is the effort to stop smoking tobacco
is an addictive
substance, especially when taken in by inhaling tobacco because of the rapid absorption through the lungs. Tobacco use is one of the major causes of death worldwide, according to the World Health Organization
Research in Western countries has found that approximately 3-5% of quit attempts succeed using willpower alone (Hughes et al, 2004). The British Medical Journal and others have reviewed the evidence regarding which methods are most effective for smokers interested in breaking free of the smoking habit, and concluded that
Nicotine dependence is most effectively treated with a combination of drugs and specialist behavioural support . . .
As detailed in the Statistics section below, multi-session psychological support from a trained counselor, either individually or in groups has been shown in clinical trials to provide the greatest benefit.
An even better chance of success can be obtained by combining medication and psychological support (see below) (USDHHS, 2000). Medication or pharmacological quitting-aids that have shown evidence of effectiveness in clinical trials include medical nicotine replacement patches or gum, the tricyclic anti-depressant nortriptyline,bupropion (Zyban, or Quomem in some countries), and the nicotinic partial agonist, varenicline (Chantix in the US and Champix elsewhere).
There are many people and organizations touting what are claimed to be effective methods of helping smokers to stop. Any smoker thinking of paying money for such help would be well advised to ask whether the claims of success are backed up by independent comparative clinical trials, how the success rates have been calculated and what numbers of smokers have been included in the figures. It is very easy to make misleading claims of success rates which are not adequately supported by evidence. A separate thorough review of the evidence for each of several methods and aids for stopping smoking is available via the Cochrane Library website, Cochrane Library.
A range of population level strategies such as advertising campaigns, smoking restriction policies, and tobacco taxes have been used to promote smoking cessation. Of these, raising the cost of smoking is the one that has the strongest evidence (West, 2006).
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 60s can still add 3 years of healthy life (Doll et al, 2004). Stopping smoking is associated with better mental health and spending less of one's life with diseases of old age.
The most common short-term effects of stopping smoking are increased irritability, depression, anxiety, restlessness, difficulty concentrating, increased appetite, constipation, mouth ulcers and increased susceptibility to upper respiratory tract infections. These mostly last for up to 4 weeks, though increased appetite typically lasts for more than 3 months. The most obvious long-term effect is weight gain (Hughes, 2007).
A U.S Surgeon General's report includes tables setting forth success rates for various methods, some of which are listed below, ranked by success rate and identified by the Surgeon General's table number.
- Quitting programs combining counseling or support elements with a prescription for Bupropion SR (Zyban/Wellbutrin) found success rates were increased to 30.5 percent, (Surgeon General's Table 25).
- Quitting programs involving 91 to 300 minutes of contact time increased six month success rates to 28 percent, regardless of other quitting method included Surgeon General's Report Table 13, page 59]
- Quitting programs involving 8 or more treatment sessions increased six month success rates to 24.7 percent (Surgeon General's Table 14, page 60)
- High intensity counseling of greater than 10 minutes increased six month success rates to 22 percent whether added to any other quitting method, nicotine replacement, or cold turkey Surgeon General's Report Table 12, page 58]
- A physician's advice to quit can increase quitting odds by 30 percent to ten percent at six months Surgeon General's Report Table 11, page 57]
- Seven percent of over-the-counter nicotine patch and gum quitters quit for at least six months
Information for smokers trying to quit
Smoking cessation services, which offer 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.
Few smokers are successful with their very first attempt. Many smokers find it difficult to quit, even in the face of serious smoking-related disease in themselves or close family members or friends. A serious commitment to arresting dependency upon nicotine is essential. The typical effort of a person that finally succeeds is the seventh to fifteenth try. Each attempt is a learning experience that moves them that much closer to their goal of eventual permanent freedom from smoking.
Some studies have concluded that those who do successfully quit smoking can gain weight. "Weight gain is not likely to negate the health benefits of smoking cessation, but its cosmetic effects may interfere with attempts to quit." (Williamson, Madans et al, 1991). Therefore, drug companies researching smoking-cessation medication often measure the weight of the participants in the study.
Major depression may challenge smoking cessation success in women. 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.
Techniques which can increase smokers' chances of successfully quitting are:
- Quitting "cold turkey": abrupt cessation of all nicotine use as opposed to tapering or gradual stepped-down nicotine weaning. It is the quitting method used by 80 to 90% of all long-term successful quitters.
- Smoking-cessation support and counseling is often offered over the internet, over the phone quitlines (e.g. 1-800-QUIT-NOW), or in person.
- Nicotine replacement therapy when used for less than eight weeks helped with withdrawal symptoms, cravings, and urges (for example, transdermal nicotine patches, gum, lozenges, sprays, and inhalers). While nicotine has been found to have some benefit in treating nicotine addiction, other treatments were more effective. See Statistics section, above.
- The antidepressant bupropion, marketed under the brand name Zyban, helps with withdrawal symptoms, cravings, and urges. Bupropion is contraindicated in epilepsy, seizure disorder; anorexia/bulimia (eating disorders), patients use of psychosis drugs (MAO inhibitors) within 14 days, patients undergoing abrupt discontinuation of ethanol or sedatives (including benzodiazepines such as Valium)
- Nicotinic receptor antagonist varenicline (Chantix) (Champix in the UK)
- Recently, a shot given multiple times over the course of several months, which primes the immune system to produce antibodies which attach to nicotine and prevent it from reaching the brain, has shown promise in helping smokers quit. However, this approach is still in the experimental stages.
Some 'alternative' techniques which have been used for smoking cessation are:
- Hypnosis clinical trials studying hypnosis as a method for smoking cessation have been inconclusive. (The Cochrane Database of Systematic Reviews 2006, Issue 3.)
- Herbal preparations such as Kava and Chamomile
- Acupuncture clinical trials have shown that acupuncture's effect on smoking cessation is equal to that of sham/placebo acupuncture. (See Cochrane Review)
- Attending a self-help group such as Nicotine Anonymous and electronic self-help groups such as Stomp It Out
- Laser therapy based on acupuncture principles but without the needles.
- 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. Allen Carr's book is one of the most famous. He claims success rates of approximately 90% using his method.
- Spirituality Spiritual beliefs and practices may help smokers quit.
- Smokeless tobacco: Snus is widely used in Sweden, and although it is much healthier than smoking, something which is reflected in the low cancer rates for Swedish men, there are still some concerns about its health impact.
- Herbal and aromatherapy "natural" program formulations.
- Vaporizer: heats to 410°F. or less, compared with 1500°F./860°C. in tip of cigarette when drawn upon; eliminates carbon monoxide and other combustion toxins.
- Smoking reduction utensil (minitoke)
- Smoking herb substitutions (non-tobacco)
- "FAUX Cigarette" or similar commercial products which can be used as alternative to smoking as well as cessation.
- Ruyan a non-smokable electronic cigarette that functions as substitutes for quitting smoking and cigarette substitutes. The advantages of this invention include smoking without tar and carbon monoxide significantly reducing the risks posed by these carcinogens.
Upon smoking cessation, the body begins to rid itself of naturally foreign substances introduced to the body 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 him or herself 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 subjective in nature, and as a result less definite timescales are often cited.
As with other addictions, apart from the dependence of the body on chemical substances, a smoking addiction is often related to everyday lifestyle events, which can include thinking deeply, eating, drinking tea, coffee or alcohol, or general socializing. As a result, smokers may miss the act of smoking particularly at these times, and this may increase the difficulty inherent in a cessation attempt. As a result of a lower dopamine response from nicotine receptors in the brain, a degree of depression may ensue, along with somatic responses where the smoker feels less able to perform the day to day tasks previously related to smoking without having the usual cigarette to accompany them.
Information for healthcare professionals
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.
One way to assist smokers who want to quit is through a telephone quitline which is easily available to all. Professionally run quitlines may help less dependent smokers, but those people who are more heavily dependent on nicotine should seek local smoking cessation services, where they exist, or assistance from a knowledgeable health professional, where they do not. Some evidence suggests that better results are achieved when counseling support and medication are used simultaneously. Quitting with a group of other people who want to quit is also a method of getting support, available through many organizations.
Health professionals may follow the "five As" with every smoking patient they come in contact with:
- Ask about smoking
- Advise quitting
- Assess current willingness to quit
- Assist in the quit attempt
- Arrange timely follow-up
- Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observations on male British doctors. Bmj 2004;328(7455):1519.
- 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 "Pharmacotherapy for nicotine dependence". CA Cancer J Clin 55 (5): 281–99; quiz 322–3, 325. 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. 2005;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.
- Williamson, DF, Madans, J, Anda, RF, Kleinman, JC, Giovino, GA, Byers, T Smoking cessation and severity of weight gain in a national cohort N Engl J Med 1991 324: 739-745
- World Health Organization, Tobacco Free Initiative
- Zhu S-H, Anderson CM, Tedeschi GJ, et al. Evidene of real-world effectiveness of a telephone quitline$for smokers. N Engl J Med 2002;347(14):1087-93.