUITTING
To increase a person’s self-esteem during quitting, reinforce their successes. If they have gone several days without smoking but then cave in and have a cigarette, try to see the positive side. For example, say something like: “Wow. You went so many days without smoking.
How did you manage to keep it down to only one?”

Not everyone will succeed with the same quitting strategy. Give the prospective quitter a menu of choices (support groups, NRT, individual counselling, etc.).

Role models can have a huge impact. Recognizing that a movie star or local hero doesn’t smoke can have a big effect on a smoker or on a potential one. The stories of non-smokers can be inspiring, especially if they were once smokers but managed to break free.

Remember that smoking helps people cope with underlying issues (anything from drug abuse to domestic violence). When people stop smoking, they will really have to confront their other problems.