Kicking the habit: How tobacco counsellors offer individual support to smokers

It is easy to become addicted to smoking, much harder to quit. That’s why despite the known health risks, long-term smokers find it difficult to kick their habit.

“People smoke for the nicotine, but die from the tar,” said the late Professor Michael Russell, a pioneering British scientist and expert in tobacco dependency. 

Smokers’ craving for cigarettes is due to nicotine, a feel-good psychoactive substance that releases dopamine and is as addictive as heroin, cocaine and even sugar.

In Belgium, smoking prevalence remains stubbornly high – around 15% according to 2018 figures – despite the country’s long-term strategy for a tobacco-free generation by 2040. Its tobacco control policies are extensive, including raising taxes, banning publicity and smoking in public places, and rightly targeting younger smokers, while also banning many alternative smoking products.

For smokers wanting to break the habit, nicotine patches, chewing gum, sprays and pastilles are among the few products officially recognised as cessation devices, but they are not effective for everyone and they are expensive. Increasing their chances of quitting by up to 50% are consultations with tobacco counsellors that are initially reimbursed by health insurance funds.

In Brussels and Wallonia, the nonprofit organisation FARES is specialised in preventing and treating tobacco addiction as well as tuberculosis. In addition to awareness-raising and prevention campaigns, it focuses on training tobacco counsellors, healthcare professionals that include physios, nurses, GPs, psychologists and psychiatrists.

Communications spokesperson Frédéric Godeaux acknowledges that while the ultimate goal is a tobacco-free generation, the organisation does not “push smokers to give up directly”. It provides individual support to smokers, while outlining the physical and mental harm of tobacco.

The organisation also educates on the positive and negative points of new products on the market. “Classic cigarettes are losing momentum, principally because of their price and people’s awareness of the damage they cause, so tobacco industries are shifting to alternatives… this is a new focus for our prevention and information campaigns.”

But Belgium could do better in terms of health prevention, insists Godeaux, pointing out that FARES is entirely dependent on state subsidies and has suffered budget restrictions.

Behaviour therapy is one approach

Cédric Migard is a project leader for FARES with expertise in addiction as well as psychiatric patients. He explains how the nicotine hit in cigarettes provides a false feeling of calm, while actually increasing arterial pressure and cardiac rhythm. “Up until 20 minutes after smoking a cigarette, you are putting your body thought a physiological stress.”

Students taking cigarette breaks during all-night revision sessions and motorists driving through the night are some examples of those in search of nicotine’s boosting effect. “Recognising the benefits that people are looking for in cigarettes is necessary to accompany them in seeking alternatives to help reduce their consumption.”

He underlines how all habits originate from a positive intention. “People don’t set out to destroy themselves. When they smoke a cigarette or drink a beer for the first time, it is for pleasure or other reasons they consider beneficial.”

While there is no simple solution to helping people to quit smoking, tobaccologists are trained in a non-confrontational approach that teases out personal motivations for reducing their habit. These could be no longer feeling out of breath when exercising or the desire to take up a sport or another activity. “We all need a carrot to take action and smoking is no different. Stopping just for the sake of it will probably not last,” underlines Migard.

Building a rapport, putting yourself in the place of the person in front of you … these are some of the guidelines for counsellors. “Cigarettes are a good way of discussing the environment of the smoker, whether it be home, school or work.”

This is especially pertinent in the mental health field. “Talking about smoking with patients is an excellent pretext for them to question their daily lives and routines, or even more complex or confrontational aspects of their existence.”  

In addition to recognised and effective cognitive behaviour therapy, there are alternative approaches. Hypnosis, mindfulness meditation, or the development of psycho-social skills, can all change personal attitudes to smoking and reduce consumption, says Migard.

A novel treatment is the ADDICT method (Accompanying Consciously Transformed Individual Addictions), which allows the person to recover some dignity in their own consumption. “If they are not abstinent, it is still possible to address the underlying causes of their addiction as well as pervious traumas. Overall, many people using this approach see their consumption decrease by a third from the first weeks of treatment."

Targeting obstinate smokers

Higher rates of smoking are linked to poverty, mental health, unemployment and lower education levels. Finding motivations to stop can require some experimentation. “It could be online mindfulness courses, yoga, gardening, small habits that help compensate for cigarettes.”

Among the benefits and incentives for smokers with mental health issues is a potential reduction in their medication. “There’s a mechanism in nicotine which reduces the capacity of some psychotropic medications; the conclusion is that if the person stops smoking, their treatment could be more effective and could be decreased.”

For people with diagnoses of bi-polar or schizophrenia, the smoking incidence is between 80% and 90%. Their tobacco consumption is often considered a secondary difficulty to their main pathology and other potential addictions such as alcoholism, says Migard. “To really do your job of accompanying someone effectively, you need to see them in their globality and recognise that smoking is part of their life. Tobacco can be a response to emptiness and solitude, the one faithful companion in life.”

This is one reason a nicotine substitution is recommended for these patients, says Migard. But it is a myth that stopping smoking can provoke psychosis or an increase in anxiety and depression.

Whatever the profile of the person wanting to reduce their consumption, establishing the extent of the smoking habit and physical dependency is a starting point. Evaluation tests exist, in short or long form, with the first ascertaining the number of cigarettes smoked per day and the time between waking and smoking the first cigarette.

How people smoke is another indicator, reveals Migard. Drawing strongly and quickly increases the combustion temperature its harmful effects, as does using rolled tobacco. Smoking a joint is estimated to be equivalent to smoking seven to 10 cigarettes because of the effect of mixing cannabis and tobacco, the conical form of a joint and the longer inhalation, he explains.

Alternative tobacco products and risk reduction

How useful are alternative tobacco products as cessation devices? “There is a consensus that electronic cigarettes offer a risk reduction compared to classic cigarettes; Belgium’s superior health council recognises that heated tobacco does not produce the same level of chemical toxicity.”

But there’s a lack of evaluation of their long-term benefits, he says. “We don’t have results for consumers using solely electronic products over a long period.”

He cites other alternatives such as traditional Swedish snus and its derivatives, including nicotine pouches that are anchored in Scandinavian culture, yet were banned in Belgium in 2023.

Electronic smoking devices, “neither an angel or a demon”, have evolved, with the fourth generation offering advantages as a cessation method because “the nicotine it uses is stronger and has a strong resemblance to a classic cigarette”.

Migard says the best tobacco harm reduction is when smokers reduce their cigarette consumption by at least 80%. “But the disadvantage is that the nicotine they use is more addictive.”

Otherwise, alternative products can play a role for some smokers to stop or reduce their habit. “We don’t usually recommend electronic devices for the first or second intervention. But when other methods have failed, they can be a last resort.”

It is possible to consult directly a tobaccologist with the first eight sessions reimbursed by health insurance. In Flanders and parts of Brussels, the Flemish Association for Respiratory Health Care and Tuberculosis Control (VRGT) is the equivalent service for Dutch speakers.

Photos: (main image) ©Belga/Virginie Lefour; ©FARES; ©Belga/Nicolas Maeterlinck