The SQuARe Trial: Staying Quit After Release from Prison

Participants in the intervention group will receive: 1. Brief counselling: Case workers will deliver one-on-one, personalised, brief (<10 minutes) cognitive-behavioural support at three time points: 1) between baseline and release from prison; 2) on the day of release from prison; and 3) two weeks after release from prison. Core tasks will include building participants' intrinsic motivation to stay quit post release, and helping them plan how to cope with cravings by identifying alternatives to replace the functions that smoking served (e.g., stress management, rewards) and strategies for dealing with friends/family who smoke, and encouraging use of evidence-based cessation assistance. The intervention will be tailored to address particular barriers to maintaining abstinence for people recently released from prison, such as smoking's association with freedom, heightened stress and anxiety levels upon and soon after release, subcultural norms related to smoking, and high levels of mental disorder and alcohol and other drug use. Normalisation of 'slip ups' and support to quit again post-relapse will be offered. 2. Relapse prevention calls from Quitline. Participants will be invited to provide a contact telephone number for a Quitline counsellor to contact them on days 1, 3, 7, 14 and 28 post release. These phone calls are anticipated to be approximately 10 minutes in duration. 3. Short-acting NRT: Nine days' supply of nicotine mouth spray will be provided to participants by an ACSO case worker on the day of release from prison, and again at a two-week follow-up contact. Each nicotine spray has 150 doses per spray pump, at 1mg per dose. Participants will be advised to use 1-2 sprays in their mouth whenever experiencing a cigarette craving, but no more than 2 sprays at once. Participants will be advised not to use more than 64 sprays within a 24 hour period, which is equal to 4 sprays per hour for 16 hours. ACSO staff will ask about nicotine spray at each follow-up, and will check for correct use, as will Quitline staff during phone calls. The following instructions will be provided to participants, verbally and in written format: “The mouth spray has a child proof button. Follow the instructions on the packet so the green pump pops up out of the top of the dispenser. If the spray is being used for the first time or it has not been used for several days, the spray should be primed. Priming involves pointing the spray away from you and depressing the dispenser with the index finger several times until a fine mist appears. This ensures the correct dosage is dispensed. Hold the pump close to your mouth and point the spray nozzle towards the side of your cheek or under your tongue, being sure to avoid the lips. Press down once. If cravings do not start to ease within a few minutes, use a second spray. Do not use more than 64 sprays within a 24 hour period, which is equal to 4 sprays per hour for 16 hours. Do not spray directly into the throat, directly onto the tongue or inhale while spraying. Do not breathe in while spraying to avoid getting it on your throat – this can cause hiccups or a burning feeling in the throat. Do not swallow for a few seconds after spraying for the best results – this is so the nicotine can be absorbed through the lining of the mouth. You should avoid eating and drinking 15 minutes before, and during, use of the mouth spray (except for water). Acidic foods or drinks, such as orange juice, coffee, beer and soft drink, interfere with the amount of nicotine passing through the lining of your mouth from the spray. If you get spray in your eye, rinse it immediately using lots of water. If you slip up and have a puff or a cigarette, don’t let it lead you back to full-time smoking. It is safe to keep using the mouth spray and re-commit to stopping smoking. If you go back to regular smoking you can also use the nicotine mouth spray to cut down the number of cigarettes you smoke before trying to stop smoking.” 4. Referral to primary care: Participants will be referred to bulk-billing General Practitioners in order to access PBS-subsidised nicotine patches. Case workers will identify a suitable bulk-billing primary care practice for each participant, and encourage the participant to make an appointment with a GP to discuss smoking cessation support. ReConnect staff will make a referral to primary care at the pre-release appointment and will follow this up with participants at subsequent appointments. Connecting prisoners with health care is a routine part of their service. For those who relapse to smoking during follow-up, combination therapy (where patches are combined with a short-acting form of NRT such as spray) is recommended best practice for nicotine-dependent smokers. Participants' visit to a GP clinic to access heavily PBS subsidised patches ($6.10 for health care card holders*) in combination with the provided nicotine spray will ensure that combination therapy is available to each participant soon after release from prison.