Smoking cessation

Essentials

• Six out of ten smokers would like to stop smoking. Smoking cessation usually needs 3–4 attempts to succeed.
• A simple encouragement by a doctor to stop smoking is effective, but a three minute counselling session is even more effective .
• Ask about the patient’s smoking habits and willingness to stop (use the six A's approach: ask, assess, account, advise, assist, arrange).
• Motivational interviewing can reinforce the patient's readiness, willingness, and ability for a lifestyle change.
• Varenicline and bupropion are effective in supporting smoking cessation.
• Nicotine replacement therapy increases the success rate of smoking cessation 1.5–2 fold .
• Nicotine dependence (F17.2) is similar to other substance dependence disorders as regards to pharmacological and behaviour control factors.
• Smoking is the most important preventable cause of mortality. 50% of smokers will die of an illness caused by smoking .
• Support to smoking cessation should be organized as a part of primary health care services.

Smoking cessation

Readiness to stop smoking

• Motivational interviewing can reinforce the patient's readiness, willingness, and ability for a lifestyle change .
  • Readiness for a lifestyle change has been described with a Stages of Change Model by Prochaska and DiClemente (apathy, denial – contemplation – decision making – smoking cessation – maintenance, i.e. permanent non-smoker)
• Determine your patient’s present stage in order to be able to support him/her in the best way possible .
• However, it is worthwhile to provide a possibility for discussion and help in cessation for everyone.
• Personal, tailored and repeated contacting of those contemplating cessation may enhance the recruitment of participants into smoking cessation programmes .
• Smoking cessation often is a long process, and support is required.

Positive effects of smoking cessation

• Carbon monoxide vanishes from the body in a day and nicotine in two days.
• Cough and mucus production alleviate within 1–2 months and lung function improves significantly within 2–3 months after cessation.
• Subjective stress will decrease . Both the quantity and quality of sleep will improve.
• The risk of myocardial infarction will halve within a year, and that of lung cancer within ten years.
• Cessation at the age of 50 will halve the risk of smoking-induced premature death, and by stopping at the age of 30 the risk may be almost completely abolished.
• In chronic obstructive pulmonary disease, smoking cessation at any stage will have a beneficial effect on prognosis.
• The risk of postoperative complications, e.g. wound infections is decreased .
• Erectile dysfunction will abate in every fourth man who stops smoking.
• The senses of smell and taste start to improve in a few days already.

Withdrawal symptoms

• Most people will experience some withdrawal symptoms which usually are caused by the decreased concentration of nicotine in the body.
  • Irritability
  • Impatience
  • Craving for a cigarette
  • Restlessness
  • Difficulty in concentrating
  • Insomnia
  • Headache
  • Increased appetite
• Symptoms will emerge within 2–12 hours after stopping smoking, peak at days 1–3 and last on average from 3 to 4 weeks.
• The duration of symptoms show great interindividual variation. The duration cannot be anticipated by the number of cigarettes smoked or by the results of a nicotine dependence test (Fagerström two question test, table ).
• Coffee may aggravate withdrawal symptoms.

Weight gain

• Weight gain should be expected after stopping smoking.
• In men, the average weight gain is 2.8 kg and in women 3.8 kg during the 6–12 months following stopping. However, 10% of men and 13% of women will gain more than 13 kg.
• Individualized guidance in dietary measures and exercise in association with smoking cessation may reduce weight gain.
• Nicotine replacement therapy, bupropion or varenicline may reduce weight gain .

Guidance and management

Discussion and single brief intervention

• The opportunity to discuss smoking should be offered to all smokers. Motivational interviewing is particularly useful .
• A three minute counselling session is more effective than simple encouragement as an aid to smoking cessation .
• The Six A's Approach
  1. Ask about the patient's smoking status at least once a year
     • This is easy to achieve in connection with medical examinations or when instigating treatment or prophylaxis for an illness.
  2. Assess the patient’s readiness and willingness to stop. Ask about previous attempts (how successful, how relapsed etc.)
  3. Keep account on smoking status
     • Use a dedicated section in the patient records (e.g. on a summary sheet or a general health status sheet)
     • Smoking habits: cigar, cigarette, snuff, pipe
     • Quantity
     • Duration (in total pack-years of smoking; e.g., 20 years of ½ a pack per day = 10 pack-years)
  4. Advise the patient to stop smoking and instigate supportive measures where necessary.
     • If you feel that stopping smoking will improve the prognosis of a particular illness, make this clear to the patient.
     • Explain to the patient how to prepare for situations where temptation to smoke is great, and about possible withdrawal symptoms.
     • Discuss the support options available.
  5. Assist and help the patient in his/her attempt to stop smoking
     • Positive feedback is essential for success
     • Each smokeless day is an achievement and warrants further encouragement
     • Where necessary, guide the patient towards further intervention (an organized group, smoking cessation nurse, regional centres).
  6. Arrange monitoring of progress at follow-up appointments.

Individual monitoring and support

• Individual counselling is effective .
• Repeated contacts and follow-up increase the possibility of success .
• Telephone counselling provides additional benefit . Tailored withdrawal programmes based on the Internet or mobile phone contacts may help in cessation .
• Counselling by a nurse alone also has a positive effect .
• An organized, gradual smoking reduction might be a beneficial treatment form .
• Counselling especially provided by oral health professionals may help in cessation of snuff use .

Group work

• A suitable size of a group is 8–12 persons.
  • A session should last about 1 ½ hours, and the group should meet 6–10 times over 6–10 weeks, according to a planned group programme which should
    • be versatile and flexible
    • progress in stages and
    • take into account the needs of the group.
  • Group work that applies behavioural scientific techniques has been shown to be more effective than self-help or short-term counselling .
  • Individual or group counselling provided at the workplace is also helpful in smoking cessation .
  • Conducting a group is facilitated by an inspired leader, a coach-like approach and a work method that is based on the potential of the participants. Influencing through information may be successful if the participants spontaneously express their need of such an approach.

Drug treatment

Varenicline

• Varenicline is effective .
• The effect is based on partial activation of nicotinic receptors.
• Treatment is initiated 1–2 weeks before smoking cessation, and the dose is titrated to the recommended dose of 1 mg twice daily during the first week. The complete treatment period is 12 weeks.
• Support and follow-up form a part of the treatment .
• Should not be used in severe renal insufficiency.
• May cause nausea.The suspected risk of varenicline to cause depression and suicidal or self-injurious behaviour appears not to be true .
• Due to varenicline's mechanism of action it should not be combined with nicotine replacement therapy.

Bupropion

• Bupropion is effective .
• The dose for the first week is 150 mg once daily. From the second week onwards the dose is 150 mg twice daily. Target stop date is agreed for the first or second treatment week. The duration of treatment is 7–9 weeks.
• The effect is based on selective blocking of the neuronal reuptake of catecholamines (noradrenaline and dopamine).
• Support and follow-up form a part of the treatment .
• It is possible to combine bupropion and nicotine replacement therapy even if the effect is not necessarily enhanced .
• Bupropion is associated with a dose-dependent risk of seizure. It is contraindicated in patients with a history of seizures. Particular caution should be exercised in concomitant administration of drugs that can lower the seizure threshold (antipsychotics, antidepressants, antimalarials, quinolones, sedating antihistamines, tramadol, theophylline, systemic corticosteroids or hypoglycaemia inducing antidiabetic drugs), as well as in patients with alcohol abuse or a history of head trauma.

Nicotine replacement therapy

• Nicotine replacement therapy significantly alleviates withdrawal symptoms .
• Follow-up and support should be offered .
• All forms of nicotine replacement therapy (chewing gum, transdermal patches, nasal spray, inhalator, sublingual tablets and lozenges) are effective and increase the success rate of smoking cessation 1.5–2 fold .
• Nicotine replacement therapy should be recommended to smokers who smoke more than 10 cigarettes per day. Dependence can be assessed by using the Fagerström Test for Nicotine Dependence, table .
• The dose of nicotine replacement must be sufficiently high; the peak effect of nicotine from tobacco is developed in one minute whereas in nicotine replacement therapy the peak is reached in 30 minutes and even then it is only half of the peak effect from tobacco.
• The recommended duration of treatment is 2–3 months.
• Suitable products are chosen individually according to the degree of dependence as well as the patient’s situation. For example:
  • For a smoker with a heavy nicotine dependence, 8–12 pieces of 4 mg nicotine chewing gum per day.
  • The strongest patch initially for 3 weeks, followed by a medium strength patch for 3 weeks and finally the mildest patch.
  • 8–12 lozenges (maximum 30 of 1 mg or 15 of 2 mg lozenges per day) or 4–6 inhalator capsules (maximum 12 capsules per day).
• Guidance in the use of the product is essential because the adverse effects are often associated with incorrect use, e.g. too quick chewing of the chewing gum.
• Different forms may be combined. The combination of a patch with either chewing gum or some other rapid-acting nicotine replacement product is more effective than any of the products alone .
• Nicotine replacement therapy, even when used for a long time, is less harmful to health than smoking.
• Nicotine chewing gum should be withdrawn gradually or be replaced by patches, because people occasionally become addicted to nicotine chewing gum, but this has not been observed with patches.
• Nicotine replacement therapy is also safe in patients with coronary heart disease. Nevertheless caution should be exercised for 2 weeks after myocardial infarction, in unstable angina and serious arrhythmias.
• Nicotine replacement therapy is a better alternative than smoking for pregnant and breastfeeding women. Smoking cessation during pregnancy may reduce the incidence of prematurity and low birth weight . Short-acting preparations are recommended.

Other drugs and interventions

• Nortriptyline is effective .
  • Treatment of nicotine dependence is not an official indication of the drug.
  • Dosage 75–100 mg per day; the dose is titrated at the start
  • Inexpensive
• Other antidepressants than bupropion and nortriptyline are not effective in smoking cessation
• Anxiolytics are of no benefit in cessation therapy .
• There is no evidence of the effectiveness of naltrexone .
• Neither acupuncture nor hypnosis are effective treatment forms. Physical exercise may aid in smoking cessation as part of the treatment . Cytisine may be effective .
• Electronic cigarettes (electronic nicotine delivery systems) have not been proven to help people quit smoking .
• Tobacco smoke increases the activity of cytochrome P450 isoenzymes and thus accelerates the clearance of certain drugs. It has been shown that smoking induces a clinically significant decrease in the concentration of the following drugs: heparin, warfarin, insulin, theophylline, flecainide, propranolol, benzodiazepines, oestradiol, fluvoxamine, mirtazapine, chlorpromazine, haloperidol, olanzapine and clozapine. Once smoking ceases, plasma concentrations may increase. Take this into account especially in association with warfarin, insulin, olanzapine, clozapine and theophylline due to their narrow therapeutic range.

Related resources

• Cochrane reviews
• Literature

Ədəbiyyat

1. Boyle P. Cancer, cigarette smoking and premature death in Europe: a review including the Recommendations of European Cancer Experts Consensus Meeting, Helsinki, October 1996. Lung Cancer 1997;17(1):1-60.
2. Doll R, Peto R, Boreham J et al. Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ 2004;328(7455):1519.
3. Danaei G, Ding EL, Mozaffarian D et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med 2009;6(4):e1000058.
4. World Health Organization 2013. Rachel Grana, PhD MPH, Neal Benowitz, MD, Stanton A. Glantz: PhD: Background Paper on E-cigarettes. (Electronic Nicotine Delivery Systems) .