• Open Access

Stressful life events, resources, and access: key considerations in quitting smoking at an Aboriginal Medical Service


Dr Michelle DiGiacomo, Nursing Research Unit, University of Western Sydney and Sydney West Area Health Service, Locked Bag 1797, Penrith DC 1797, New South Wales. Fax: (02) 9840 3629; e-mail: michelle_digiacomo@wsahs.nsw.gov.au


Objective: Aboriginal and Torres Strait Islander people experience adverse health outcomes and have high rates of smoking and related illnesses. This brief report describes stress as a barrier to quitting smoking derived from reflections within an Aboriginal Medical Service and makes recommendations for intervention development.

Methods: A high-intensity smoking cessation program was conducted within a suburban Aboriginal Medical Service in Western Sydney, Australia, over a 10-month period. The intervention included weekly cessation counselling sessions and dispensation of free nicotine replacement therapy (NRT).

Results: During the observation period, 32 clients made quit attempts. To date, three clients (9%) have quit smoking. Chronic and intercurrent life stressors were noted to be the main barriers to smoking cessation described by participants.

Conclusions: Achieving smoking cessation among Indigenous people is made significantly more complex because of multiple life stressors experienced.

Implications: Future interventions targeting Indigenous Australians should take greater account of stressful life events and their impact on quitting smoking.

Susan, 43, presented to the cessation clinic wanting to quit smoking. Her younger sister had recently died of a smoking-related illness. Susan began using nicotine replacement therapy (NRT) and returned for several weeks to the clinic to speak with the counsellors and collect more NRT. She expressed happiness at her success upon each visit and enthusiastically reported that she noticed physical benefits of no longer smoking. After a few weeks, Susan shifted to fortnightly appointments, that being the normal progression of the program.

Two months passed and during that time Susan did not attend the clinic. She returned one day and reported in a solemn tone that she had “blown it”. When asked by the counsellors what had happened to make her begin smoking again, Susan explained that her brother had died suddenly and she felt overwhelmed by grief. She had sunken into feelings of hopelessness and started smoking again because she “just didn’ t care anymore”. She felt ashamed that her response to this loss was to resume smoking after all she had achieved in the program. She was now ready to try again.

The experience of Susan does not represent a unique case, but rather depicts life events common to many Indigenous people. Indigenous Australians (Aboriginal and Torres Strait Islander people) suffer a greater burden of disease and ill health than other Australians. Indigenous people die younger and experience diminished quality of life from a range of chronic conditions.1 These problems arise from the complex interplay of a range of biomedical, social, and psychological factors, including intentional removal of children from their families and policies that promote marginalisation.2

Smoking is a preventable cause of morbidity and mortality among the 50% of Indigenous Australians who use tobacco,3 but only minimal data exists on the effectiveness of cessation interventions in this population.4 While evidence derived from interventions in other populations is useful, differences in contextual and socio-economic factors may denote an inappropriate match to the needs of Indigenous people.5

This brief report describes a smoking cessation intervention at an Aboriginal Medical Service (AMS). Although not a research project, observations of this clinically based intervention provide useful information for clinicians and intervention development.


From August 2005 to June 2006 we conducted a high-intensity smoking cessation program within a primary care setting at a suburban AMS in Western Sydney, Australia. All AMS clients and staff who smoked were invited by general practitioners and Aboriginal Health Workers (AHWs) to participate. Clients who chose to participate underwent a preliminary cardiovascular screening and spirometry conducted by AHWs.

The intervention

Following recruitment and screening by AHWs, clients met with cessation counsellors (two non-Indigenous health professionals) to discuss their smoking behaviour. Nicotine dependency was assessed using the Fagerstrom Nicotine Dependence Scale.6

In an effort to tailor the intervention to the needs of each client, counsellors obtained relevant contextual information by asking clients about their family, work, living situation, health status, and any further background information clients thought pertinent. Striking features of these conversations were stories of loss and grief resulting from adverse life events.

Given the documented efficacy of NRT use in quit attempts,7 this supply was provided to the client without cost (NRT funded by the local area health service). Smoking-related behaviour change was discussed and arrangements made for weekly follow-up. A condition of receipt of free NRT was ongoing participation in counselling sessions. Progression through the intervention remained flexible to meet the diverse needs of clients. AHWs concurrently engaged in culturally appropriate cessation counselling via brief opportunistic interventions.

Data from cardiovascular screenings, nicotine dependence assessments, interview notes, and NRT usage were recorded. Preliminary analysis signalled occurrence of multiple stressful life events that led to use of the Holmes and Rahe Social Readjustment Rating Scale (SRRS).8 This list of 43 life events that occurred in the past year are ranked from most to least stressful and summed to indicate incidence and severity of minor, moderate, or severe life crises.


Thirty-seven clients, 10 males and 27 females aged 18–70 years, were screened by AHWs. Eighty-six per cent of clients scored moderate to high levels of dependency according to the Fagerstrom Scale6 and reported usually smoking 20 or more cigarettes per day. Clients reported having smoked for an average of 19 years, with the majority of individuals starting during adolescence. Five clients never started NRT use because they were not yet ready to quit (4) or were pregnant (1). Of the 32 remaining clients, three (9%) quit smoking and have been smoke-free for six months. Twenty-three clients started NRT, but continued for less than four weeks before relapsing. A further six clients persisted for four or more weeks with repeated visits to the cessation clinic, but eventually relapsed. The majority of clients reported that they relapsed because of stress that occurred during or in the year prior to the quit attempt. The SRRS8 indicated that of 78% of these clients could be classified as having major or moderate life crises. Examples of reported stressors included the death of one or more family members, domestic violence, effects of a family member's drug problem, considerable care-giving responsibilities, and imprisonment of a family member. Ongoing stressful life events were of an unexpected magnitude within the context of the program and highlighted a significant barrier to persevering with quit attempts.


A quit rate of 9% achieved in this intervention is comparable to evaluations of cessation interventions in other Australian Indigenous populations. Mark et al.9,10 achieved a 6% quit rate at three months through provision of subsidised NRT for three weeks and counselling in the form of quit smoking groups. Our slightly higher success rate may relate to our unrestricted duration of free NRT and counselling. In another study, Ivers et al.9 achieved 15% self-reported abstinence at six months (10% carbon monoxide levels verified) for those who used free patches and a brief intervention. These collective outcomes are lower than NRT use in other populations.11

Each quit attempt indicates a positive orientation towards lifestyle modification regardless of outcome. Although cessation success is not related to cost of NRT,12 offering a free patch has been found to be an effective prompt for smokers to make a quit attempt.13 Therefore, it is assumed that the provision of free NRT in this intervention is partially responsible for the 32 attempts made. The number of quit attempts may also be related to AHWs’ active involvement in the program. Dispensing just one-week supplies of NRT facilitated compliance with counselling strategies. Furthermore, the intervention took place in an accessible, culturally appropriate environment and was facilitated by AHWs who were pivotal in communicating accessibility and enthusiasm for the service among community members.14

Stress and relapse

The crux of this paper is not the rate of quit success, but rather the pervasiveness of stress as a significant barrier to cessation. Stress has been identified as a significant barrier to quitting among AHWs.9 Unusual or life-altering stressful events such as death of a spouse or family member may require considerable adjustment and may trigger impulses to smoke.15 The number and intensity of stressful life events common to many of our clients placed them within moderate or major life crisis categories. Although many people who try to quit smoking encounter stress, the experience of the authors and the extant literature indicate these challenges are amplified in Indigenous Australians. It is important that health professionals consider this issue to develop culturally competent interventions.

Strengths and limitations

It is important to note that this is not a research study, but rather a review of cases to inform smoking cessation strategies. The convenience sample of smokers and the small sample size may have an impact upon generalisability of findings. The use of introductory interviews facilitated an in-depth awareness of socio-environmental factors that affect a person's quit attempt. Objective validation of nicotine levels was not assessed in all clients, but self-report of cigarette smoking is a suitable measure in Aboriginal communities.16 A key strength is that the project was a culturally appropriate intervention developed and implemented by AHWs within a collaborative framework.

Recommendations for future research and practice

Based upon data collected, we make the following comments for consideration in smoking cessation programs among Indigenous Australians. First, engagement of the local community and inclusion of AHWs in recruitment of participants and intervention implementation is critical. Second, the intervention needs to take place in an accessible, community-controlled, and culturally appropriate environment. Third, subsidised NRT should be provided and augmented by an individualised, flexible counselling program. Fourth, high rates of current and previous stressful life events need to be anticipated and the relationship of these events to the resolve to quit explored. On the basis of our experience to date, future interventions may assess stress levels throughout the cessation attempt. Feasibility and acceptability of supplementary programs such as counselling or support groups should also be explored.


Observations of this collaborative, community-based intervention will assist in the development of smoking cessation programs within Indigenous communities. This intervention has shed light on pragmatic issues associated with implementing a culturally appropriate cessation program for Indigenous communities. There remains a need to identify and assess alternative coping strategies for significant levels of stress experienced by Indigenous people, particularly those who want to quit smoking.


We would like to thank Sydney West Area Health Service for providing funding for the NRT for this program.