Smoking cessation

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Smoking cessation (colloquially quitting smoking) is the process of discontinuing tobacco smoking. Tobacco contains nicotine, which is addictive.[1]

Smoking cessation can be achieved with or without assistance from healthcare professionals or the use of medications.[2] Methods that have been found to be effective include interventions directed at or via health care providers and health care systems; medications including nicotine replacement therapy (NRT) and varenicline; individual and group counselling; and Web-based or stand-alone and computer programs. Although stopping smoking can cause short-term side effects such as reversible weight gain, smoking cessation services and activities are cost-effective because of the positive health benefits.

Tobacco contains nicotine. Smoking cigarettes can lead to nicotine addiction.[4]:2300–2301 The addiction begins when nicotine acts on nicotinic acetylcholine receptors to release neurotransmitters such as dopamine, glutamate, and gamma-aminobutyric acid.[4]:2296 Cessation of smoking leads to symptoms of nicotine withdrawal such as anxiety and irritability.[4]:2298 Professional smoking cessation support methods generally endeavour to address both nicotine addiction and nicotine withdrawal symptoms.

Studies have shown that it takes between 6 to 12 weeks post quitting before the amount of nicotinic receptors in the brain return to the level of a non smoker.[5]

Methods[edit]

Major reviews of the scientific literature on smoking cessation include:

Unassisted methods[edit]

As it is common for ex-smokers to have made a number of attempts (often using different approaches on each occasion) to stop smoking before achieving long-term abstinence, identifying which approach or technique is eventually most successful is difficult; it has been estimated, for example, that "only about 4% to 7% of people are able to quit smoking on any given attempt without medicines or other help.".[12] However, in analysing 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.[13] The most frequent unassisted methods were "cold turkey" and "gradually decreased number" of cigarettes.[13] A 1995 meta-analysis estimated that the quit rate from unaided methods was 7.3% after an average of 10 months of follow-up.[14]

Cold turkey[edit]

"Cold turkey" is a colloquial term indicating abrupt withdrawal from an addictive drug, and in this context indicates sudden and complete cessation of all nicotine use. In three studies, it was the quitting method cited by 76%,[15] 85%,[13] or 88%[16] 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 remaining 20% found it very difficult.[2] Cold turkey methods have been advanced by J. Wayne McFarland and Elman J. Folkenburg;[17][18] Joel Spitzer and John R. Polito;[19] Allen Carr,[20] and Jason Wright.[21]

Healthcare provider and systems[edit]

Interventions delivered via healthcare providers and healthcare systems have been shown to improve smoking cessation among people who visit those providers.

Biochemical feedback[edit]

Various methods exist which allow a smoker to see the impact of their tobacco use, and the immediate effects of quitting. Using biochemical feedback methods can allow tobacco-users to be identified and assessed, and the use of monitoring throughout an effort to quit can increase motivation to quit.[31][32]

While both measures offer high sensitivity and specificity, they differ in usage method and cost. As an example, breath CO monitoring is non-invasive, while cotinine testing relies on a bodily fluid. These two methods can be used either alone or together, for example, in a situation where abstinence verification needs additional confirmation.[35]

Single medications[edit]

A 21mg dose Nicoderm CQ patch applied to the left arm.

The American Cancer Society estimates that "between about 25% and 33% of smokers who use medicines can stay smoke-free for over 6 months."[12] Single medications include:

A study found that 93 percent of over-the-counter NRT users relapse and return to smoking within six months.[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.[7]:55,116–117[55]
  2. Nortriptyline, another antidepressant, has similar success rates to bupropion but has side effects including dry mouth and sedation.[7]:56,117–118[40]

Combinations of medications[edit]

The 2008 US Guideline specifies that three combinations of medications are effective[7]:118–120:

Cut down to quit[edit]

Gradual reduction involves slowly reducing one's daily intake of nicotine. This can theoretically be accomplished through repeated changes to cigarettes with lower levels of nicotine, by gradually reducing the number of cigarettes smoked each day, or by smoking only a fraction of a cigarette on each occasion. A 2009 systematic review by researchers at the University of Birmingham found that gradual nicotine replacement therapy could be effective in smoking cessation.[56][57] A 2010 Cochrane review found that abrupt cessation and gradual reduction with pre-quit NRT produced similar quit rates whether or not pharmacotherapy or psychological support was used. [58][59] According to a more recent 2012 Cochrane systematic review analysis of 10 studies and 3670 patients, overall relative risk reduction between smokers who attempted to quit with abrupt cessation or with gradual reduction techniques was 0.06. This analysis demonstrated that there was no significant difference in quit rates between smokers who quit by gradual reduction or abrupt cessation as measured by abstinence from smoking of at least six months from the quit day, suggesting that patients who want to quit can choose between these two methods.[60]

Community interventions[edit]

A Cochrane review found evidence that community interventions using "multiple channels to provide reinforcement, support and norms for not smoking" had an effect on smoking cessation outcomes among adults.[61] Specific methods used in the community to encourage smoking cessation among adults include:

Competitions and incentives[edit]

One 2008 Cochrane review concluded that "incentives and competitions have not been shown to enhance long-term cessation rates."[66] However, a trial published in 2009 found that financial incentives for smoking cessation led to significantly higher rates of smoking cessation 15–18 months after enrollment.[67] Furthermore, a different 2008 Cochrane review found that one type of competition, "Quit and Win," did increase quit rates among participants.[68]

Psychosocial approaches[edit]

Self-help[edit]

Some health organizations manage text messaging services to help people avoid smoking

A 2005 Cochrane review found that self-help materials may produce only a small increase in quit rates.[85] In the 2008 Guideline, "the effect of self-help was weak," and the number of types of self-help did not produce higher abstinence rates.[7]:89–91 Nevertheless, self-help modalities for smoking cessation include:

Substitutes for cigarettes[edit]

Alternative approaches[edit]

Special populations[edit]

Children and adolescents[edit]

Methods used with children and adolescents include:

A Cochrane review, mainly of studies combining motivational enhancement and psychological support, concluded that "complex approaches" for smoking cessation among young people show promise.[119] The 2008 US Guideline recommends counselling-style support for adolescent smokers on the basis of a meta-analysis of seven studies.[7]:159–161 Neither the Cochrane review nor the 2008 Guideline recommends medications for adolescents who smoke.

Pregnant women[edit]

Smoking during pregnancy can cause adverse health effects in both the woman and the fetus. The 2008 US 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.[7]:165–167 Mothers who smoke during pregnancy have a greater tendency towards premature births. Their babies are often underdeveloped, have smaller organs, and weigh much less compared with the normal baby. In addition, these babies have worse immune systems, making them more susceptible to many diseases in early childhood, such as middle ear inflammations and asthmatic bronchitis which can bring about a lot of agony and suffering. As well, there is a high chance that they will become smokers themselves when grown up.

It is a widely spread myth that a female smoker can cause harm to her fetus by quitting immediately upon discovering that she is with child. Though this idea does seem to follow logic, it is not based on any medical study or fact.[121]

Workers[edit]

A 2008 Cochrane review of smoking cessation activities in work-places concluded that "interventions directed towards individual smokers increase the likelihood of quitting smoking."[122] A 2010 systematic review determined that worksite incentives and competitions needed to be combined with additional interventions to produce significant increases in smoking cessation rates.[123]

Hospitalised smokers[edit]

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[44]:59

Smokers who are hospitalised may be particularly motivated to quit.[7]:149–150 A 2007 Cochrane review found that interventions beginning during a hospital stay and continuing for one month or more after discharge were effective in producing abstinence.[124] But the use of Swedish snus should be considered for use by patients who require not only the nicotine but the other alkaloids present in tobacco that users enjoy.

Comparison of success rates[edit]

Comparison of success rates across interventions can be difficult because of different definitions of "success" across studies.[12] Robert West and Saul Shiffman, authorities in this field recognised by government health departments in a number of countries [44]:73,76,80, have concluded that, used together, "behavioural support" and "medication" can quadruple the chances that a quit attempt will be successful. In 2010 the US 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.[125] 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.[125]

A 2008 systematic review in the European Journal of Cancer Prevention found that group behavioural therapy was the most effective intervention strategy for smoking cessation, followed by bupropion, intensive physician advice, nicotine replacement therapy, individual counselling, telephone counselling, nursing interventions, and tailored self-help interventions; the study did not discuss varenicline.[62]

Individuals who sustained damage to the insula were able to more easily abstain from smoking.[126]

Factors affecting success[edit]

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.[127]

There is an important social component to smoking. A 2008 study of 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%.[128] Nevertheless, a Cochrane review determined that interventions to increase social support for a smoker's cessation attempt did not increase long-term quit rates.[129]

Smokers who are trying to quit are faced with social influences that may persuade them to conform and continue smoking. Cravings are easier to detain when ones environment does not provoke the habit. If a person who stopped smoking has close relationships with active smokers they are often put into situations that make the urge to conform more tempting. However, in a small group with at least one other not smoking, the likelihood of conformity decreases. The social influence to smoke cigarettes has been proven to rely on simple variables. One researched variable depends on whether the influence is from a friend or non-friend.[130] the research shows that individuals are 77% more likely to conform to non-friends, while close friendships decrease conformity. Therefore, if an acquaintance offers a cigarette as a polite gesture, the person who has stopped smoking will be more likely to break his commitment than if a friend had offered.

Smokers with major depressive disorder may be less successful at quitting smoking than non-depressed smokers.[7]:81[131]

Relapse (resuming smoking after quitting) has been related to psychological issues such as low self-efficacy[132] or non-optimal coping responses;[133] however, psychological approaches to prevent relapse have not been proven to be successful.[134] In contrast, varenicline may help some relapsed smokers.[134]

Side effects[edit]

Duration of nicotine withdrawal symptoms
Craving for tobacco3 to 8 weeks[135]
DizzinessFew days[135]
Insomnia1 to 2 weeks[135]
Headaches1 to 2 weeks[135]
Chest discomfort1 to 2 weeks[135]
Constipation1 to 2 weeks[135]
Irritability2 to 4 weeks[135]
Fatigue2 to 4 weeks[135]
Cough or nasal dripFew weeks[135]
Lack of concentrationFew weeks[135]
HungerUp to several weeks[135]

Symptoms[edit]

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."[40] 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.[40]

Weight gain[edit]

Giving up smoking is associated with an average weight gain of 4–5 kilograms (8.8–11.0 lb) after 12 months, most of which occurs within the first three months of quitting.[136]

The possible causes of the weight gain include:

The 2008 Guideline suggests that sustained-release bupropion, nicotine gum, and nicotine lozenge be used "to delay weight gain after quitting."[7]:173–176 However, a 2012 Cochrane review concluded that "The data are not sufficient to make strong clinical recommendations for effective programmes" for preventing weight gain.[140]

Depression[edit]

Like other physically addictive drugs, nicotine withdrawal causes down-regulation of the production of dopamine and other stimulatory neurotransmitters as the brain attempts to compensate for artificial stimulation. Therefore, when people stop smoking, depressive symptoms or actual depression may result.[131][141] This side effect of smoking cessation may be particularly common in women, as depression is more common among women than among men.[142]

Anxiety[edit]

A recent study by The British Journal of Psychiatry has found that smokers who successfully quit feel less anxious afterwards with the effect being greater among those who had mood and anxiety disorders than those that smoked for pleasure.[143]

Health benefits[edit]

Many of tobacco's detrimental health effects can be reduced or largely removed through smoking cessation. The health benefits over time of stopping smoking include:[144]

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.[146] Stopping in one's sixties can still add three years of healthy life.[146] 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.[147]

Another published study, "Smoking Cessation Reduces Postoperative Complications: A Systematic Review and Meta-analysis," examined six randomized trials and 15 observational studies to look at the effects of preoperative smoking cessation on postoperative complications. The findings were: 1) taken together, the studies demonstrated decreased likelihood of postoperative complications in patients who ceased smoking prior to surgery; 2) overall, each week of cessation prior to surgery increased the magnitude of the effect by 19%. A significant positive effect was noted in trials where smoking cessation occurred at least four weeks prior to surgery; 3) For the six randomized trials, they demonstrated on average a relative risk reduction of 41% for postoperative complications.[148]

Cost-effectiveness[edit]

Smokers as a percentage of the population for the United States, the Netherlands, Norway, Japan, and Finland.

Cost-effectiveness analyses of smoking cessation activities have shown that they increase quality-adjusted life years (QALYs) at costs comparable with other types of interventions to treat and prevent disease.[7]:134–137 Studies of the cost-effectiveness of smoking cessation include:

Statistical trends[edit]

The frequency of smoking cessation among smokers varies across countries. Smoking cessation increased in Spain between 1965 and 2000,[152] in Scotland between 1998 and 2007,[153] and in Italy after 2000.[154] In contrast, in the U.S. the cessation rate was "stable (or varied little)" between 1998 and 2008,[155] and in China smoking cessation rates declined between 1998 and 2003.[156]

Nevertheless, in a growing number of countries there are now 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.[157]

See also[edit]

Bibliography[edit]

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