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Smoking cessation

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This article is about the cessation of smoking in general. For information regarding cannabis smoking, see Smoking cessation (cannabis).

Template:Globalize/USA Smoking cessation (colloquially quitting smoking) is the process of discontinuing the practice of inhaling a smoked substance.[1] Smoking cessation programs mainly target tobacco smoking, but may also encompass other substances that can be difficult to stop using due to the development of strong physical addictions or psychological dependencies resulting from their habitual use. This article focuses exclusively on cessation of cigarette smoking. However, the methods described may apply to cessation of smoking other substances.

It is believed that very few smokers can successfully quit the habit in their very first attempt. Many studies indicated that many smokers find it difficult to quit, even after they get afflicted with tobacco related diseases. A serious commitment and resolve is required to arrest nicotine dependency.

  • In a growing number of countries, there are more ex-smokers than smokers.[2] For example, in the U.S. as of 2010, there were 47 million ex-smokers and 46 million smokers.[3]
  • Up to three-quarters of ex-smokers have quit without assistance (“cold turkey” or cut down then quit), and unaided cessation is by far the most common method used by most successful ex-smokers.[2]
  • A serious attempt at stopping need not involve using nicotine replacement therapy (NRT) or other drugs or getting professional support.[2]
  • Early “failure” is a normal part of trying to stop. Many initial efforts are not serious attempts.[2]
  • NRT, other prescribed pharmaceuticals, and professional counselling or support also help many smokers, but are certainly not necessary for quitting.[2]

Smoking addiction

Individuals who sustained damage to the insula were able to more easily abstain from smoking.[4]

Tobacco contains the chemical nicotine. Smoking cigarettes leads to a dependence on nicotine. Cessation of smoking leads to physiological symptoms of withdrawal.[citation needed] Methods of smoking cessation must address this dependency and subsequent withdrawal symptoms.

Methods of smoking cessation

Major reviews of the scientific literature on smoking cessation include:

  • Systematic reviews of the Cochrane Tobacco Addiction Group of the Cochrane Collaboration.[5] As of 2011, this independent, international, not-for-profit organization has published over 60 systematic reviews "on interventions to prevent and treat tobacco addiction"[5] which will be referred to as "Cochrane reviews."
  • Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update of the United States Department of Health and Human Services, which will be referred to as the "2008 Guideline."[6] The Guideline was originally published in 1996[7] and revised in 2000[8]. For the 2008 Guideline, experts screened over 8700 research articles published between 1975 and 2007.[6]: 13–14  More than 300 studies were used in meta-analyses of relevant treatments; an additional 600 reports were not included in meta-analyses, but helped formulate the recommendations.[6]: 22  Limitations of the 2008 Guideline include its not evaluating studies of "cold turkey" methods ("unaided quit attempts") and its focus on studies that followed up subjects only to about 6 months after "quit date" (even though almost one-third of former smokers who relapse before one year will do so 7–12 months after "quit date").[6]: 19, 23 [9][10]

Unassisted methods

Analyzing a 1986 U.S. survey, Fiore et al. (1990) found that 95% of former smokers who had been abstinent for 1-10 years had made an unassisted last quit attempt.[11] The most frequent unassisted methods were "cold turkey" and "gradually decreased number" of cigarettes.[11] A 1995 meta-analysis estimated that the quit rate from unaided methods was 7.3% after an average of 10 months of follow-up.[12]

Cold turkey

"Cold turkey" is abrupt cessation of all nicotine use. In three studies, it was the quitting method used by 76%[13], 85%[11], or 88%[14] of long-term successful quitters. In a large British study of ex-smokers in the 1980s, before the advent of pharmacotherapy, 53% of the ex-smokers said that it was “not at all difficult” to stop, 27% said it was “fairly difficult”, and the remainder found it very difficult.[2] Cold turkey methods have been advanced by J. Wayne McFarland and Elman J. Folkenburg[15][16]; Joel Spitzer and John R. Polito[17]; and Allen Carr[18].

Cut down to quit

Gradual reduction involves slowly reducing one's daily intake of nicotine. This can be done in three ways: (a) by repeated changes to cigarettes with lower levels of nicotine, (b) by gradually reducing the number of cigarettes smoked each day, or (c) by smoking only a fraction of a cigarette each time lighting up. As of 2010, and unlike earlier studies which claimed some benefit for gradual reduction, a Cochrane review found that abrupt cessation and gradual reduction with pre-quit NRT produced similar quit rates.[19][20]

Health care provider and system interventions

Interventions related to health care providers and health care systems have been shown to improve smoking cessation among people who visit those providers.

  • A clinic screening system (e.g., computer prompts) to identify whether or not a person smokes doubled abstinence rates, from 3.1% to 6.4%.[6]: 78–79  Similarly, the Task Force on Community Preventive Services determined that provider reminders alone or with provider education are effective in promoting smoking cessation.[21]: 33–38 
  • A 2008 Guideline meta-analysis estimated that physician advice to quit smoking led to a quit rate of 10.2%, as opposed to a quit rate of 7.9% among patients who did not receive physician advice to quit smoking.[6]: 82–83  A Cochrane review found that even brief advice from physicians had "a small effect on cessation rates."[22] However, one study from Ireland involving vignettes found that physicians' probability of giving smoking cessation advice declines with the patient's age[23], and another study from the U.S. found that only 81% of smokers age 50 or greater received advice on quitting from their physicians in the preceding year.[24]
  • For person-to-person counseling sessions, the duration of each session, the total amount of contact time, and the number of sessions all correlated with the effectiveness of smoking cessation. For example, "Higher intensity counseling (>10 minutes)" produced a quit rate of 22.1% as opposed to 10.9% for "no contact"; over 300 minutes of contact time produced a quit rate of 25.5% as opposed to 11.0% for "no minutes"; and more than 8 sessions produced a quit rate of 24.7% as opposed to 12.4% for 0–1 sessions.[6]: 83–86 
  • Both physicians and nonphysicians increased abstinence rates compared with self-help or no clinicians.[6]: 87–88  For example, a Cochrane review of 31 studies found that nursing interventions increased the likelihood of quitting by 28%.[25]
  • According to the 2008 Guideline, based on two studies the training of clinicians in smoking cessation methods may increase abstinence rates[6]: 130 ; however, a Cochrane review found "no strong evidence" that such training decreased smoking in patients[26].
  • Reducing or eliminating the costs of cessation therapies for smokers increased quit rates in three meta-analyses.[6]: 139–140 [21]: 38–40 [27]

Pharmacological

The U.S. Food and Drug Administration has approved seven medications for treating nicotine addiction. All of these helped with withdrawal symptoms and cravings.

A 21mg dose Nicoderm CQ patch applied to the left arm.
  • Nicotine replacement therapy (NRT): Five of the approved medications are different methods of delivering nicotine in a form that does not involve the risks of smoking. The five NRT medications, which in a Cochrane review increased the chances of stopping smoking by 50 to 70% compared to placebo or to no treatment,[28] are:
    1. transdermal nicotine patches deliver doses of the addictive chemical nicotine, thus reducing the unpleasant effects of nicotine withdrawal. These patches can give smaller and smaller doses of nicotine, slowly reducing dependence upon nicotine and thus tobacco. A Cochrane review found further increased chance of success in a combination of the nicotine patch and a faster acting form.[28] Also, this method becomes most effective when combined with other medication and psychological support.[29]
    2. gum
    3. lozenges
    4. sprays
    5. inhalers.
A study found that 93 percent of over-the-counter NRT users relapse and return to smoking within six months.[30] A 2009 systematic review by researchers at the University of Birmingham found that gradual nicotine replacement therapy was effective in smoking cessation.[31][32]
  • Antidepressants: bupropion is an antidepressant marketed under the brand name Zyban.
    Bupropion is contraindicated in epilepsy, seizure disorder; anorexia/bulimia (eating disorders), patients' use of antidepressant drugs (MAO inhibitors) within 14 days, patients undergoing abrupt discontinuation of ethanol or sedatives (including benzodiazepines such as Valium)[33][34]
  • Nicotinic receptor agonist: varenicline is a marketed by Pfizer in the U.S. as Chantix and Champix in the UK and Canada. Varenicline Tartrate is a prescription drug that can be used to alleviate some of the withdrawal symptoms. It can also be taken as a form of aversion therapy by smokers to make the act of smoking non-appealing or with adverse effects, similar to acamprosate or disulfiram for ethanol addiction.
  • Cytisine (Tabex) is the basis of Pfizer's development of varenicline, and is an extremely inexpensive plant extract. It has been in use since the 1960s in former Soviet-bloc countries. It was the first medication approved as an aid to smoking cessation, and has very few side effects in small doses.[35][36]: 70  Pfizer funded and managed all studies of varenicline included in a 2008 Cochrane review[37] and unfortunately as of 2009, Cochrane reports, "The evidence on cytisine is limited at present, and no firm conclusions can yet be drawn about its effectiveness as an aid to quitting."[38]

Two other medications have been used in trials for smoking cessation, although they are not approved by the FDA for this purpose. They may be used under careful physician supervision if the first line medications are contraindicated for the patient.

  1. Clonidine may reduce withdrawal symptoms and "approximately doubles abstinence rates when compared to a placebo," but its side effects include dry mouth and sedation, and abruptly stopping the drug can cause high blood pressure and other side effects.[6]: 55, 116–117 [39]
  2. Nortriptyline, another antidepressant, has similar success rates to bupropion but has side effects including dry mouth and sedation[34][6]: 56, 117–118 .

Community interventions

A Cochrane review concluded that there was "limited evidence" that community interventions using "multiple channels to provide reinforcement, support and norms for not smoking" had an effect on smoking cessation among adults.[40] Specific methods used in the community to encourage smoking cessation among adults include:

  • Policies making workplaces[13] and public places smoke-free.
  • Voluntary rules making homes smoke-free, which are thought to promote smoking cessation.[13][41]
  • Initiatives to educate the public regarding the health effects of secondhand smoke
  • Increasing the price of tobacco products, for example by taxation. The Task Force on Community Preventive Services found "strong scientific evidence" that this is effective in increasing tobacco use cessation.[21]: 28–30 
  • Mass media campaigns. The Task Force on Community Preventive Services declared that "strong scientific evidence" existed for these when "combined with other interventions"[21]: 30–32 , but a Cochrane review concluded that it was "difficult to establish their independent role and value"[42].

Competitions and incentives

One 2008 Cochrane review concluded that "incentives and competitions have not been shown to enhance long-term cessation rates."[43] However, a randomized trial published in 2009 found that financial incentives for smoking cessation led to significantly higher rates of smoking cessation 15-18 months after enrollment.[44] Furthermore, a different 2008 Cochrane review found that one type of competition, "Quit and Win," did increase quit rates among participants.[45]

Psychosocial approaches

  • Great American Smokeout is an annual event that invites smokers to quit for one day, hoping they will be able to extend this forever.
  • The World Health Organization's World No Tobacco Day is held on May 31 each year.
  • Smoking-cessation support and counseling is often offered over the internet, over phone quitlines[46][47] (e.g., the US toll-free number 1-800-QUIT-NOW), or in person. Three meta-analyses have concluded that telephone cessation support is effective.[6]: 91–92 [21]: 40–42 [48]
  • Attending a self-help group such as Nicotine Anonymous[49] and electronic self-help groups such as Stomp It Out[50]
  • Group or individual therapy can help people who want to quit. Some smoking cessation programs employ a combination of coaching, motivational interviewing, cognitive behavioral therapy, and pharmacological counseling.
  • The Transtheoretical Model including "stages of change" has been used in tailoring smoking cessation methods to individuals.[51][52][53][54] However, a 2010 Cochrane review concluded that "stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents."[55]

Self-help

  • Interactive web- and computer-based programs that assist participants in quitting. A meta-analysis published in 2009[56] and a Cochrane review published in 2010[57] noted that the scientific evidence for such programs was "sufficient" but "did not show consistent effects."
  • Quit meters: Small computer programs that keep track of quit statistics such as amount of "quit-time", cigarettes not smoked, and money saved.
  • Self-help books such as Allen Carr's Easy Way to Stop Smoking.[18] A Cochrane review found that such self-help materials may produce a small increase in quit rates.[58]
  • Spirituality: In one survey of adult smokers, 88% reported a history of spiritual practice or belief, and of those more than three-quarters were of the opinion that using spiritual resources may help them quit smoking.[59]
  • Newsgroups: dating back to Usenet days, alt.support.stop-smoking has been used by people quitting smoking as a place to go to for support from others. It is accessible through Google Groups.[60]

Substitutes for cigarettes

  • One hitter: a screened miniature smoking utensil with narrow bowl diameter permits using a 25-mg serving each time instead of lighting up an entire cigarette (usually 700-mg). Traditional forms include kiseru (Japan), midwakh (U.A.E.), etc.
  • Vaporizer: heats to 410 °F (210 °C) or less, compared with 1,500 °F (820 °C) in the tip of a cigarette when drawn upon; eliminates carbon monoxide and other combustion toxins.
  • Electronic cigarette: Shaped like a cigar or cigarette to satisfy habitual tactile cravings, this device contains a rechargeable battery and a heating element that vaporizes liquid nicotine (and other flavorings) from an insertable cartridge, at lower initial cost than a vaporizer but with similar advantages including significantly reducing tar and carbon monoxide. In September 2008, the World Health Organization issued a release proclaiming that it does not consider the electronic cigarette to be a legitimate smoking cessation aid, stating that to its knowledge, "no rigorous, peer-reviewed studies have been conducted showing that the electronic cigarette is a safe and effective nicotine replacement therapy;"[61] however, sales have continued to rise with individual successes widely reported.
  • Smokeless tobacco: There is little smoking in Sweden, which is reflected in the low cancer rates for Swedish men. It is claimed that Swedish men are more likely to use snus (a form of steam-cured, rather than heat-cured, smokeless tobacco) than to smoke.[citation needed] There is a scientific debate over claims that spit tobacco might reduce the exposure of smokers to carcinogens or the risk for cancer (and even be used as a way to stop smoking). Some oral and spit tobaccos increase the risk for leukoplakia, a precursor to oral cancer.[62] Chewing tobacco has been known to cause cancer, particularly of the mouth and throat.
  • Smoking herb substitutions (non-tobacco).[63]

Alternative approaches

  • Acupuncture. A Cochrane review concludes that acupuncture "do[es] not appear to help smokers who are trying to quit"[64], a meta-analysis from the 2008 Guideline showed no difference between acupuncture and placebo[6]: 99–100 , and the 2008 Guideline found no scientific studies supporting laser therapy based on acupuncture principles but without the needles.[6]: 99 . Nevertheless, acupuncture has been called a "reasonable option" for smoking cessation because of its low risk[65].
  • Aromatherapy. A 2006 book reviewing the scientific literature on aromatherapy[66] identified only one study on smoking cessation and aromatherapy; the study concerned black pepper oil.[67]
  • Hypnosis. Clinical trials studying hypnosis and hypnotherapy as a method for smoking cessation have been inconclusive[6]: 100 [68]; however, a randomized trial published in 2008 found that hypnosis and nicotine patches "compares favorably" with standard behavioral counseling and nicotine patches in 12-month quit rates[69].

Smoking cessation in special populations

Children and adolescents

Methods used with children and adolescents include:

  • Motivational enhancement[70]
  • Psychological support[70]
  • Youth anti-tobacco activities, such as sport involvement
  • School-based curriculum, such as life-skills training [1]
  • Access reduction to tobacco
  • Anti-tobacco media [2] and [3]
  • Family communication

A Cochrane review, mainly of studies combining motivational enhancement and psychological support, concluded that "complex approaches" for smoking cessation among young people show promise.[70] The 2008 Guideline recommends counseling for adolescent smokers on the basis of a meta-analysis of seven studies.[6]: 159–161  Neither the Cochrane review nor the 2008 Guideline recommends medications for adolescents who smoke.

Pregnant women

Smoking during pregnancy can cause adverse health effects in both the woman and the fetus. The 2008 Guideline determined that "person-to-person psychosocial interventions" (typically including "intensive counseling") increased abstinence rates in pregnant women who smoke to 13.3%, compared with 7.6% in usual care.[6]: 165–167 

Comparison of success rates

Simple bar chart says "Varenicline + support" about 16, "NRT/bupropion + support" about 12.5, "NRT alone" about 7, "Telephone support" about 6, "Group support" about 5, "One-to-one support" about 4 and "Tailored online support" about 2.5.
Percent increase of success for six months over unaided attempts for each type of quitting (chart from West & Shiffman based on Cochrane review data[36]: 59 

Robert West and Saul Shiffman have authored works on smoking cessation. They believe that, used together, "behavioral support" and "medication" can quadruple the chances that a quit attempt will be successful. Both, however, disclosed that they are paid researchers or consultants to pharmaceutical companies or manufacturers of smoking cessation medications.[36]: 73, 76, 80 

The American Cancer Society (ACS) states "quit smoking programs, like other programs that treat addictions, often have fairly low success rates."[71] The ACS asserts that success rates may vary from project to project because "success" can be defined differently across projects.[71] Nevertheless, according to the ACS, "only about 4% to 7% of people are able to quit smoking on any given attempt without medicines or other help," and "about 25% and 33% of smokers who use medicines can stay smoke-free for over 6 months."[71]

In 2010 the National Tobacco Cessation Collaborative (NTCC) created What Works to Quit: A Guide to Quit Smoking Methods, which compares the efficacy and cost of 17 smoking cessation methods. The guide, based on the 2008 Guideline, reports that smokers using a combination method of pharmacological and psychosocial approaches have the most success compared to those who use pharmaceutical or psychosocial approaches in isolation.[72]

Factors affecting success

Quitting can be harder for individuals with dark pigmented skin compared to individuals with pale skin since nicotine has an affinity for melanin-containing tissues. Studies suggest this can cause the phenomenon of increased nicotine dependence and lower smoking cessation rate in darker pigmented individuals.[73]

There is an important social component to smoking. A 2008 study analyzing a densely interconnected network of over 12,000 individuals found that smoking cessation by any given individual reduced the chances of others around them lighting up by the following amounts: a spouse by 67%, a sibling by 25%, a friend by 36%, and a coworker by 34%.[74] Nevertheless, a Cochrane review determined that interventions to increase social support for a smoker's cessation program did not increase long-term quit rates.[75]

Smokers with major depressive disorder are less successful at quitting smoking than non-depressed smokers.[6]: 81 [76]

Side effects

Symptoms

In a 2007 review of the effects of abstinence from tobacco, Hughes concluded that "anger, anxiety, depression, difficulty concentrating, impatience, insomnia, and restlessness are valid withdrawal symptoms that peak within the first week and last 2–4 weeks."[34] In contrast, "constipation, cough, dizziness, increased dreaming, and mouth ulcers" may or may not be symptoms of withdrawal, while drowsiness, fatigue, and certain physical symptoms ("dry mouth, flu symptoms, headaches, heart racing, skin rash, sweating, tremor") were not symptoms of withdrawal.[34]

Weight gain

People who successfully quit smoking may gain weight. In a 1991 study that found that the mean weight gain due to smoking cessation was 2.8 kg (6.2 lb) for men and 3.8 kg (8.4 lb) for women, the researchers concluded "weight gain is not likely to negate the health benefits of smoking cessation, but its cosmetic effects may interfere with attempts to quit."[77]

The causes of the weight gain are unclear, but hypotheses include:

  • Smoking over expresses the gene AZGP1 which stimulates lipolysis, so smoking cessation may decrease lipolysis.[78]
  • Smoking suppresses appetite, which may be caused by nicotine's effect on central autonomic neurons (e.g., via regulation of melanin concentrating hormone neurons in the hypothalamus).[79]
  • Heavy smokers are reported to burn 200 calories per day more than non-smokers eating the same diet.[80] Possible reasons for this phenomenon include nicotine's ability to increase energy metabolism or nicotine's effect on peripheral neurons.[79]

The 2008 Guideline suggests that sustained-release bupropion, nicotine gum, and nicotine lozenge be used "to delay weight gain after quitting."[6]: 173–176  However, a 2009 Cochrane review concluded that "The data are not sufficient to make strong clinical recommendations for effective programmes" for preventing weight gain.[81]

Depression

When people with a history of depression stop smoking, depressive symptoms or actual depression may result.[76][82] This side effect of smoking cessation may be particularly common in women, as depression is more common among women than among men.[83]

Health benefits

Many of tobacco's health effects can be minimized through smoking cessation. The health benefits over time of stopping smoking include[84]:

  • Within 20 minutes after quitting, blood pressure and heart rate decrease
  • Within 12 hours, carbon monoxide levels in the blood decrease to normal
  • Within 3 months, circulation and lung function improve
  • Within 9 months, there are decreases in cough and shortness of breath
  • Within 1 year, the risk of coronary heart disease is cut in half
  • Within 5 years, the risk of stroke falls to the same as a non-smoker, and the risks of many cancers (mouth, throat, esophagus, bladder, cervix) decrease significantly
  • Within 10 years, the risk of dying from lung cancer is cut in half[85], and the risks of larynx and pancreas cancers decrease
  • Within 15 years, the risk of coronary heart disease drops to the level of a non-smoker

The British doctors study showed that those who stopped smoking before they reached 30 years of age lived almost as long as those who never smoked.[86] Stopping in one's sixties can still add three years of healthy life.[86] A randomized trial from the U.S. and Canada showed that a smoking cessation program lasting 10 weeks decreased mortality from all causes over 14 years later.[87]

See also

Template:MultiCol

Notes

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Further reading

  • Henningfield J, Fant R, Buchhalter A, Stitzer M (2005). "Pharmacotherapy for nicotine dependence". CA Cancer J Clin. 55 (5): 281–99, quiz 322–3, 325. doi:10.3322/canjclin.55.5.281. PMID 16166074.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  • Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004;99(1):29-38.
  • Hutter HP, et al. Smoking cessation at the workplace: 1 year success of short seminars. International Archives of Occupational & Environmental Health. 2006;79:42-48.
  • Marks DF (2005). Overcoming your smoking habit: a self-help guide using cognitive behavioral techniques. London: Robinson. ISBN 1845290674.
  • Peters MJ, Morgan LC. The pharmacotherapy of smoking cessation. Med J Aust 2002;176:486-490. PMID 12065013.
  • West R. Tobacco control: present and future. Br Med Bull 2006;77-78:123-36.
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