Smoking cessation

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. 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. For example, in the U.S. as of 2010, there were 47 million ex-smokers and 46 million smokers.)
• 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.
• A serious attempt at stopping need not involve using nicotine replacement therapy (NRT) or other drugs or getting professional support.
• Early “failure” is a normal part of trying to stop. Many initial efforts are not serious attempts.
• NRT, other prescribed pharmaceuticals, and professional counselling or support also help many smokers, but are certainly not necessary for quitting.

Smoking addiction

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

Methods of smoking cessation

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.

Cold turkey

"Cold turkey" is abrupt cessation of all nicotine use. It is the quitting method used by 80% to 90% of long-term successful quitters in some populations. 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. Cold turkey methods have been advanced by J. Wayne McFarland and Elman J. Folkenburg; Joel Spitzer and John R. Polito; and Allen Carr.

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.

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 Cochrane found in 1996 increased the chances of stopping smoking by 50 to 70% compared to placebo or to no treatment, 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. Cochrane found further increased chance of success in a combination of the nicotine patch and a faster acting form. Also, this method becomes most effective when combined with other medication and psychological support.
  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.

• 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)
• 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. Pfizer funded and managed all studies of varenicline that were reviewed in a 2008 Cochrane review 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."

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 craving for cigarettes after cessation. However, it does not consistently ameliorate other withdrawal symptoms.
2. Nortriptyline, another antidepressant, has similar success rates to bupropion.

Population-based approaches

With adults:

• Policies making workplaces and public places smoke-free
• Voluntary rules making homes smoke-free, which are thought to promote smoking cessation and to reduce the number of children initiating smoking.
• Initiatives to educate the public regarding the health effects of secondhand smoke

With children:

• 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

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 the phone quitlines (e.g. the US toll-free number 1-800-QUIT-NOW), or in person.
• Attending a self-help group such as Nicotine Anonymous and electronic self-help groups such as Stomp It Out
• 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. 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."

Self-help

• Interactive web- and computer-based programs that assist participants in quitting. A meta-analysis published in 2009 and a systematic review published in 2010 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".
• Spirituality Spiritual beliefs and practices may help some smokers quit.
• 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.

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;" 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. 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. Chewing tobacco has been known to cause cancer, particularly of the mouth and throat.
• Smoking herb substitutions (non-tobacco).

Alternative medical approaches

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

• Hypnosis clinical trials studying hypnosis as a method for smoking cessation have been inconclusive although many people have successfully quit smoking using hypnosis and hypnotherapy.
• Aromatherapy based treatments and herbal preparations such as Kava and Chamomile, the efficacy of which has not been established.
• Acupuncture: although a Cochrane review concludes that acupuncture "do[es] not appear to help smokers who are trying to quit", it has been called a "reasonable option" for smoking cessation because of its low risk.
• Laser therapy based on acupuncture principles but without the needles.

Comparison of success rates

Percent increase of success for six months over unaided attempts for each type of quitting (chart from West & Shiffman based on Cochrane review data

The American Cancer Society (ACS) website says, "The truth is that quit smoking programs, like other programs that treat addictions, often have fairly low success rates." ACS says, "Success rates are hard to figure out for many reasons...not all programs define success in the same way." The ACS says "that between about 25% and 33% of smokers who use medicines can stay smoke-free for over 6 months". 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 Update to the Treating Tobacco Use and Dependence report, 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.

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.

There is an important social component to smoking, which can be utilized by the counselors while advising the addicts. 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%.

About 10% of people who quit unaided will remain non-smokers for 12 months. Researchers at the University of Birmingham think about half of people who abstain for six months will maintain abstinence for the rest of their lives.

Controlled trials

To determine the benefit or harm of a new therapy, ideally, a randomized controlled trial is conducted. In such a trial, one group of people is exposed to the treatment and another similar group is not. After some months or years have elapsed, the two groups are compared. In the case of smoking cessation trials, the measures focus on rate of successful withdrawal, length of time in withdrawal, and relapses.

Many people and organizations tout what are claimed to be effective methods of helping smokers to stop. Such claims of success are rarely backed up by independent comparative clinical trials or correctly calculated success rates. A separate thorough review of the evidence for each of several methods and aids for stopping smoking is available via the Cochrane Library website.

Many such trials have been conducted to determine the health effects of quitting smoking although most have used quitting plus other lifestyle changes in diet and exercise, with or without drugs to improve blood pressure and blood cholesterol. The Cochrane Collaboration have examined these trials and concluded that such interventions do not improve life expectancy or the death rate due to heart disease. They conclude that "Contrary to expectations, these lifestyle changes had little or no impact on the risk of heart attack or death" and "The continued enthusiasm for health promotion practices given the failure of these community intervention trials is curious, especially given the huge resources which have been put into them."

U.S. Clinical Practice Guideline

The Guideline was published in 2000 called Clinical Practice Guideline: Treating Tobacco Use and Dependence and updated in 2008 in the publication "Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update" (to be called here the "Clinical Practice Guideline", or "2008 update" or simply "Guideline" report).

Experts screened over 8700 research articles published between 1975 and 2007. More than 300 studies passed the criteria for the gold standard trials. Using these 300 studies for a meta-analysis of relevant treatments, it gives advice on smoking cessation treatment. An additional 600 reports were not included in the meta-analysis, but helped formulate the recommendations. In general:

a) Control groups quit at a rate of around 10%.

b) Pharmacological treatments resulted in 15-33% quit rates.

d) Psychosocial interventions resulted in 14-25% quit rates.

e) Little or no evidence was found to support use of hypnosis, acupuncture, or laser therapy as treatments for smoking cessation, alternate medicine or cigarette substitutes.

The following results are shown in Table 6.26 comparing placebo effect to pharmacological treatments.

• The placebo quit rate for all of these comparisons was (13.8%) (table 6.26).
• All forms of drugs approved by the FDA for smoking cessation show more than twice the quit rate of the placebo group.
• The quit rate for using Varenicline(2 mg/day) (33.2%) as much as tripled over the placebo (13.8%) (Table 6.26). This was one of the highest quit rates for any single treatment. However, counter indications and adverse side effects might make it use undesirable for many smokers.
• Nicotine gum increased quit rate to 19%.
• All other FDA approved drugs alone increased quit rate about equally well (22.5-26.7%).
• Use of non-FDA approved, second line medications, did not significantly increase quit rates.
• The Nicotine Patch plus ad lib use of gum or spray increased quit rates to 36.5%, the largest quit rate reported in the study.
• The patch plus other FDA approved medications raised quit rates to between 25.8-28.9%.
• A physician's advice to quit can, significantly, increase quitting odds by 25 percent to (7.9% for no advise to 10.2% for advice. (Table 6.7) Not reported in the Guideline, several studies have found that smoking cessation advice is not always given in primary care in patients aged 65 and older, despite the significant health benefits which can ensue in the older population.
• Intensity of clinical intervention affects the degree of successful cessations.

• 1) Contact of 3 to 10 minutes can increase quit rate 60%. (Table 6.8)
• 2) Cessation programs involving more than 30 minutes of contact time increased success rates over no contact (11%) as much as 2 to almost 3 times (26% to 38.4%), regardless of other quitting method included (Table 6.9)

• Number of Sessions: Programs involving 8 or more treatment sessions can double success rates (24%) over 0 or 1 session (12%). (Table 6.10)
• Multiple formats of psychosocial interventions increase quit rates: 10% for no intervention, average 15.1% for one format, 18.5% for 2 formats, and 23.2% for three or four formats (Table 6.14).
• Self-help: Evidence did not support the efficacy of any self-help method (Table 6.15). The Authors advise more research on this in the future.
• Quitlines counseling significantly increased quit rate (12.7%) over self-help, minimal or no counseling (8.5%). Quitline counseling combined with medication (28.1%) also increased quit rate over medication alone (23.2%).
• Computerized Interventions (web-based or stand-alone) was identified in the Guideline report as having significant effects on quit rate, but no specifics were given.
• High intensity counseling of two or more sessions increased success rates to 27.6 to 32% when added to using any form of medication (Table 6.22, 6.23)
• The success rate of counseling alone (14.6%) was improved by adding use of medication to any counseling form (22.1%)

The Guideline has been criticized in that it included studies that followed up subjects only to about 6 months after "quit day" and in that it did not examine evidence regarding unaided quit attempts.

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." 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.

Weight gain

Some studies have concluded that those who do 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." Therefore, drug companies researching smoking-cessation medication often measure the weight of the participants in the study. In 2009, it was found that smoking over expresses the gene AZGP1 which stimulates lipolysis, which is the possible reason why smoking cessation leads to weight gain. Ex-smokers have to overcome the fact that nicotine is an appetite suppressant. Also, heavy smokers burn 200 calories per day more than non-smokers eating the same diet.

Depression

In the case of many adults,but more especially women, a major hurdle for quitting may emanate from clinical depression and challenge smoking cessation. Quitting smoking is especially difficult during certain phases of the reproductive cycle, phases that have also been associated with greater levels of dysphoria, and subgroups of women who have a high risk of continuing to smoke also have a high risk of developing depression. Since many women who are depressed may be less likely to seek formal cessation treatment, practitioners have a unique opportunity to persuade their patients to quit.

Health benefits

Many of tobacco's health effects can be minimized through smoking cessation. The immediate effects of smoking cessation include:

• Within 20 minutes, blood pressure decreases, pulse returns to its normal level
• After 8 hours, carbon monoxide levels in the blood return to normal, oxygen level increases
• After 24 hours, chance of heart attack starts to decrease; breath, hair and body stop smelling like smoke
• After 48 hours, damaged nerve endings begin to recover; sense of taste and smell improve
• After 72 hours, the body is virtually free of nicotine; bronchial tubes relax, breathing becomes easier
• After 2–12 weeks, lungs can hold more air, exercise becomes easier and circulation improves

Longer-term effects include:

• After 1 year, the risk of coronary heart disease is cut in half
• After 5 years, the risk of stroke falls to the same as a non-smoker
• After 10 years, the risk of lung cancer is cut in half and the risk of other cancers decreases significantly
• After 15 years, the risk of coronary heart disease drops, usually 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. Smoking cessation will almost always lead to a longer and healthier life. Stopping in early adulthood can add up to 10 years of healthy life and stopping in one's sixties can still add three years of healthy life. Stopping smoking is associated with better mental health and spending less of one's life with diseases of old age.

Some research has indicated that some of the damage caused by smoking tobacco can be moderated with the use of antioxidants.

Upon smoking cessation, the body begins to rid itself of foreign substances introduced through smoking. These include substances in the blood such as nicotine and carbon monoxide, and also accumulated particulate matter and tar from the lungs. As a consequence, though the smoker may begin coughing more, cardiovascular efficiency increases.

Many of the effects of smoking cessation can be seen as landmarks, often cited by smoking cessation services, by which a smoker can encourage himself to keep going. Some are of a certain nature, such as those of nicotine clearing the bloodstream completely in 48 to 72 hours, and cotinine (a metabolite of nicotine) clearing the bloodstream within 10 to 14 days. Other effects, such as improved circulation, are more variable in nature, and as a result less definite timescales are often cited.

See also

• American Legacy Foundation
• Carbon monoxide breath monitor
• Coerced abstinence
• Bijan Daneshmand
• Electronic cigarette
• Health promotion
• Herbal tobacco alternatives
• List of smoking bans in the United States
• Massachusetts Tobacco Cessation and Prevention Program (MTCP)
• National Tobacco Cessation Collaborative
• Nicotine Anonymous
• Nicotine replacement therapy
• NicVAX
• Smoking cessation (cannabis)
• Smoking cessation programs in Canada
• Tobacco and health
• Tobacco cessation clinic
• U.S. government and smoking cessation
• Youth Tobacco Cessation Collaborative

Further reading

• Helgason AR, Tomson T, Lund KE, Galanti R, Ahnve S, Gilljam H. Factors related to abstinence in a telephone helpline for smoking cessation. European J Public Health 2004: 14;306-310.
• 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) Full text
• 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 H.P. et al. Smoking Cessation at the Workplace:1 year success of short seminars. International Archives of Occupational & Environmental Health. 2006;79:42-48.
• Marks, D.F. The QUIT FOR LIFE Programme: An Easier Way To Quit Smoking and Not Start Again. Leicester: British Psychological Society. 1993.
• Marks, D.F. & Sykes, C. M. Randomized controlled trial of cognitive behavioural therapy for smokers living in a deprived area of London: outcome at one-year follow-up. Psychology, Health & Medicine 2002;7:17-24.
• Marks, D.F. Overcoming Your Smoking Habit. London: Robinson. 2005.
• Peters MJ, Morgan LC. The pharmacotherapy of smoking cessation. Med J Aust 2002;176:486-490. Fulltext. PMID 12065013.
• Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2004(3):CD000146.
• USDHHS. Treating Tobacco Use and Dependence. Rockville, MD: Agency for Healthcare Research Quality; 2000.
• West R. Tobacco control: present and future. Br Med Bull 2006;77-78:123-36.
• Williams LN , “Oral Health is Within REACH”, Navy Medicine, Mar-Apr 2001
• Williams LN, “Tobacco Cessation: An Access to Care Issue”, Navy Medicine, 2002
• World Health Organization, Tobacco Free Initiative
• Zhu S-H, Anderson CM, Tedeschi GJ, et al. Evidence of real-world effectiveness of a telephone quitline for smokers. N Engl J Med 2002;347(14):1087-93.